Chest pain with NonDiagnostic ECG but Diagnostic CT Scan

An elderly woman presented with chest pain that radiated to the back for several hours.Here is here initial ECG:There is only a nonspecific flat T-wave in aVL.  It is essentially normal.The first troponin returned at 0.099 ng/mL (elevated, consistent with Non-Occlusion MI)Providers were concerned with aortic dissection, so they order a chest aorta CT.This showed no dissection but did show the following:Notice the area of the lateral wall (lower right) that has no contrast enhancement (It is dark, where areas of enhancement are light-colored). This transmural ischemia, but not necessarily completed infarction (yet). A slice at a slightly different level:Again, an area with absence of contrast enhancement (dark-, not light-colored).These were read by our fantastic chief of radiology, Gopal Punjabi, who has his own blog on Spectral CT: https://www.ctspectral.com/   https://twitter.com/CtSpectralWith continued symptoms, an elevated troponin, and no other explanation, this is acute MI with ongoing ischemia until proven otherwise.The CT scan confirms no other explanation and also confirms that this is acuteTransmural ischemia diagnostic of OMI (Occlusion MI).If the patient were no longer symptomatic, one could conclude that the infarct is completed, and emergent angiogram +/- PCI would not be necessary.The cardiologists did not want to go to the cath lab.She had subsequent ECGs:First at 1.5 hours:This possibly shows some inferior STD, but pro...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs