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.

YOU TOO CAN HAVE 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.

This is for the version housed on Telegram:

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

You can get the full PM Cardio app here if you live in the UK or EU (or say you do upon registration):

https://qrco.de/bebW8d