Chest pain relieved by Maalox and viscous lidocaine

An otherwise health male in his early 40's presented with "burning" in his epigastrium that radiated to his throat and was relieved with Maalox and lidocaine.  He had an ECG recorded:

Sinus Rhythm.  This was read as normal by the emergency physician and by the computer.  QTc is 400 ms.  What do you think?  See below.

Marquette (GE) 12 SL

There are a few subtle signs of coronary occlusion here.  

First, look at V4-V6.  The T-wave is almost as tall as the R-wave.  This should not be.  Here is a normal relationship:

Second, look at aVL.  It has a massive T-wave compared to the size of the QRS.  There is also a tiny amount of ST elevation but, again, it must be considered in the context of a very small amplitude QRS.

Sometimes the T-wave can appear to be relatively large because the QRS axis is perpendicular to the lead (so the QRS looks small) but the T-wave axis is parallel.  However, here are the two axes:

Finally, look at lead III:

There is minimal ST depression.  Although the T-wave appears also to be inverted, we know from the above graphic of T-wave axis, that there is not an abnormal T-QRS axis (they are nearly equal), which is what defines T-wave inversion.

None of these findings are diagnostic of ischemia, but they should give you a high index of suspicion and prompt serial ECGs at a minimum.

Formula: There is not enough ST elevation in V2-V4 to be applying the LAD/early repol formula, but if it is applied, one gets 1.5 mm of STE at 60 ms after the J-point in lead V3, 400 ms QTc, and 6 mm of R-wave amplitude in V4.  The formula results in 23.43, just above the 23.4 cutoff!

Years later, I sent this to the Queen of Hearts:

The Queen of Hearts PM Cardio App is now available in the European Union (CE approved) the App Store and on Google Play.  For Americans, you need to wait for the FDA.  But in the meantime:

YOU HAVE THE OPPORTUNITY TO GET EARLY ACCESS TO THE PM Cardio AI BOT!!  (THE PM CARDIO OMI AI APP)

If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.  It is not yet available, but this is your way to get on the list.

https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg

The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. He was defibrillated.  



Here is his post resuscitation ECG:

Now the diagnosis is obvious.  Anterolateral STEMI.  
The rhythm is sinus with PVCs that occur after a P-wave but before it conducts.  In V1, it appears to be alternating RBBB and normal conduction with high ST elevation.  However, the 1st, 3rd, and 5th complexes in V1 are PVCs with RBBB morphology.  The 2nd and 4th are sinus with normal conduction with deep QS-waves (not LBBB).  Notice how visible the ST elevation is in the PVCs. 

There was a 100% proximal LAD Occlusion.  He underwent PCI and had a good outcome.

Learning Points:

1. T-wave size must be assessed relative to the QRS amplitude
2. Ischemia comes and goes.  It may incidentally go away with antacids!