- HPI: 60M with acute chest pain x 30 min, pale & diaphoretic
- Cath: Large proximal LAD thrombus with TIMI-1 flow. It was a wraparound LAD, explaining the inferior ST elevation with reciprocal ST depression in aVL (the opposite of what you expect with a proximal LAD occlusion). It was stented.
- 4V formula score: 18.38 (>18.2 is the most accurate cutoff suggestive of LAD OMI)
- Key ECG: There is upward concavity. There is no STD. There are no Q-waves. There is no terminal QRS distortion. So early repolarization is a possibility, however, there is very suspicious STE in III and aVF, with STD in aVL. This makes the ECG nearly diagnostic of ischemia, though if it is LAD occlusion, there should be ST depression in III, so it is a bit confusing. Unless you consider a wraparound LAD.
- Link to full case @ Dr. Smith’s ECG Blog: 2017-06-21