Chest pain, ST Depression maximal in V2-V4, and a Blood Pressure of 238/118.

A Middle-aged male had sudden onset severe substernal chest pain that woke him from sleep.His BP was 238/118 on arrival.Here is his first ED ECG:What do you think?There is ST depression maximal in V2-V4, which normally would be all but diagnostic for posterior MI. However, the extremely elevated BP makes it likely thatthis STD is really subendocardial ischemia from high oxygen demand.  (There are also incidentally large U-waves -- the K was 4.1).It is best to first manage the BP and then repeat the ECG.So the physician did just that.  He obtained a chest CT to rule out aortic dissection (which was negative).He also gave nitroglycerine to bring the Systolic BP down to 180 mmHg, at which time the chest pain resolved.  Then he recorded another ECG:The ST depression and pain is gone!  It must have been demand ischemia, right?He gave aspirin, heparin and transferred to the nearest PCI center.The initial troponin at that referral center was " negative " , so they observed the patient.  A later troponin returned at 0.346 ng/mL (unfortunately, I don ' t have the assay -- don ' t even know if TnI or TnT.  In any case, that level is elevated and diagnostic of either type 1 or type 2 MI).Shortly thereafter, the patient had sudden onset 10/10 pain again.  Another ECG was recorded:The ST depression is back!He went for emergent angiogram and was found to have a 100% proximal circumflex occlusion with TIMI-0 flow.Comment:The physician was worried that...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs