A woman in her 60s with chest pain and prominent J waves

Case submitted by Dan Singer MD and Ryan Barnicle MD, Written by Pendell MeyersA woman in her 60s with history of smoking presented to the ED with left sided chest pain radiating to the left arm and back, starting at about 1330. She described the pain as a " heaviness, " without exacerbating or alleviating factors. Her pain at the time of arrival was 10/10.Here is her triage ECG (no prior for comparison):What do you think?Findings: - Sinus rhythm at around 100 bpm - Grossly normal QRS complex - 1.0 mm STE in lead III, and just a hint of STE in aVF (both of which have to be measured just after significant J waves) - STD and T wave inversion in lead I and aVL - A suggestion of almost STD in V2, with negative T wave in V2Interpretation:Diagnostic of inferior (and likely also posterior) STEMI(-) OMI. Although J waves (J-point notching) are usually considered a morphologic feature that makes STE less likely to be due to OMI, we have many examples of OMI with J waves on this blog (just like every other ECG rule of thumb you ' ve ever learned). If the inferior leads were viewed in isolation, I would be suspicious of the volume underneath the T waves especially in lead III, but I would not be 100% certain that they are hyperacute. However, lead aVL solves the case as usual, confirming inferior OMI: lead aVL has a narrow normal QRS complex followed bySTD and large-volume T wave inversion. Lead aVL makes STE and T waves in lead III extremely likely to be due to...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs