Wednesday, February 14, 2024

A 40-something with 2 hours of new active chest pain and new T-wave inversion

A 41-year-old male who presents to the emergency department with chest pain. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling.  No shortness of breath.  No recent travel. No cough. No cardiac history. 


Here is his ECG:



He had a previous ECG on file, from many years prior:

What do you think?












There is new T-wave inversion in inferior leads and V3-V6.  This is recorded during pain.  The faculty physician thought this is highly likely to be ACS.  


However, most T-wave inversion during pain is nonspecific.  T-wave inversion AFTER resolution of anginal type pain is highly likely to be due to reperfusion.


On occasion, unstable angina can present with reversible T-wave inversion during pain.  When the ischemia is resolved, if there is no infarction, the T-wave can normalize.  This is in contrast to Wellens' syndrome, which involves at least a small amount of infarction (troponin elevation) and in which the T-wave inversion evolves into deeper and deeper T-wave inversion.


See these 2 contrasting cases:

Classic Evolution of Wellens' T-waves over 26 hours


Dynamic, Reversible, Ischemic T-wave inversion mimics Wellens'. All trops negative.

This case directly above was not in the era of high sensitivity troponin.  Unstable angina in the era of hs trop still exists.  I have never seen it with undetectable hs trops, but acute MI is possible after a single initial hs trop below the limit of detection.  


In our study of a single initial hs troponin I below the limit of detection (1.9 ng/L, Abbott Architect), the NPV and sensitivity for acute MI was not 100%, rather 99.6% and 98.8%.  In other words, it is possible for a subsequent troponin to be elevated above the 99% URL when the first one is undetectable, but is very uncommon. I do not think it is possible for a 2nd trop to remain undetectable in a patient then goes on to rule in for acute MI, unless there is a 2nd event. 


I know of no data on unstable angina/30-day adverse events/acute MI after 2 serial undetectable trops.  Unstable angina would be exceedingly rare in such a situation, but still possible.  Acute MI would not be possible unless there was another event. 


Back to this case:


These T-wave inversions do not look ischemic to me.  They look very nonspecific.  When I see a case like this, I am skeptical that the ECG is manifesting acute ischemia or reperfused OMI.  Unless the patient on history and exam clearly looks like he/she is having an acute MI, I am satisfied to wait for the troponin.



Here is the Queen's interpretation:

The Queen agrees.  The Queen does not even know if there is active pain or pain that has resolved.  She only sees the morphology of these T-wave inversions and does not think that they look ischemic. 
In Version 1, if the Queen sees reperfusion T-waves, she calls it OMI.
But in this case, she knows that these are not reperfusion T-waves; she knows that the morphology is nonspecific.
Therefore, she says "Not OMI"

I think this is remarkable that she knows the difference between ischemic T-waves and Non-ischemic T-waves from morphology alone!

She explains here:

I don't think this explanation tells me why she is not convinced by this T-wave inversion.  For most of the leads with T-wave inversion, she just says "OMI - low confidence".  But her overall impression is "Not OMI with High confidence".

Outcome:


All hs troponin I ﹤ 3 ng/L (undetectable).  There was no repeat ECG.  Again, although T-waves can reversibly invert with unstable angina, unstable angina with 2 high sensitivity trops below the limit of detection could possibly occur, but is extremely unlikely.


My impression was correct and so was the Queen's: this is NOT ischemic T-wave inversion.


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