This is a 71 year old man with a history of hypothyroidism, but otherwise healthy. He developed substernal chest pain while exercising, associated with nausea and dizziness, and came to the ED still having chest pain.
+ EKG Interpretation
Dr. Ohlbaum's Explanation
There are P waves before every QRS, and QRS after every P - nothing extra and nothing missing. The rate is 72 so it is normal sinus rhythm. The P waves are normal in appearance. The QRS is narrow, the axis is normal and there are no pathologic Q waves.
But what about the ST’s?
There is ST depression of greater than 2 mm in V2-V6 but there is ST elevation in V1 and AVR. The ST depression in the precordial leads raises the question of POSTERIOR injury but posterior leads were recorded and there was no ST elevation in the posterior leads. In this setting, with acute chest pain, ST depression in multiple precordial leads along with ST elevation in V1 and AVR is strongly suggestive of left main or proximal lad occlusion.
The EKG was repeated in about 20 min and look at the next page to see what happened. Within just a few minutes he developed ST ELEVATION across the precordium. The patient was sent emergently to the cath lab and had 2 stents placed in his LAD.
Post-cath, he is doing well.