ST Elevation and Positive Troponin. Is it STEMI? No. And it is not even ACS.

A male in his 60s complained of constant chest pain for 12 hours.  He has a h/o DM and HTN and has been off his meds, including clonidine, for 3 days.  His first two BP measurements were 176/108 and 191/126, with a pulse of 100-112.  Here is his initial ECG:ED ECG with pain:There is sinus tach at a rate just above 100.  There is profound LVH, with deep S-waves in V1-V3 and a large R-wave in V6.  There is left atrial enlargement, with a very large negative deflection of the P-wave in V1, also supporting LVH.  There is 3-4 mm of ST elevation in V1-V3: this is classic for the pseudoSTEMI pattern of LVH: 1) location: V1-V3 and 2) preceded by a deep, high voltage S-wave.  Armstrong et al., concluded that an ST/S ratio of less than 0.25 in the presence of LVH is very unlikely to be due to STEMI.  There are small Q-waves in III and aVF that suggest, but are not diagnostic of, old inferior MI.Although this ECG is abnormal, I see no evidence of ischemia on this ECG.  It is nondiagnostic.  There certainly could be ischemia hidden in this ECG.  But there is nothing specific for ischemia.   And it is not an ECG that should result in cath lab activation.Just to prove the point, I will show his previous ECG when he was symptom free:It is very similar but at a higher heart rate.  But there are also clearly inferior Q-waves, strongly suggesting that he had a pre-existing inf...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs