A woman in her 70s with coronary artery disease and diabetes presented to the emergency department with sudden-onset severe chest pain and shortness of breath. Vital signs were unremarkable and the physical examination was notable for lower extremity edema and wheezing. Her initial troponin I level was 0.03 ng/mL (normal level, <0.045 ng/mL). The admission electrocardiogram (ECG) showed normal sinus rhythm with incomplete right bundle branch block (RBBB) and new ST elevations in V2 to V4. Urgent cardiac catheterization was performed revealing an acute 100% lesion of the proximal left anterior descending artery, which was treated with successful balloon angioplasty and placement of a stent. Nonetheless, the patient required placement of an Impella ventricular assist device (Abiomed) for cardiogenic shock. An echocardiogram revealed an ejection fraction of 20% with severe hypokinesis of the anterior and apical walls. The patient was transferred to intensive care and a repeat ECG was performed (Figure).
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Sadek AS, Basil A, Whitman IR. Electrocardiographic Progression of Cardiac Conduction Disease: When So Much Depends on a Fascicle. JAMA Intern Med. Published online August 26, 2019. doi:10.1001/jamainternmed.2019.3547
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