Sweating and nausea while going home from a party

The rhythm is irregularly irregular with no discernible P waves, which is diagnostic for atrial fibrillation. Atrial flutter would show regular sawtooth baseline activity, typically at about 300 per minute, with grouped or variable ventricular responses. Sinus tachycardia with artefact would still show P waves preceding each QRS at a constant interval. Multifocal atrial tachycardia requires at least three distinct P-wave morphologies, and there are no P waves here at all.

There is convex ST elevation of about 3 mm in leads II and aVF and about 2.5 mm in III, with reciprocal ST depression in aVL. This distribution is an acute inferior STEMI until proved otherwise and demands activation of the primary PCI pathway. Pericarditis typically causes widespread concave ST elevation without a reciprocal territory. There is no voltage criterion for left ventricular hypertrophy, and the QRS is narrow without the peaked T waves or broadening of hyperkalaemia.

The inferior leads now show Q waves that were absent on the arrival tracing, the ST elevation has largely resolved, and deep symmetric T-wave inversion has developed in II, III and aVF. This combination is the expected evolution of a reperfused infarct. Re-occlusion would show persistent or worsening ST elevation, not resolution. The chest leads are unremarkable, with nothing to suggest posterior involvement, and pericarditis does not produce the focal Q waves and territorial T-wave inversion seen here.

The strip shows AF at baseline, then a run of about seven broad, regular complexes at roughly 165 per minute lasting approximately 2.5 seconds, which terminates spontaneously and AF resumes. This is non-sustained monomorphic VT, defined as three or more consecutive ventricular beats lasting fewer than 30 seconds. AF with aberrant conduction would remain irregularly irregular, and torsades de pointes would show the characteristic rotating QRS axis. The run is too short to be classified as sustained VT.

Non-sustained VT in the first 24 to 48 hours after reperfusion is common and is not by itself an indication for antiarrhythmic drugs or an ICD. The 2022 ESC ventricular arrhythmia guideline advises against prophylactic antiarrhythmic drugs other than a beta-blocker in this setting. The correct response is to correct potassium and magnesium if abnormal and to prescribe a beta-blocker if no contraindications are present. Repeat angiography is reserved for signs of re-occlusion, and in this case, no clinical signs or ECG suggestive of re-occlusion is present.

Q waves persist in III and aVF, the ST segments are now isoelectric, and the inferior T waves are flat to shallowly inverted. This is the chronic appearance of an established inferior infarction. There is no persistent ST elevation to suggest aneurysm formation, and no acute ST changes to indicate a new ischaemic event. The tracing is not normal because the inferior Q waves and T-wave changes are pathological, even though the patient is well.

A patient with AF who needs long-term anticoagulation and has just had a stent needs both protections, but not all three drugs for long. AUGUSTUS showed that apixaban with a P2Y12 inhibitor, usually clopidogrel, and without aspirin caused less bleeding than regimens with a vitamin K antagonist or aspirin, without a significant difference in ischaemic events. Stopping the anticoagulant leaves the stroke risk of AF untreated, and an anticoagulant alone is not the usual plan in the first year after stenting.