What is the infarct artery????? And have you ever seen a troponin this high?

An elderly woman with h/o stroke and aphasia seemed different to her daughter, and was pointing all over her body as if in pain.They called 911.She had a history of PCI to the circumflex and also of severe mitral regurgitation, status post bioprosthetic valve replacement.  Also a h/o LV aneurysm with thrombus, on anticoagulation, as well as a dual chamber pacemaker. On arrival, the BP was 60/30.Here is the initial ECG:There is atrial pacing and Right Bundle Branch Block (RBBB)There is STE in I and aVL, V5, V6, with reciprocal STD in II, III, aVFThere is appropriately discordant ST depression in V1-V3 (appropriate to RBBB) TheRBBB is newand the previous ECG had no ST elevation What is the infarct artery?The cath lab was activated.Here is the bedside echo (POCUS): Short AxisExtremely poor LV function and massive wall motion abnormalityLong AxisExtremely poor LV function and massive wall motion abnormalityAt 20 minutes, just before cath, another ECG was recorded:More (worsening) STEHer initial troponin I returned at 0.341 ng/mL (URL = 0.030 ng/mL) (not per L, not high sensitivity)Lactate was 3.7 mEq/LHer BP with pressors came up to 80, then 100.Angiogramshowed a 99% left main thrombotic occlusion with TIMI-1 flow (this is considered " occlusion " even though there is some flow.  It was opened and stented with resulting TIMI-3 (normal) flow.The  stent to LCX is patent.  OM1 is occluded and OM2 has 60% stenosis.  Her RCA is a mediu...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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