First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

This male in his 40's had been having intermittent chest pain for one week.  He awoke from sleep with crushing central chest pain and called ems.  EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain.  He arrived in the ED and had this ECG recorded: There are Wellens' waves, type A (upsloping ST segment then inversion of the terminal part of the T-wave - terminal T-wave inversion, or biphasic T-waves) in V2-V4, and aVL.  Type B waves are deeper and symmetric.When the patient had chest pain, prior to nitroglycerine, what do you think the ECG showed?  See below.Here is the prehospital ECG, with pain: Hyperacute anterolateral STEMI The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow.  A stent was placed.Here is the 3 hour post angio ECG: The Wellens' waves are receding (this is unusual) The next AM, another ECG was recorded: The Wellens' waves are still present, and not evolving A transthoracic echo was entirely normal.  The peak troponin I was 0.364 ng/ml.The reperfusion was so early that wall motion recovered completely and early.   For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering.  I have seen cases of Wellens' syndrome that were ignored because of either negative troponins or normal echo or both an...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs