A man in his 30s with chest pain

Written by Pendell Meyers, case submitted by Tom FieroA man in his 30s walked into the ED complaining of chest pain. His triage ECG was done at 11:30 (no prior was available):What do you think?Sinus tachycardiaNormal QRS complex pattern, with borderline low voltageVery slight STE in leads V2-V5Proportionally large and fat T-waves in V4-5 with straightening of the ST segmentsT-waves also concerning in II, III, aVF, with inappropriately negative T-waves in aVLUsing the LAD OMI vs. BER formula:3 Variable: 27.34 (positive for OMI, using STE60V3=1.5mm, QTc=444, RWV4=2.0mm)4 Variable: 23.01 (positive for OMI, using QRS amplitude V2=7.5mm) (> 18.2 is most accurate cutoff;> 19.0 is 97% specific)This ECG was sent to Pendell, Smith, and Grauer. All immediately diagnosed LAD occlusion.This ECG pattern as a whole is extremely specific for full thickness, complete ischemia of the anterior, lateral, and inferior/apical walls. There are several etiologies of this (including takotsubo cardiomyopathy, coronary spasm, etc), however the overwhelmingly most likely, most important, and most treatable etiology is acute Occlusion MI (OMI), in this case likely a wraparound LAD that supplies the anterior wall and wraps around to the apex (showing up in the inferior leads). The only way to differentiate OMI from other, less treatable causes is emergent angiogram.This ECG was interpreted as " no STEMI " and the clinician initiated a typical workup for undifferentiated chest pain.Approxi...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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