Extremely Subtle ECG, but Bedside Echo Shows Wall Motion Abnormality and Ischemic Pain Cannot Be Controlled Medically

A male in his 40's with no previous cardiac history had presented to a clinic recently with chest burning, had a nondiagnostic ECG, and was diagnosed with reflux. He presented to an ED with 2.5 hours of chest burning a few days later.  His BP was 152/84.  Here is the initial ECG:Sinus rhythm,  Q-wave in III with minimal ST elevation and minimal ST depression in I and aVL.  There is a suspiciously minimally biphasic T-wave in V6.  This is a nonspecific ECG.The ECG from the clinic was sought for comparison:Compared to this one, the ST depression in I and aVL seen above is new and T-waves are nonspecifically different in diffuse leads.  The patient continued to have chest pain of an ischemic quality. The clinical presentation worried the ED physicians, so they performed a bedside ultrasound (parasternal short axis view): Cardiac Ultrasound Parasternal Short Axis from Stephen Smith on Vimeo.The curved white line shows the wall (lateral) which has hypokinesisThe wall motion abnormality confirms that these nonspecific T-wave changes are indeed ischemic.  The chest pain is therefore ischemic.  The physicians attempted to control the pain with nitroglycerine, both sublingual and intravenous, titrating to 60 mcg/min, and BP down to 100/57.  Thus, they were trying to treat this "NonSTEMI" medically, as there was no ECG indication for immediate reperfusion therapy.They recorded a posterior ECG:Leads "V4" to "V6" are really V7 to V9.  Not...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs