This is the conclusion to 58 year old female CC: Chest pain.
Let's take another look at the 12-lead ECG.
Remember, ST-elevation needs to be explained, and if the etiology involves myocardial infarction, urgent time-sensitive decisions need to be made.
In this case, we have ST-elevation in leads V1-V5, which suggests the possibility of acute LAD occlusion.
This finding is all-the-more concerning when we consider that R-wave progression is poor (absent) and the QTc is prolonged at 481 ms. Both of these findings point away from benign early repolarzation.
It's all too easy to dismiss a patient like this as having a mere anxiety attack. We need to keep an open mind and careful not to stimatize our patient.
How else might we explain the ST-elevation in the precordial leads?
We can consider the possibility that the ST-elevation is "old" or from a previous MI (the ECG finding we sometimes refer to as left ventricular aneurysm).
However, when we measure the T/QRS ratio we see that the T-waves are far more acute-looking than we would expect with left ventricular aneurysm.
The T/QRS ratio is 0.45 in lead V2 which is way above our threshold of 0.36.
Another possibility that some of you very astutely pointed out in the comments is Tako-Tsubo (or Takotsubo) Cardiomyopathy. I found that suggestion particularly interesting because it does seem to tie together all of the elements of this case.
In this case, the treating paramedic wasn't sure what to make of the ST-elevation in the precordial leads so he transmitted it over the LIFENET to the receiving hospital.
The two ED physicians weren't sure what to make of it either, but to be on the safe side they called a "Code STEMI".
The following 12-lead ECG was captured en route to the hospital.
The differences between this ECG and the previous ECG are not dramatic, but if you scrutinize the two you will see that there are differences in QRS, ST and T wave morphology.
By the time the patient arrived in the emergency department her chest pain was completely gone.
After a discussion with the cardiologist she consented to cardiac catheterization.
There was an acute 99% occlusion of the LAD which was successfully stented.
Diagnosis: Acute ST-elevation myocardial infarction.