A man in his 40s with chest pain and syncope after cocaine use

Written by Pendell Meyers, with edits by Steve SmithA man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). He also described a syncopal episode just prior to onset of symptoms. He had used cocaine approximately 20 minutes prior to onset of symptoms.He still had active pain on arrival to the ED.Here is his triage ECG:What do you think?His baseline ECG was on file:--Sinus rhythm--Subtle STE in V1-V5, II, III, and aVF--Q-waves in V1-V5, as well as II, III, and aVF which must be assumed new until proven otherwise--Possibly large area under the T-wave (concern for hyperacute T-waves) in V4, II, III, and aVF, with reciprocal negative T-wave in aVL--These Q-waves are so fully developed that it appears to be a nearly completed MI, at a stage when it is likely that all ST elevation is resolved. STE occurs primarily in viable ischemic myocardium; persistent STE after completed infarction is ominous and portends development of an aneurysm.--There is also an interesting Brugada-like morphology in V1 (also similar to hyperkalemia, which sometimes mimics brugada). This morphology can be cause by or associated with cocaine:A Patient with Cocaine Chest Pain and Prehospital Computer interpretation of ***STEMI***This is OMI of the anterior, lateral, and inferior walls until proven otherwise. This distribution is classic for a type III " wrapa...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs