Massive ST Elevation in a 38 year old with Syncope

This ECG was texted by a former resident with the words " 38 year old, syncope while urinating.  Negative troponin. "What do you think?There is massive ST Elevation of 5 mm (at the J-point, relative to the PQ junction) in lead V2.  There is 3 mm in lead V1 and 2.5 in lead V3.  But there is also 57 mm QRS in V2 and a 19 mm R-wave in V4.  The QT interval is not very long.My response was this:" I have seen this pattern before and it is very unlikely to be OMI. "  I did not know what " troponin negative " referred to [single troponin?  below the level of detection?  2 serially negative trops below the LoD?  Or below the 99th percentile.]  Nevertheless, I added: " And if you now have negative serial troponins, you have proven it. "Clearly the provider who sent this to me strongly suspected it was a false positive (as he/she did not act on it except to measure troponin), and I don ' t know if that is due to low pretest probability, patient appearance/exam, or knowledge of this PseudoSTEMI pattern.Can we use the formula?12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusionFirst, we must answer all these questions in the negative:1. Is there BBB?2. Is there T-wave inversion?3. Is the ST segment more than 5 mm in any lead (here it = 5 mm)4. Is there terminal QRS distortion?5. Do any of the leads with ST Elevation have a convex ST segment (here they are stra...
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