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: Source Type: blogs