A woman in her 60s with 6 hours of chest pain, dyspnea, tachycardia, and hypoxemia

Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI paradigm, providers believe things that their common sense would never support and they act in ways that their judgment would never allow otherwise.Learning Points:1. When the QRS is wide, the J point will hide. Find it where you can, then trace it down and copy it over.2. RBBB and LAFB is a very ominous sign of LAD occlusion in the setting of a sick patient with ACS.  In the setting of LAD ACS, patients with RBBB + LAFB are extremely ill, most are either post cardiac arrest or in cardiogenic shock.Here are several more cases of RBBB + LAFB.3. Even in the outdated STEMI era guidelines, there are indications for emergent cath without STEMI criteria, including ongoing ischemia despite medial management, ACS causing cardiogenic shock, and ACS causing hemodynamic or electrical instability.4. Use ultrasound in ACS to look for WMA.References:Widimsky PW, RohÃ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs