A man in his 60s with chest pain. Cardiologist refuses to take to the lab. Obvious STEMI, even with criteria. Yet final diagnosis " NSTEMI " . This happens far too often.

Submitted by Anonymous MD, edits by MeyersA man in his 60s with past medical history of multiple sclerosis and hypertension was brought in by EMS from home for chest pain thatstarted acutely just prior to arrival. He rated the pain at 9/10, describes as pressure, radiates towards the left arm with associated shortness of breath, diaphoresis and had one episode of emesis. He did not have a prior history of CAD or other cardiac disease. His pain improved to 6/10 after EMS gave him 3 sprays of sublingual nitroglycerin and 324 mg of aspirin. Prehospital ECGs:What do you think?Both ECGs are diagnostic of acute LAD OMI until proven otherwise, with STE in V1-3 and I/aVL, hyperacute T waves in V1-V4 and I/aVL, poor R wave progression, and reciprocal findings in inferior leads. Probably does not meet STEMI criteria in these ECGs, but it is obvious nonetheless. Smith: In addition, the 1st and 3rd complexes in V1-V3 are RBBB-like PVCs, and they are even more diagnostic than the conducted beats, with concordant STE in V1 and massive STE in V2. Prehospital STEMI was activated. Bedside ECG immediately upon patient arrival (with active chest pain):Despite the poor quality, leads V1 and V2 have progressed to meet frank STEMI criteria. Cardiology at bedside upon patient arrival andcancelled “Code STEMI”,despite the EM provider ' s concerns.Initial troponin (the assay is Troponin I with reference range 0-0.045 ng/mL):<0.015 ng/mL.A bedside echo reportedly s...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs