Chest pain, a ‘normal’ ECG, a ' normal trop ' , and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Written by Jesse McLaren, with comments from Smith and GrauerA 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. ECG was labeled ‘normal’ by the computer (confirmed by the overreading cardiologist) and the high-sensitivity Troponin I was normal at a value of 11 ng/L (Abbott Alinity assay, where normal is<26 in males,<16 in females; this assay is nearly identical to the Abbott Architect high sensitivity assay). So the patient was low risk according to HEART and EDACS scores. Should this patient be discharged home? How about a stress test?       There ’s sinus bradycardia with normal conduction, normal axis, normal R wave progression, and normal voltages. There are biphasic T waves in III/aVF with reciprocal down/up T wave in aVL, and a disproportionately tall T wave in V2. This is diagnostic of inferoposterior reperfusion. Comparison to the old ECG below (from 4 years prior) confirms that all these changes are new (and can ’t be explained by the slight shift in axis in the frontal plane, or lead placement of V2): If these new primary biphasic T waves were in the anterior leads, in a patient with resolved chest pain, this might have been recognized as “Wellens syndrome”, associated with critical LAD stenosis. This would have led to an admission for angiogram regardless of the atypical pain or negative troponin—or could even have led to cath lab activation...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs