A woman in her 40s with acute chest pain

Case written by Neha Ray MD, Brandon Fetterolf MD, and Pendell Meyers MDA woman in her 40s with a history of rheumatoid arthritis, anemia, and thrombocytopenia presented to the ED with acute onset chest pain starting around 5am on the morning of presentation.  It woke her from sleep. The chest pain was midsternal, severe, sharp, and constant. On the previous night she had had a mild version of the same pain that she thought was heartburn (esophageal reflux). She reported some radiation to the left arm. She also reports 3 episodes of non-bloody vomiting over the course of the morning. She had a recent admission for endoscopy and colonoscopy which failed to show any source of bleeding. She denied any fevers, chills, sick contacts, diarrhea, or abdominal pain.Here is her triage ECG:What do you think?An old ECG from 4 years ago was available:The current triage ECG shows normal sinus rhythm with: - New pathologic QS-waves ( " QS-wave " means there is no R-wave at all; the entire QRS is negative) in the anterior, lateral, and inferior leads.  These QS-waves alone are all but diagnostic of infarction of indeterminate age. - In the anterolateral leads, the are QS-waves with obliteration of the previously normal R wave progression - Very slight STE in leads II, III, aVF, V3-V6 that does not meet STEMI criteria - T waves in V3 and V4 are not consistent with old MI, but rather are hyperacute.  (They are not consistent with chronic, old LV aneurysm...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs