Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

60-something with h/o MI and stents presented with chest pain radiating to the back and nausea/vomiting.Time zeroWhat do you think?There is inferior ST elevation.  Is it normal variant?  Is it ischemic (OMI)?  [Pericarditis? (NOT!)]There is one finding that argues against inferior OMI (There is absence of reciprocal ST depression in aVL; STD aVL is extremely sensitive for inferior OMI;  Reference: Bischof and Smith). However, there is alsostraightening of the inferior ST segments, and astraight ST segment in aVF; this is extremely rare in normal variant STE)._______There is alsoterminal QRS distortion in II, III, aVF [absence of S-wave and J-wave (notch)].  The significance of this in inferior leads is unknown, but I suspect it is a marker for inferior OMI vs. normal variant.Terminal QRS distortion is definitely significant for anterior OMI in V2 and V3:An intoxicated, agitated, 20-something with chest pain______Here is an ECG from one month ago:There is a definite change in the inferior leads, with new ST elevation.Previously, all inferior leads had appropriate upward concavity.The patient was given aspirin, heparin, and IV nitroglycerine.Another ECG was recorded at 35 minutes:It is hard to discern a differenceAt this point, the first troponin I returned at 0.55 ng/mL (significantly elevated)A D dimer was also elevated.Another ECG was recorded at 58 minutes:Again, no big difference.There was concern for aortic dissection, so a CT was done a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs