Unusual: Troponin Trajectory to Help Determine Ongoing/Recurrent Infarction vs. Completed Infarction.

A 40-something male with no PMH of any kind presented  to urgent care on a weekend (cath team is at home) with cough starting 2 weeks prior and SOB one week prior.He underwent a chest x-ray:As this was consistent with " pulmonary edema vs. viral infection, " and he was transferred to the EDThe faculty physician did an immediate cardiac and lung ultrasound:Many B lines (probable pulmonary edema)Parasternal short axis cardiac ultrasound:The anterior wall is closest to the transducer and shows an obvious wall motion abnormalityFurther history:The patient denied chest pain but stated that he had had about 3 episodes of chest pressure, lasting 5 minutes each, in the past week.The physician was alarmed by these findings and ordered an ECG:This is diagnostic of Anterior MI, but:Is this an " old " MI, a completed transmural anterior MI, or is there ongoing myocyte necrosis?The QS-waves suggest that there is no myocardium left.  The T-waves are taller than one would expect in a completed MI, but the highest T/QRS ratio of V1-V4 is still only about 0.33, close to diagnosing acute STEMI, but not quite (see discussion of ratio below).A ratio less than 0.36 is still consistent with a subacute STEMI.Is it old, or is it subacute and ongoing?  We usually determine this from ongoing chest pain, but this patient NEVER had chest pain.The ECG in a true " old anterior MI with persistent ST Elevation, " usually associated with an aneurysm, looks like th...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs