A case of misinterpreted troponins, in spite of a very suspicious ECG....

This 50-something male with previous history of MI presented for intermittent CP and SOB for 2 days. CP lasted for hours at a time, was described as pleuritic, without radiation, but relieved by nitro. He was given nitro and full dose aspirin by EMS.  Prehospital ECG was similar to first ED ECG.Here is the ED ECG for ED visit #1:It is very abnormal, with potentially ischemic downsloping ST depressionThere were 3 ECGs during an ED visit for chest pain one month earlier.  Let's call that ED visit zero.Here is the last EKG from ED visit zero:There is minimal ST depression without the downsloping.Here is the first EKG ED visit zero:This looks more like the one at the top and is more suggestive of ischemia.On ED visit zero, the patient had 3 troponins below the level of detection.  Contemporary troponin I, Abbott, LoD = 0.010 ng/mL, 99% URL = 0.030 ng/mLSo back to visit number 1.  This 2nd ECG was recorded.It look substantially less ischemic than EKG 1.Thus, there are dynamic ECG changes.So the ECGs alone are all but diagnostic of ischemia in the setting of chest pain in a patient with known coronary diseaseThe initial contemporary troponin I was 0.023 ng/mL.  The second was 0.025 ng/mL.The patient was admitted.The inpatient team recorded these contemporary troponins over 15 hours.As you can see, there was a rise and fall of troponin, with several values above the 99th percentile of 0.030 ng/mL.  This is diagnostic of myocardial in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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