What does the tracing show?

Anterior ST-elevation myocardial infarction

Inferior ST-elevation myocardial infarction

Which feature on the paper separates it from a territorial occlusion?

No reciprocal depression in any lead except aVR

The ST elevation is concave rather than convex

The T waves stay upright in the elevated leads

Echocardiogram, anti-inflammatory treatment and admission

Thrombolysis here, given the distance to the PCI centre

Discharge on anti-inflammatories with a follow-up appointment

Transfer to the PCI centre for immediate angiography

A pericardial effusion large enough to compromise filling

The recording gain has been halved

An extensive infarct with loss of R-wave voltage

Hyperinflated lungs damping the voltages

Sharp central chest pain for a day, worse lying flat

Fit and well, no medication. A week of sore throat, aches and fever that was settling until the chest pain began. Sent in by the university health service. The nearest primary PCI centre is ninety minutes away.

Stage 2 of 2

Eighteen hours later he is breathless sitting still, cool at the fingers, with a blood pressure of 92/68 and a jugular venous pressure to the ear lobe. The heart sounds are quieter than they were. This tracing was recorded as the medical registrar arrived.

Tracing 2 of 2 for the quiz “Sharp central chest pain for a day, worse lying flat”. — Twelve-lead the following morning, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 122
SpO₂ (%): 96
Respiratory rate: 24
Temperature (°C): 37.6
Systolic BP (mmHg): 92
Diastolic BP (mmHg): 68

What has happened?

AThe recording gain has been halved Your answer
BAn extensive infarct with loss of R-wave voltage Your answer
CA pericardial effusion large enough to compromise filling Correct answer Your answer
DHyperinflated lungs damping the voltages Your answer

Sharp central chest pain for a day, worse lying flat

The case

On arrival

Bloods

Observations

Diagnosis

Discussion