A 50-something woman with chest pain, BP 230/120, and LBBB with 7 mm ST Elevation

A 50-something woman with history of CHF of unknown etiology, and of HTN, presented for evaluation of chest pressure.Her BP was 223/125, Sp02 98% on RA. HR 106, RR 18. Here was her ED ECG:There is sinus rhythm with Left Bundle Branch Block (LBBB)There is a large amount of ST Elevation in V2 and V3 (more than 5 mm)Thus, this meets the unweighted Sgarbossa Criteria of 5 mm of discordant ST ElevationBut it does NOT meet the Smith Modified Sgarbossa Criteria, which depend on the ST/S ratio.This ratio is critical because LBBB with very large depolarization voltage (QRS) also has very large repolarization voltage (ST/T).Here the highest ratio is 6-7/60, which is 10-11%, which isnormalThere is no concordant STE or concordant STD in V1-V3The patient was given NTG with improvement of pain.This was recorded 3.5 hours later.There is no evolution A bedside echo showed good function, concentric LVH, and no wall motion abnormality could be seen.Her first troponin was elevated at 0.217 ng/mL, but this does not absolutely differentiate between acute and chronic myocardial injury.Patients with heart failure and cardiomyopathy frequently have elevated troponins from chronic injury, but not usually this high.Acute MI is a subcategory of acute injury (Injury caused by ischemia).Type I MI is acute MI caused by plaque rupture, whereas Type II MI is caused by supply/demand mismatch or endothelial dysfunction and a few other entities.By far most likely this will be acute MI, but it is very...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs