This is the discussion for "Snapshot: 64 Year Old Male–Chest Pain".
First, let's talk about the patient presentation.What is concerning is the substernal chest pain, radiating to the shoulder and neck area. While this occurred about 30 minutes after exercise, it did not occur during exercise, so that is somewhat atypical. Still, enough red flags in the history to be very concerned.
Here is another look at the 12 lead:
It is a regular sinus rhythm, at a rate of 65. The PRI is on the long side of normal at 200 ms, and the QRS is slightly wide at just over 100 ms. The axis is normal, and there does not appear to be anything causing secondary ST changes.
The question is, do we see signs of ischemia on this ECG?
This is not an obvious ECG, so as we would expect, many of you said yes, and many said no. Is this a normal ECG? We don't have an old ECG for comparison, but I would say this ECG is not normal.
Let's break it down. What jumps out at me most on this ECG are the morphologies in leads I and aVL:
There is almost 1 mm of flat ST depression in lead I, and a very notable T wave inversion in aVL.
While the T waves look large in leads III and aVF relative to the size of the QRS, there appears to be no ST elevation at this time.
Dr. Stephen Smith, of the famed Dr. Smith's ECG Blog, has written numerous times that depression and/or T wave inversions in aVL will often precede ST elevation in the inferior leads in IWMI.
Also see this recent case by Dr. Amal Mattu for another case on this subject.
Are there any other findings on this ECG that might support these concerns?
There is about 1 mm of ST elevation in V1. Could there be RV involvement?
At the very least, I would be very concerned about a developing IWMI. The patient's discomfort is diminished, but not resolved. His complaints of "indigestion" are common with IWMI, and diaphoresis is another red flag.
Having said that, would I activate the cath lab based on this ECG? I have to say I would probably not activate based on this ECG alone.
I think this ECG is very concerning, but not yet diagnostic. I would certainly acquire serial ECGs and scrutinize the inferior leads for any subtle signs of change.
Dynamic changes would be a clincher. I would also treat with ASA and NTG, and would divert to PCI center if any changes in the ECG evolved.
This being a "Snapshot" case, we do not have follow up on this patient, or repeat ECGs.
We run into this in the field often. The spectrum of ACS is far and wide, and we are often presented with borderline ECGs.
I think the best course is to treat based on what is best for the patient, and do serial ECGs!
Thanks for all of the insightful comments on this case!
Any additional thoughts?