The cardiologist disagreed with cath lab activation. What do you think?

This was sent by a reader who is obviously a very astute clinician.A middle aged male presented after 4 days of intermittent chest pressure which suddenly became worse and radiated down his left arm.  Here was his initial ECG:What do you think?The emergency physician recognized that the " inferior ST depression " was reciprocal to high lateral OMI (very subtle STE in aVL).  There is some minimal downsloping ST depression in V3 and V4, further confirming the diagnosis.She activated the cath lab at the referral institution (she is at a smaller hospital without a cath lab).The patient suddenly had much worse pain and this ECG was recorded:What is going on?There are no P-waves.  The rate is regular and is about 100.  Complexes are wide.  So it is too slow for VT andtoo wide for a junctional rhythm.  This isAccelerated Idioventricular Rhythm (AIVR).  AIVR is sometimes seen duringreperfusion and is usually a good sign, a sign of reperfusion.  It is often accompanied by relief of pain because the myocardium is again receiving oxygen.   This AIVR also has superimposed high lateral OMI andinferior reciprocal ST depression that is out of proportion to the preceding R-wave.In this context, it further confirms acute coronary syndrome. Clinical Course:Immediately after the AIVR ECG, the pain became much better.  This ECG was recorded:It is back in sinus rhythm with a normal QRS.  There is still ischemic S...

Source: Dr. Smith's ECG Blog - December 2, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs