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There is ST elevation in I, II and aVF (i.e. missing out III) and V5 and V6 (and a hint in V4). There is apparent ST depression in aVR, but as some of you point out, this actually represents PR elevation. Of note, III is NOT elevated, which makes an inferolateral STEMI pretty unlikely. One might also expect some ST segment depression in aVL, and clearly there is none. As mentioned in one comment, there is likely to be left atrial abnormality with an asymmetrically bifid P-wave most marked in II. The first TnT was 16….now what? Do you activate the cath lab? Is it clearly pericarditis, or could it be STEMI? Give me a plan…

the underneaths of EM

This 53 year old man is an ex-smoker, with HTN well controlled by a single agent.
He presented to the ED under duress from his wife and GP with intermittent atypical pain which is sometimes worse with exertion, has a slight pleuritic variation, and radiates to shoulders. He mentions a more severe pain 2 days ago lasting a couple of hours with onset at rest. This was preceded by about three weeks of occasional slight exertional dyspnoea and chest tightness.
This is his ECG with mild residual discomfort:

What are your thoughts?

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About dreapadoir

Emergency Physician, author of Emergency Medicine blog, photographer at
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2 Responses to Previous Post

  1. keeweedoc says:

    Plan, more Hx, Exam. “weird ST changes, atypical pain”
    give him some good pain relief.
    peon echo looking for pericardial fluid?
    His ECG earns him a look over by cardiology, they can decide about cath lab ect.
    sorry i know its a cop out but prob what i would do.

  2. Pingback: The LITFL Review 073

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