54 year old male CC: Chest pain – Discussion

This is the discussion for 54 year old male CC: Chest pain.

Once again we see the importance of serial ECGs in the treatment of a suspected ACS patient. The difference between the first and second 12-lead ECG is the key to solving this case.

As you can see, the T-waves become more pronounced in leads V2-V5 (blue) and the ST-depression becomes more obvious in leads III and aVF (red).

When you consider any ECG abnormality you should “consider the company it keeps”.

Without the benefit of the first ECG that provides the baseline, you might be forgiven for thinking the T-waves in the second ECG represent benign early repolarization.

However, with changes on serially obtained ECGs that correspond to new symptoms, the T-wave changes strongly suggest acute developing anterior STEMI.

The reciprocal changes in the inferior leads remove all doubt.


  • Strong work by the medics. At least they didn't pull the old "okay, sign here" and go off on their way. Another good case Tom.

  • Tom B says:

    I agree with you, Adam! One day we will wake up and realize that "human factors" play a huge role, and most likely the primary role, in medical errors.

  • Paul says:

    I don’t know if anyone noticed, but there is actually a noticeable increase in ST-segment height in lead AvR when comparing the first 12-lead to the second. I can’t really tell due to the baseline wander in V1 on the second 12-lead, but the ST-elevation in AvR may actually be greater than the elevation in V1(suggesting occlusion at the LMCA). It is at the very least, of equal elevation.

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