A woman in her 50s with shortness of breath

 Case written by Neha Ray, MD, with edits by Meyers, Smith, GrauerA woman in her 50s presented for evaluation of multiple episodes of syncope with shortness of breath. On EMS arrival, she was GCS 15 with HR 110s. En route to the ED, the patient had 4 more episodes of syncope and became hemodynamically unstable with SBP in the 80s and HR 160s. The first recorded SpO2 was 73%. On arrival to the ED, patient was diaphoretic and in extremis. Her initial EKG is below. Paramedics arrive to the ED and state that they are worried about inferior STEMI. What do you see? What do you think?The ECG shows sinus tachycardia with prominent T-wave inversions in the inferior and anterior leads. The patient also has right axis deviation, and an S1Q3T3 pattern. There is a hint of inappropriate STE in III, with reciprocal STD in I and aVL.  It would be easy to mistake this ECG for inferior OMI (STE in III with reciprocal STD in aVL). But several features give it away as a mimic of OMI and instead all but diagnostic of right heart strain.  Most important is tachycardia, which should always make you doubt the diagnosis of OMI.  When there is tachycardia, there is either OMI with cardiogenic shock (which should have poor LV function on echo or valvular dysfunction) or there is another etiology. T-waves: 1) when inverted in both anterior and inferior leads, PE is far more likely than ACS. 2) Domed T-wave inversion 3) T-wave inversion during pain, in contrast to post-...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs