This 38 yo male presented with chest pain with activity for 4 days, worse on the day of presentation, and associated with SOB. He has a h/o Renal failure and has a transplant, lately struggling with CMV infection. His exam was negative. Here is the ECG
There is sinus rhythm at a rate of about 100 (faster than normal for ACS). There is T-wave inversion in V1-V3, with some inversion also in lead III.
The patient had an initial troponin of 0.22 ng/ml and an NT-proBNP of 3200 ng/ml. He was diagnosed with NSTEMI and admitted to the hospital on heparin.
Anterior T-wave inversion, when accompanied by T-wave inversion in lead III, especially if tachycardic, should make you think of PE. A simple emergency physician performed bedside ultrasound would have confirmed this. Troponin will not help you in this diagnosis because, when there are T-wave inversions (in my experience), the troponin is positive. (This would make a good study).