A 63 year old male had chest pain and syncope after playing hockey (this is Minnesota). A prehospital ECG showed inferior ST elevation and the cath lab was activated by paramedics from the field. Initial BP was 96/60 with a pulse of 65. While waiting for the cath team, an ED ECG was recorded.
This is an obvious inferior STEMI. However, the computer algorithm read "ST elevation with normally inflected T-waves, probably early repolarization. Marked ST depression, probable subendocardial ischemia."
Just remember: if it can be so wrong in this case, then it can also be wrong in the cases you may miss.
There was no right sided ECG available, but a bedside ED echo showed good LV fct, a very large and poorly functioning RV, and a full IVC, all indicative of an RV MI. Volume loading improved blood pressure.
Immediate cath confirmed a very proximal RCA occlusion.
A 67 yo male with h/o mechanical aortic valve and h/o MI stopped taking his coumadin months ago due to depression. In the last couple weeks he has had some CP with exertion. On the day of presentation he had the onset of CP 5 hours previous.
3:01 PM. Read by computer as "nonspecific ST and T wave abnormality"
There is ST elevation of 1 mm in at least 2 inferior leads, and reciprocal ST depression and T-wave inversion in aVL. There is also some ST depression in V2 and V3; any ST depression in these leads is abnormal. This is diagnostic of inferior posterior STEMI.
There was some disagreement about intervention, partly because of the possibility of an emoblism from the valve, and after aspirin and heparin, the patient had some resolution of symptoms, so he underwent a second ECG 1.5 hours later.
The next day, cath revealed an embolism in OM-1, 100% occluded. Peak troponin I was 22 ng/ml. The ECG showed increased T-wave amplitude in V2 and V3, which I have noticed frequently in reperfused posterior STEMI and call "posterior reperfusion T-waves."