Discussion for 51 Year Old Male: Chest Pain

Here is the conclusion to 51 year old male: Chest Pain. You may wish to review the case.

Here is the ECG again:

 

There is a regular sinus rhythm at a rate of about 70. The QRS is narrow. The axis is normal, at about 15 degrees.

Let's take a look at the constellation of ST changes:

There is ST elevation in leads I, aVL, V2-V6. There is slight ST depression in III and aVF (and arguably in lead II) with ugly looking T wave inversions. Some of you also noted the suspicious looking Q waves in III and aVF.

Pericarditis and Early Repol were put forth as possibilities. Remember though, that neither of those will have reciprocal changes (excepting myocarditis, which may present as STEMI). Here, we have reciprocal changes inferiorly. If you were inclined to be thinking about STEMI mimics in this case, those changes should put ischemia at the top of the list.  In addition, as some of you pointed out, the ST changes do not look like Early Repol, and the amount of ST elevation here is alarming.

The crew in this case, along with the physician, decided this was STEMI. The patient was given Heparin, ASA, anti-emetics, and Morphine. His condition improved enroute, and his BP climbed to 124/75.

Upon arrival at the hospital, he was taken directly to the cath lab. There was a complete blockage of the LAD.

 

Here is the cath lab image showing the blockage:

Here is the image after revascularization:

 

I don't know about you, but I always find these images amazing. Fortunately, our patient was discharged from the hospital to cardiac rehab a few days later. He was expected to recover nicely. 

Enjoy the holiday!

 

 

 

 

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Comments
Ivan Rios
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
Thanks for writing Tyler. They are the same thing. Strain pattern is just the result of increased pressures against the ventricles which alters the way repolarization occurs from epicardium to endocardium. Similar to stepping on a puddle of water. Your show spreads the water away from the area of pressure. The ST segment is slightly…
2014-12-17 18:44:24
Tyler
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
Can you explain how these ST segment and T wave changes can be differentiated from right strain pattern?
2014-12-17 18:18:25
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2014-12-17 17:26:42
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