An elderly man who dies 12 hours later - could he have been saved?

Sent by Anonymous, written by Pendell Meyers and Steve SmithAn elderly man with good neurologic baseline but history of CABG presented to the ED with acute lightheadedness, shortness of breath, and chest pressure radiating to both arms. He had just recently been admitted for similar symptoms which had been diagnosed as an NSTEMI, and he received a stent to the ostial LCX one week ago. At that time his EF was 30%. He returned to the same hospital where he had just received his LCX stent.Here is his first ECG at triage, with chest pain temporarily resolved:He then had spontaneous return of chest pain while in the ED, with this ECG:What do you think?The first ECG has an intra-ventricular conduction delay (IVCD) which is of the LBBB type (for textbook LBBB most would list a monophasic R wave in lateral leads V6 which is not present in this case).  For such a QRS complex, the modified Sgarbossa criteria should be used. With the exception of lead V2, there is appropriate ST segment discordance.  However, in V2 there is no discordance (i.e., it is isoelectric, which suggests that there isrelative ST depression).  Moreover, the ST segment is downsloping, which should never happen in LBBB. This is nearly diagnostic of posterior OMI, to the point where serial ECGs and close investigation is mandated. Additionally, there may be evidence of inferior involvement, with slightly too much STE and large volume T waves.The 2nd ECG does indeed evolve to the po...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs