Typical Chest Pain: Would you activate the cath lab? Would you advocate if the interventionalist was not interested?

A 50-something woman complained of acute chest pain radiating to the left arm, onset while driving.  It would briefly improve with NTG.Here is the first ED ECG:What do you think?When I saw this, I immediately said: " This isAslanger ' s Pattern. " 1. Inferior OMI, with STE in lead III only, and reciprocal STD in aVL.2. Diffuse subendocardial ischemia (ST depression, STD, in I, II, V3-V6) with reciprocal STE in aVR.Aslanger ' s pattern is a combination of inferior OMI and diffuse subendocardial ischemia.  The subendocardial ischemia produces an ST depression vector toward leads II and V5 (with reciprocal STE in aVR) and the simultaneous inferior OMI results in STE in lead III only, but not in the other inferior leads.  If there is inferior OMI, why is there no STE in II and aVF?  Because the ST depression (STD) vector towards lead II cancels part of the STE vector that would otherwise manifest in II and aVF.  That STD vector cannot, however, cancel the STE in III, which is too far to the right. In fact, the STE vector must be directly rightward (180 degrees, or minus 180 degrees) in ordernot to register in lead aVF.  But of course, that rightward STE vector also registers as STE in aVR.  When there is subendocardial ischemia alone, the STE vector is towards aVR, or actually a bithigher than aVR; thus, there is no STE in III or any other inferior lead.So: lead III registers STE of subepicardial ischemia due to inferior...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs