Hypotension, chest pain, and precordial ST depression maximal in V3. Is this OMI?

One of my partners showed me this ECG of a 60-something male with a history of MI and stent who was hypotensive with chest pain, and asked, "Steve, should I activate the cath lab?"

What do you think?

Normally, a patient with coronary disease, chest pain, and maximal ST depression in lead V3 has posterior OMI and, yes, the cath lab should be activated.  But one should always be skeptical of ACS when vital signs are abnormal.  If there is tachycardia, hypotension, hypoxia/respiratory failure, I am always suspicious that the ECG findings are due to supply demand (subendocardial) ischemia (i.e., Type 2 MI if troponins have a rise and/or fall).  

The ECG only diagnoses ischemia (subendocardial or transmural), NOT the etiology of the ischemia.

If there is tachycardia, hypotension, or both that are a result of ACS (rather than the cause of ischemia), then the hypotension/tachycardia are due to poor LV function or valve disorder.  So a bedside echo should help you make the distinction.

This patient had hypotension.  

My response was this: "There is definitely ischemia. But is the ischemia caused by the hypotension? Or is the hypotension caused by the ischemia? Let's go evaluate the patient together." 

So we did a bedside echocardiogram, and the patient had a hyperdynamic function with the LV completely collapsing with each beat. The inferior vena cava was collapsing as well.    The BP was 80/40 without tachycardia and the patient did indeed complain of chest pain.  He had been found on a bus not feeling well. 

PMCardio Queen of Hearts AI Model always asks:

In this case, if you answer that the clinical scenario is a good one for ACS, then she diagnoses "STEMI/STEMI equivalent"

If you answer that it is not a good clinical context, then she answers like this ("Signs of STEMI or equivalent in a patient outside the intended use population"): 

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We recorded a posterior ECG (V4-V6 are now V7-V9) on the back:

V4-V6 = V7-V9

Notice that there is ST depression in V7-V9, which is what you expect with subendocardial ischemia because the subendocardial ischemia is global and circumferential.

 

The case was a complicated medical case, and the hypotension resolved with both fluids and norepinephrine.

After resuscitation, this ECG was recorded:

Then the patient then had a wide complex tachycardia on the monitor, so another 12-lead was recorded:

This is Ventricular Tachycardia (VT)

 

Troponins

So this is a type 2 myocardial infarction 

Because of the episode of VT, the patient underwent angiogram (otherwise, there would not have been an indication for angiogram):

Angiogram:

Impression and recommendation: Patent proximal LAD stents with 50-60% stenosis of the ostial-proximal Cx, similar to what is described inthe prior angiogram report of in 2023.

So there is no acute coronary syndrome. 

Formal echo:

Small left ventricular cavity size, borderline increased wall thickness, and normal LV systolic function.

The estimated left ventricular ejection fraction is 60%.

No regional left ventricular wall motion abnormality.

The patient was offered an ICD for unexplained ventricular dysrhythmia, but he refused it.