A 40-something with sharp chest pain, worse with lying down, better leaning forward

p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Helvetica; background-color: #fefefe}A 40-something y.o. male with only PMH of DM and tobacco use presented with chest pain. Patient complained of 2 days of sharp, constant, sternal chest pain, 10/10, waxing and waning, worse with laying down and improved with leaning forward or walking.  He has not had pain like this before.Here is his ED ECG:Diffuse ST Elevation.The only reciprocal depression is in aVRThere is a lot of PR depression.The inferolateral T/ST ratio is low (i.e., T-waves are not large in spite of STE)What do you think?This was texted to me and my answer was this:" This looks like myo- or pericarditis, but you diagnose myopericarditis at your peril. "Since pain has been present so long, then troponin should be elevated in either MI or myocarditis.  If elevated, the patient needs the cath lab to be certain it is not acute coronary occlusion (occlusion myocardial infarction -- OMI).Initial troponin I was23.11 ng/mL (see profile below).Here is the formal echo:Regional wall motion abnormality-lateral .p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px ' Courier New ' } p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px ' Courier New ' ; background-color: #fefefe} span.s1 {background-color: #fefefe}Regional wall motion abnormality-inferolateral.Since it could not be definitively proven that this was myocarditis and not acute MI, the cath lab was activated.p.p1 {margin: 0.0px ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs