Viral symptoms, then acute chest pain and this ECG. What do you do?

A late 30 ' s male presented with fever, sore throat, headache, vomiting, and body aches ( " bones hurting " ) for 2 days.He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain.He had this ECG at time 0What do you think?There was an old ECG for comparison:Very normalInterpretation:There is serious widespread ST elevation that could easily by due to a wraparound LAD with anterior and inferior MI.  It could also be due to pericarditis or myocarditis, but I always say that " you diagnose pericarditis at your peril. "If you thought it might just be early repolarization, we could use the formula to assess this:QTc = 358RAV4 = 7QRSV2 = 15STE60V3 = 4Formula value = 18.72, consistent with LAD occlusion.The clinical presentation is very suggestive of myo-pericarditis.  But one should always remember that acute MI is a far more common pathology than myo- or pericarditis.Other thoughts:There is no abnormal PR depression.The T-waves are taller than expected for myo-pericarditis, and more typical of acute MI.The location in V2-V4 as much as inferior and lateral is unusual for myo-pericarditis.Exam revealed no friction rubWhat do you want to do?A bedside echo was done immediately.  Here is the parasternal short axis, performed by a real expert in emergency department point of care cardiac ultrasound:There does not appear to be an anterior wall motion abnormality.This makes anterior MI...

Source: Dr. Smith's ECG Blog - January 9, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs