Active chest pain. Fake? or Inferior OMI? Hyperacute T waves?

Written by Pendell Meyers

A middle aged man called EMS for acute chest pain.

EMS recorded this ECG during active symptoms and transmitted it to the ED:

I had no information when I was shown the ECG. I said "Not OMI. Some probably thought the inferior leads showed findings of OMI, but that's a fake." Others probably thought lead V4 has a hyperacute T wave. But these T waves are asymmetric and not "fat" enough. 

I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 mm of STE in II and III, or III and aVF, or V4 and V5, so some might say it fulfills STEMI criteria (remember, the interrater reliability of STEMI criteria is poor as shown in references below):

McCabe et al. Physician accuracy in interpreting potential ST-segment elevation myocardial infarction electrocardiograms. Journal of the American Heart Association 2013;2:e000268.

Carley et al. What’s the point of ST elevation? Emerg Med J. 2002;19:126-128.

Tandberg et al. Observer variation in measured ST-segment elevation. Ann Emerg Med. 1999 Oct;34(4 Pt 1);448-52.

The Queen of Hearts is also able to see that it is not OMI:

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: https://bit.ly/omi-queen-form

Code STEMI was activated for perceived inferior STEMI.

He was taken directly to the cath lab where no culprit lesion was found. He had 50% stenosis of the LAD which was deemed not culprit, and all other vessels were normal. No intervention.

Initial high sensitivity troponin I less than 6 ng/L, as was a second troponin after cath. None further were ordered.

Echo was completely normal.

Some prior ECGs were available for comparison:

Prior 1:

Prior 2:

Here is his post cath ECG:

Post Cath:

I showed all three of these ECGs to QOH, she said NOT OMI with high confidence on all three.

Learning Points:

False positive STEMI activations are unfortunately common. Expert training and hopefully soon AI such as QOH may help reduce false positive activations and improve interrater reliability.