Anterior Wall Changes and Abnormal ECG, UNCONFIRMED!

A 60 yo male with a history of CAD, MI, and HTN presents with retrosternal chest discomfort. He is hemodynamically stable. The prehospital provider obtains a 12 lead ECG.

12 lead ECG interpretation: 

A sinus tachycardia is present, and there are plenty of abnormal ST segment changes to point out. First, there is minimal ST segment elevation in V1, V2, and V3 .The ST approaches 2 mm in V2. In addition, the ST segments have a non-concave, or worrisome, appearance in V4. There is T wave inversion in aVL and downsloping ST segments in lead I. Those ST segments resemble the pattern of "ventricular strain."

Sinus tachycardia, ST segment elevation in the anterior precordial leads, anterior and lateral T wave inversion consistent with ischemia.

12 lead ECG case discussion: 

The paramedic scrutinized the anterior ECG changes and declared a, "STEMI." Though the receiving facility determined that the initial prehospital ECG changes did not meet strict STEMI criteria, the paramedic was clearly advocating for the patient's best interest by electing to transport directly to a cardiac interventional center. Previous ECGs from the same patient reflected prior ST segment abnormalities, and the patient wasd admitted to the cardiology service for further testing. Minor, baseline ST segment elevations in precordial leads in addition to high left ventricular voltage can confound the diagnosis of STEMI. The presence of at least 2 mm of elevation plus the identification of reciprocal change (in the form of ST segment depression) makes the diagnosis of STEMI much more likely. Always remember that serial ECGs are extremely important when dealing with concerning or "borderline" presentations.