This is fairly simple straightforward case but it reinforced something for me.
4am standby call for a STEMI. At 4am. Was he shovelling snow at 4am?
Chest pain for 9 hours.
There’s ST elevation in a lot of leads – meaning that it would have to be a really funky anatomic variant to explain such a huge territory of infarction. Either that or multiple acute occlusions in different vessels. That’s a give away.
It’s pretty damn saddle shaped. That’s a give away too.
There’s ST depression in aVR. Hmmm.
That was what got me. Because Amal Mattu is such a good teacher I have a whole differential for ST elevation. And I remember that if there’s ST depression on an ECG with ST elevation then I’ve made my diagnosis – it’s a STEMI.
And at 4am that’s what you remember and what makes you a little uncomfortable calling this as straightforward pericarditis.
You ring cardiology and tell them you think it was just pericarditis but are a little concerned by the ST depression. They come and see the patient and with no wall motion abnormality on echo and no evolution on serial ECGs they call it as pericarditis too.
In pericarditis you’re allowed ST depression in V1 and aVR but nowhere else.
So did Dr Mattu teach us wrong?
Of course not. In fact I was there when he told me at ICEM 2012. I even tweeted it. So much for long term memory…
Check out the full video by Amal below: