3/19/2023 0 Comments Sr lad borderline ivcdGranted, reciprocal ST depression is not always present with OMI - and it is possible to have OMI superimposed on a baseline tracing of early repolarization … This is the reason access to Echo in the ED at the time of symptoms is so valuable. Additional ECG features against acute OMI - are how generalized the ST elevation is, and the lack of reciprocal ST-T wave depression.In contrast - T wave inversion at the same time as there is ST elevation is common with acute infarction, and may be seen in some types of repolarization variants. With the typical evolution of acute pericarditis - ST segments first return to the baseline before T wave inversion occurs. An additional ECG feature against the diagnosis of acute pericarditis is the finding in lead V2 of beginning T wave inversion at the same time that there is still significant ST elevation in this lead ( BLUE arrows within the blue rectangle in Figure-1 ).Such historical information can sometimes prove invaluable in suggesting when chest discomfort might be the result an arrhythmia. It would be interesting to know more about the nature of this patient’s chest pressure and palpitations - including whether both started at the same time, whether both were ongoing in the ED, and whether the patient was aware of when he had a regular vs irregular heart rate. Often overlooked is awareness that new-onset arrhythmias ( including faster SVT rhythms, as well as slow AFib ) may present to the ED as chest discomfort. Carmichael - “sudden onset of heart palpitations and chest tightness at rest” is not a typical history for acute pericarditis. Was QRS amplitude equally large as it is here on the prior tracing? As a result, the amount of ST elevation relative to QRS amplitude in a given lead is proportionately not so excessive. But QRS amplitude in leads V3-through-V6 is also dramatically increased ( off the page in lead V4, and overlapping neighboring leads in V3, V4, V5). Clearly, the amount of ST elevation seen in Figure-1 is marked ( at least 4mm in lead V3). Change in any of these features complicates judgment about serial differences. While impossible to comment on this comparison ( since we are not given the prior ECG) - caveats to be aware of that may affect lead-to-lead comparison of serial tracings, are the need to make note of any change in: i ) frontal plane axis ii ) in R wave progression and, iii ) in QRS amplitude in the various leads. Cardiology later thought there was no significant change between the 2 tracings. The principal factor that prompted cath lab activation was concern that the ST elevation in Figure-1 was significantly increased from a prior ECG that showed early repolarization.
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