What is a useful next step in the evaluation of this patient with Chest pain and this ECG?

Written by Pendell Meyers, submitted by Daryl Williams, edits by Steve SmithA man in his sixties with prior CAD and CABG experienced chest pain and pressure off and on for three days. He saw his primary doctor during this time who had suspected GI related symptoms and increased his PPI medication. On the third day it became more intense and had associated radiation to his neck and left arm, and this reminded the patient of his prior MI symptoms, so he presented to the Emergency Department. It is unclear how long he had constant symptoms during those three days.Here is his triage ECG (no prior was available in our system):What do you think?Raw Findings: - Normal, narrow QRS complex (other than the Q waves) - 0.5 mm STE in III and aVF - STD in I and aVL, V2-V5 (maximal in V2) - Q waves in II, III, and aVF, as well as very small Q waves in V5 and V6Interpretation:Acute to subacute inferoposterior OMIInferior STE with Q waves and slight STE without obviously hyperacute T waves could be acute, subacute, chronic (inferior LV aneurysm), or acute on chronic (new MI superimposed on an old LV aneurysm.The tall R-wave in V2 could be due to old or subacute posterior MI.Old MI with persistent STE, just like acute MI, may indeed have reciprocal ST depression (aVL) and old posterior MI (posterior aneurysm) can have persistent ST depression. So a large R-wave in V2 with ST depression could be old or subacute, as well as acute.There is no good way to differentiate inferior...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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Written by Pendell MeyersA man in his 50s with HTN, HLD, obesity, and restrictive lung disease presented with shortness of breath worsening over the past 3 days. He also had a cough and subjective fevers. He denied chest pain. His vitals were within normal limits.Here is his triage ECG (no baseline available):What do you think?Findings: - sinus rhythm at about 100 bpm - STE in I and aVL (meets STEMI criteria) - hint of STD in III and aVF - STD in V1 and V2 - hyperacute T-waves in I and aVL (with reciprocal negative hyperacute T in III)Interpretation:This is definitive evidence of acute transmural i...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
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