A 40-something healthy male with transient chest squeezing
A 40-something man with Hx of treated HTN had chest " squeezing, " with SOB and diaphoresis, 10 hours prior to presentation. It lasted 5 minutes then resolved. There was an exertional component. Then, 1 hour before arrival, it recurred, again lasting 5 minutes. His 3rd and last episode was worse, had radiation to both arms, and was 10/10. 911 was called and this prehospital ECG was recorded at time zero:Limb leads:Note the artifact that is simultaneously recorded in all limb leads. This was mistaken by the treating physicians for ST depression initially.Precordial leads:What do you think?This is diagnostic of LAD OMI. There is STE that does not meet STEMI criteria in V1-V6. There are normal size T-waves in V1-V3, butthese T-waves are enormous relative to the QRS amplitude. These are hyperacute T-waves. Moreover, any time there is ST Elevation of any amount, it must be explained: is it normal STE? Or ischemic?One sign that eliminates the possibility of normal STE is" Terminal QRS distortion. " That is the absence of both an S-wave and a J-wave in EITHER V2 or V3. Here there is no S-wave in V3 and also no J-wave. This is diagnostic of ischemic STE and of LAD OMI.See these previous posts on Terminal QRS distortion:Paper published: Terminal QRS distortion not found in any ECG of Early RepolarizationBest Explanation of Terminal QRS Distortion in Diagnosis of Electrocardiographically Subtle LAD ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Steve Smith Source Type: blogs