Here is my response:
“Old MI with superimposed LAD or First Diagonal acute ischemia. Q-wave in V2, aVL suggest old MI, but T-wave is too large in both to be old. Alternative is subacute MI of these vessels.”
This is a 40-something who complained of several 10-20 minute episodes of chest pain over the previous few hours. He had no prior medical history, but is a smoker with a positive family history of CAD. He arrived at 7:30 pain free and had this ECG recorded at 7:32. I will repost it here:
|See above description|
The first troponin was undetectable (cTnT, < 0.01 ng/mL) and he was sent to the observation unit for serial troponins without recording any more ECGs.
Smith comment: this is not acceptable. One should at least perform many serial ECGs to look for either resolution or evolution of these T-waves. Since his pain had resolved and was still gone, one would expect resolution of the large T-waves and minimal ST elevation and this would be diagnostic.
At 8:30 he complained that his pain was returning and another ECG was recorded at 8:42:
The ECG was interpreted as No Change.
At 8:50 he had “seizure like activity” that resolved (probably an episode of pulseless VT) and was moved to the ICU, where he had this ECG:
|Obvious proximal LAD occlusion (STEMI)|
Here is his next 12-lead:
|Ventricular Fibrillation is not supposed to be captured on a 12-lead ECG!|
This is after defibrillation and the patient had a pulse and was awake:
|Slow and sick! Take me to the cath lab!!|
This was recorded just before he was taken to the cath lab:
Here is the angiogram:
|Proximal LAD occlusion|
Here annotated with arrows:
1. Real ECG findings of coronary occlusion can be extremely subtle!
2. Learn to recognize hyperacute T-waves.
3. Learn to recognize down-up T-waves
4. Learn to recognize the reciprocity between aVL and III
5. Troponins are not reliable for diagnosis of early ischemia/occlusion
6. There is still a role for observation!