Misleading chest pain #1

30 year old man with acute onset chest pain two hours earlier. Radiation to the neck and left arm.

ECG shows ST-elevation V4-V6 with a hint of ST-elevation V2-V3. The morphology leans towards the convex, valley, side. Reciprocal ST depression might be suspected in limb lead III. The patient informs of a fever and diarrhea for the past three days.

Ultrasound of course:

Can you see the regional wall motion abnormality? The inferolateral part of the apex is affected. So how do we proceed? The history and age raises a suspicion of perimyocarditis, but STEMI must be excluded. An emergency percutaneous coronary angiography was performed and showed absolutely fine coronary artery. The first highly sensitive Troponin T 650. In conclusion myocarditis with localized inferolateral RWMA was diagnosed.

See also Amal Mattu’s approach on how to differ myocardial infarction from pericarditis by ECG.


Creeping NSTEMI

35-year-old woman seeking due to exercise-induced chest pain for three days which has now transitioned into constant pain.

ECG on arrival shows ST depression v4-v6.

Repeat ECG after 15 minutes shows regression of the ST-depressions.

The patient has just performed a stress-ECG!

Can you see the regional wall motion abnormality (RWMA)?

In a stepwise fashion, evaluate each region. As a novice it might be difficult to distinguish RWMA from normal myocardium when looking at the heart as a whole. Feel free placing the mouse pointer over the endocardium to look for dynamic changes in the wall thickness. This is referred to as radial contraction.

Systematic review shows RWMA in the apex and the entire lateral wall.

NSTEMI treatment was instituted. Because of persistent chestpain PCI was performed two hours later showing total occlusion of the LCx.