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This patient presented with acute pulmonary edema without chest pain.A bit of history prior to showing the ECG:The patient had been hospitalized at a different hospital for pneumonia and NonSTEMI for a week. The troponin I had peaked at 40 ng/mL, and echo showed multiple wall motion abnormalities and EF of 35%.  The patient suffered third degree heart block with bradycardia and required permanent pacemaker placement.  A troponin that high is usually associated with Occlusion.I reviewed the ECGs from that hospital and they donot show OMI.  But many ECGs in patients with OMI do not reveal the OMI, even when I interpret them.The patient unequivocally had myocardial infarction by very high troponin I (of 40 ng/mL!) and was diagnosed with a type 1 MI.However, for unknown reasons, the patient did not get an angiogram. Without an angiogram there could of course also beno intervention on the ruptured plaque that would have caused this.That is not standard practice, and I don ' t know why it was not done.Then the patient presented with pulmonary edema 2 weeks later.Here is the ECG:What do you think?ED physician interpretation:  " Ventricular paced rhythm with ST elevation out of proportion to the preceding S-wave in both V4 and V5.  Meets Smith Modified Sgarbossa Criteria in 2 leads (only 1 is necessary), diagnostic of acute OMI. "Smith interpretation: same.Cardiology was consulted.Cardiologist: " Current findings and clinical presentation not a definite ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs