A man in his 50s with chest pain and shortness of breath

Submitted by Ali Khan MD, written by Pendell MeyersA man in his early 50s presented with exertional chest pain and dyspnea. He had family history of early CAD. Otherwise, no clear risk factors. Vitals were within normal limits. No prior ECG was available. Here is his triage ECG:What do you think?This is yet another subtle inferior (and likely also posterior) OMI. There is a small and narrow QRS complex with reasonable axis and R wave progression, therefore the QRS cannot explain any abnormalities of the ST segment and/or T waves. The T waves in II, III, and aVF are subtly too large for their QRS, and the most important finding is that, in aVL, there is reciprocal STD and proportionally-large-volume T wave inversion (a " reciprocal negative hyperacute T wave " ). There is also slight STD in I. The picture is not of perfect quality, but I believe there could be a hint of STD in V3-V4. Sinus brady at 60 bpm is another piece of evidence pointing to an RCA OMI, which supplies the SA and AV nodes, causing bradycardia and heart blocks during occlusion. Dr. Khan immediately understood this ECG and called his cardiologist asking for emergent cath. He also sent this picture to me in real time with no information at all, and I responded: " It is diagnostic of inferior OMI to me. But it will be a hard sell to most cardiologists. " This was not meant to be critical of cardiology, but it does reflect my truthful expectation based on prior experience and cases that we are sen...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs