Is there evidence of OMI on this ECG?

This is another one from Amandeep ( " Deep " ) Singh, with many comments by Smith.  Dept Emergency Medicine, Highland Hospital, Oakland.Case67yo male with h/o schizophrenia and who has become increasingly distrustful of Western medicine presents with chest pain radiating to the right shoulder associated with shortness of breath for 24 hours duration.  He states that he was unable to sleep secondary to the pain.  The patient seems very worried about his right shoulder and is requesting a x-ray.  An x-ray was obtained, as well as an ECG and a troponin.  Prior to the troponin result, the RN notes that the patient was " pacing at the doorway, stating he wants to leave and be called with lab values.  Pt. does not want to wait any longer.  MD aware. "Here is the initial ECG.  Would you allow this patient to leave the ED?I sent this ECG without any clinical information to Steve Smith, and he responded: " Ischemic ST depression in V4 and V5.  So if this is someone with symptoms compatible with ACS, this ECG is diagnostic of ACS. "Analysis of 2 issues: STD V4-5, and Delayed Activation WaveDespite baseline wander, the initial ECG shows subtle ischemic ST depression in V4-V5.  1. ST Depression in V4, V5 (by Smith):Meyers and Smith recently wrote this article: Ischemic ST depression maximal in V1-V4 (vs. V5-V6) of any amplitude, is specific for Occlusion Myocardial Infarction (vs. non-occl...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs