Crushing Chest pain, Tachycardia, and Very Elevated Blood Pressure in a 40-something Man.

A 40-something male called 911 for 2 hours of crushing, non-radiating, chest pain at about 11 AM.  He reported a similar episode last year when his blood pressure was very out of control and that again he has not taken his BP meds for 2 months.  He stated he had drunk 12 cans of Mountain Dew (high caffeine content) overnight. On exam, he was very anxious,  holding his chest, breathing normally.  Chest pain was worse with palpation.  His BP was 250/150 with a heart rate of 150.Here are 2 prehospital ECGs, 6 minutes apart:Heart rate 156.  ST Elevation. Large T-wavesThe computer read both ECGs as " Early Repolarization "  What do you think?There is definitely anterior ST Elevation.  There is also STE in I and aVL, with reciprocal STD in inferior leads.  There is also extreme tachycardia and elevated BP.  Tachycardia can exacerbate pre-existing normal ST Elevation.  Moreover, both tachycardia and hypertension can result in demand ischemia.  Tachycardia is not seen in ACS unless there is a severe complication such as cardiogenic shock.  Therefore, if there is ACS here, there is also another underlying pathology contributing to tachycardia and elevated BP (toxic, volume depletion, and more).  The combination of untreated hypertension, anxiety, and caffeine could be the source of all this.Exception!!!  The STE in I and aVL,with inferior reciprocal ST depression, should ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs