A man in his sixties with chest pain

Written by Pendell MeyersA man in his sixties with no prior history of CAD presented with fluctuating central chest pain that started the night before presentation, then went away, then woke him up from sleep the morning of presentation. The pain was 10/10 on arrival, with SOB. Although he also had some nasal drip and sore throat, he had no cough or fevers (this occurred during peak COVID).Here is his triage ECG:What do you think?Normal P-waves would have upright morphology in the inferior leads (especially lead II) and usually biphasic (up-down) morphology in V1. These p-waves are negative in almost all leads except for aVR and aVL, so the axis of the P-wave is almost directly upward. In addition, the P-wave is very close to the QRS, signifying that the atrial rhythm originates close to the AV node and creates a retrograde P-wave by going from the bottom of the atrium to the top.Therefore this is likely an ectopic rhythm, originating from the low atrium or the junction.There is apparent STE in II, III, aVF, and reciprocal STD in aVL.I texted this ECG with no clinical information to Dr. Smith, and he said: " High junctional rhythm with retrograde P wave before QRS. This often causes false positive ST elevation in inferior leads, so I think pseudoSTEMI. "I asked for more explanation, and Dr. Smith said: " Because the atrial repolarization wave, which usually causes PR depression, will cause PR elevation when the atrium is depolarized in the opposite direction. Then becaus...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs