35 yo woman with LAD occlusion manifesting with only hyperacute Ts and inferior ST depression

A 35 yo woman had the sudden onset of epigastric pain, more severe and different from her usual acid-related pain. She presented ambulatory. She had an ECG ordered by the triage nurse. The patient and the ECG were placed in a far-away room.


The computerized ECG read was
"Minimal ST depression, inferior leads" and
"ST Elev, Probable normal early repolarization pattern."

This ECG is diagnostic of STEMI: the T-waves in V2 and V3 tower over the entire QRS. As described in 3 previous cases, inferior ST depression is due to high lateral STEMI (see these posts http://hqmeded-ecg.blogspot.com/2010/08/st-depression-does-not-localize-2-cases.html ,
http://hqmeded-ecg.blogspot.com/2009/01/st-depression-limited-to-inferior-leads.html )

Early repolarization always has prominent R-waves in V2-V4. This is not early repol.

Because of a variety of issues, the physician did not see this ECG immediately. Had the computer read "ischemia" or "AMI", the tech would have brought it immediately to his attention. He did not rush to see it because it was a 35 year old woman with atypical symptoms. When he did see it, he recognized STEMI immediately.

The next ECG showed anterior Q-waves. She did go to the cath lab with some delay and had an ostial LAD occlusion that was opened. She had a subsequent EF of 50%.

• Anyone, of any age or sex can have MI.
• Do not trust the computer.
• You must read the ECG yourself.
• Have a system to review all ECGs that have been recorded.

Earlier posts on early repolarization use the application of a regression equation to differentiate early repol from anterior STEMI. See these posts:

I have also derived a simpler rule which is undergoing peer review right now
If 2 of 3 of these are positive, then it is anterior STEMI over early repol with a sensitivity and specificity of 90%
1) R-wave in V4 <> 392 ms
3) ST elevation at 60 ms after the J-point > 2 mm