Transient Inferior Injury Seen Clearly by Comparison Between First and Second ECGs. Also an example of a Right Ventricular "Pseudoanteroseptal" MI

A middle-aged woman with a history of hypertension presented with typical chest pain.  Her BP was 160/80.  Here was her presenting ECG, with chest pain:

There is no definite evidence of ischemia here.  There is, however, a very suggestive finding: T-wave inversion, with some ST depression, in lead aVL and some ST depression in lead I.  This suggests inferior MI.  There was no old ECG in her records for comparison.

The pain improved with Nitroglycerine.  Creatinine was 4.3.  She underwent another ECG at 6 hours (when she was pain free):

The T-waves in leads II, III, and aVF are now significantly smaller, the reciprocal ST depression is less, and the T-wave in aVL is upright.  The T-wave in I has also changed.

The troponin peaked at 16 and there was a "probable" inferior wall motion abnormality.

Because the patient had advanced renal insufficiency and because there was "no evidence for a current of injury on her presenting EKG's", a non-invasive approach was undertaken.  While undergoing a stress test as a part of the non-invasive approach, she developed chest pain and hypotension and had this ECG:

There is sinus bradycardia with massive inferior ST elevation, as well as ST elevation in V1-V3, diagnostic of inferior and right ventricular (RV) STEMI.  When there is ST elevation due to RVMI in V1-V3 in a left sided ECG, it is also called a "Pseudoanteroseptal MI".

She went immediately to angiogram and had occlusion of the RCA at the ostium.

Looking back, one can see ST elevation in V1-V3 on the initial ECG that is nonspecific, but, in retrospect, is probably due to RV Injury.