A man in his 40s with epigastric pain and a dynamic ECG

 Case written and submitted by Dr. Arjun J V, peer reviewed by Meyers, Smith, GrauerA 49 year male patient was brought to our ED at around 9 PM on with complaints of epigastric pain since that afternoon. The patient had the same complaints on and off for many years which would resolve on taking OTC antacids. However, this time the pain was persistent and included new diaphoresis, so he presented to an outside facility where this ECG was recorded:What do you think?There is sinus rhythm with a narrow QRS complex with normal axis. There is slight PR depression in III, followed by some STE with upright T wave. Lead aVL shows a negative QRS complex with a seemingly large negative T wave. Lead I also has a negative T wave. There is STE in the anterior leads but with reassuring large voltage QRS and reassuring morphology; to me it fits with normal variant anterior STE, not concerning for OMI. The question is: is this concerning for subtle inferior OMI? On on hand, the T wave in III is not definitively hyperacute, but the T wave in aVL may be fairly big for its QRS complex. We have shown many examples of this. At the outside hospital, the patient was given DAPT and was referred to a higher centre with Cath lab facilities. The providers were concerned for inferior OMI. The patient was hemodynamically stable but had persistent discomfort. An ECG was obtained at the receiving facility on arrival: What has changed compared to the first ECG? What does it mean?Now ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs