Saw this ECG while reading through a stack. Lots here: myocardial stunning, MRI viability, P2Y12 inhibitors and CABG.

I had just finished passing the shift off to my partner and the next shift of residents.  It was 11:30 PM.  I turned to the computer system to finish reading any EKGs from the shift and I saw this one, which had been recorded after the end of my shift at 11:11.Usually these are brought immediately by the tech to the faculty physician.  I ' m not certain whether another faculty had seen this or not.What do you think?I immediately saw the ST depression in V2 and V3 of at least 1.5 mm.  There is also minimal STD in II, III, aVF.  When you see this inferior STD, you should not think " inferior ischemia " because ischemic ST depression does not localize to a myocardial territory (it usually manifests with an STD vector towards leads II and V5, with reciprocal ST elevation in aVR).Instead, when you see this, you should be thinking that it is reciprocal (opposite) ST Elevation in the opposite lead (aVL).  So I looked at aVL and of course there is ST Elevation there; it is miniscule, but so is the QRS!The STD in V2, V3 is diagnostic of posterior OMI, and this would usually be due to the circumflex or a branch thereof.  And when the circumflex is involved, it is likely that the high lateral wall (aVL) will also be involved.Therefore, the entire picture presented by this ECG is a circumflex (or branch) OMI.But it must be in the context of a clinical presentation consistent with ACS.So I looked at the chief complaint on the computer: " l...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs