A man in his 50s with acute chest pain and diffuse ST depression

Submitted by Alex Bracey, with edits by Meyers and SmithA man in his 50s with history of type B aortic dissection with prior TEVAR experienced acute onset chest pain at rest and presented to the Emergency Department. Here is his ECG on arrival:What do you think?Here is a prior ECG on file (presumed baseline):There is sinus rhythm with minimal STD in V5, V6, II, III, aVF. There is the tiniest amount of STE in aVL, but the T wave is not hyperacute (instead there is a terminal inversion). I would call this ECG consistent with subendocardial ischemia, but also the question of possible high lateral OMI (for which I am not yet convinced and would need serial ECGs, echo, etc.). The team was worried foremost for possible aortic dissection given his history and presentation. He was neurologically intact with ongoing pain, without obvious vascular signs.A CT aortogram was performed and is shown below:This was read as an acute type A aortic dissection.He was transferred to a surgical center for management.On arrival he complained of increasing chest pain, and a repeat ECG was ordered:This ECG shows interval increased severity of diffuse subendocardial ischemia (non-occlusion ischemia). There is now STD from V3-V5 (maximal in V5 slightly greater than V4), as well as leads I, III, aVF, I (maximal in II), with obligatory reciprocal STE in aVR. I see no signs of superimposed high lateral OMI which we were considering from the first ECG.Knowing that the patient has aortic dissectio...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs