Chest Pain in an Adult Male With an Ominous ECG

William Brady, MD

Can you discern the anomaly in this patient's ECG? What clue(s) does it provide to the underlying pathology?

A 47-year-old man with no previous medical history called 911 complaining of chest pain; EMS treated the patient with aspirin and sublingual nitrates and obtained an ECG (Figure1) at 9:50 am. He was transported emergently to the emergency department (ED) with chest pain described as an aching sensation. The pain was associated with nausea, dyspnea, and diaphoresis and had begun intermittently approximately 5 hours before the 911 call that morning. On ED arrival, the patient was ill-appearing with significant diaphoresis. The examination was otherwise unremarkable. An ECG (Figure 2) was obtained at 10:03 am while management continued.

The high-risk findings noted on the ECG in Figure 2 include which of the following:   

A. ST-segment elevation in lead aVr.

B. Prominent T waves in the right to mid-precordial leads.

C. ST-segment depression in the right to mid-precordial leads.

D. All of the above.

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