A male in his 30's who is an elite athlete with no risk factors for coronary disease had brief epigastric pain followed by brief syncope. He presented to the ED never having had any chest pain or SOB, and with mild epigastric pain.
Here is his prehospital ECG:
The ST segment in V2 has a saddleback morphology. In my experience, a saddleback in V2 has always been a STEMI mimic, not STEMI. So I approach these with great skepticism.
There is an rSR' in V1 and V2, possibly due to right ventricular hypertrophy (given the right axis deviation), but without right bundle branch block (QRS duration is only 102 ms). There is right ventricular conduction delay. The large P-wave in lead II supports right atrial enlargement and possible right ventricular hypertrophy, which may all be affecting the ST segments.
The absence of chest pain in a young healthy male should make you more skeptical of STEMI and suggest a false positive. However, we all know that chest pain is far from universal in STEMI. In a recent study, 14% of men under age 55 do not complain of chest pain with their ACS.
On arrival in the ED, he underwent another ECG:
The cath lab was activated and the patient was taken for angiogram, which was normal. There was a small first diagonal and the angiographer noted that "a ruptured plaque that may have caused a temporary D1 occlusion is not inconceivable."
An echocardiogram the next day was completely normal. Initial Troponin I was 0.058 (99% reference 0.025) and succeeding ones were 0.073, 0.044, and 0.069. This rather random rise and fall suggests false positives, which we have had many of since changing to our new Abbott assay.
Here is his ECG at 24 hours:
This is a tough case and the safe thing to do was done: an angiogram, in order to be certain this was not a STEMI.
Because of some reasonable doubt, it would also have been reasonable, if it could be obtained quickly, to get a stat echocardiogram with high resolution (using contrast (Definity). I think it would have shown normal wall motion all around and saved the patient an angiogram.
Nevertheless, it is good to remember:
1. Saddleback in V2 should make you doubt the diagnosis of anterior STEMI
2. Absence of Chest pain or SOB in a young, healthy male should make you skeptical and lead you to think about seeking confirmation of your ECG diagnosis.
3. The early repolarization/anterior STEMI formula does have false positives and negatives. Accuracy was about 90% (which was far better than ST elevation)
Here is his prehospital ECG:
The ST segment in V2 has a saddleback morphology. In my experience, a saddleback in V2 has always been a STEMI mimic, not STEMI. So I approach these with great skepticism.
There is an rSR' in V1 and V2, possibly due to right ventricular hypertrophy (given the right axis deviation), but without right bundle branch block (QRS duration is only 102 ms). There is right ventricular conduction delay. The large P-wave in lead II supports right atrial enlargement and possible right ventricular hypertrophy, which may all be affecting the ST segments.
On arrival in the ED, he underwent another ECG:
The cath lab was activated and the patient was taken for angiogram, which was normal. There was a small first diagonal and the angiographer noted that "a ruptured plaque that may have caused a temporary D1 occlusion is not inconceivable."
An echocardiogram the next day was completely normal. Initial Troponin I was 0.058 (99% reference 0.025) and succeeding ones were 0.073, 0.044, and 0.069. This rather random rise and fall suggests false positives, which we have had many of since changing to our new Abbott assay.
Here is his ECG at 24 hours:
This is a tough case and the safe thing to do was done: an angiogram, in order to be certain this was not a STEMI.
Because of some reasonable doubt, it would also have been reasonable, if it could be obtained quickly, to get a stat echocardiogram with high resolution (using contrast (Definity). I think it would have shown normal wall motion all around and saved the patient an angiogram.
Nevertheless, it is good to remember:
1. Saddleback in V2 should make you doubt the diagnosis of anterior STEMI
2. Absence of Chest pain or SOB in a young, healthy male should make you skeptical and lead you to think about seeking confirmation of your ECG diagnosis.
3. The early repolarization/anterior STEMI formula does have false positives and negatives. Accuracy was about 90% (which was far better than ST elevation)