Even when the story is obvious, with intractable pain, the STEMI paradigm can cause preventable delays

 Written by Pendell MeyersA man in his early 60s presented with acute chest pain rated 10/10 with associated nausea and vomiting with known history of multivessel CAD. He presented at 2300 with onset of symptoms at 2230. He was awoken from sleep by the symptoms, which were identical to prior MI for which he received a stent years ago. On arrival his heart rate was 43 bpm and blood pressure 91/62. Atropine and IV fluid was given.Here was his triage ECG:What do you think? Baseline below for comparison, but try first without it.His baseline ECG was available on file:The presentation ECG shows diagnostic evidence of posterolateral OMI. There is sinus bradycardia with a relatively normal QRS complex, followed by some STE in aVL, with upright hyperacute T wave, with reciprocal STD in the inferior leads and negative hyperacute T waves. The posterior involvement is suggested by STD in V3-V4, which is highly specific for posterior OMI in the setting of ACS and no QRS explanation (RVH, RBBB, etc.) for such STD. This ECG is very easy for readers of this blog. But it does not meet STEMI criteria. The EM providers evaluated the patient and concluded, easily, that the patient was having ACS. But they did not understand the ECG, documenting " no clear STEMI. " CT pulmonary angiogram was chest negative for PE.Initial troponin I was 15 ng/L (99% upper reference limit for men is 20 ng/L for this assay). Remember how his symptoms started just 30 minutes prior to arrival!Repe...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs