Dr. Josu Abecia Valencia, from Spain, asked me my opinion on this case.  He has a great Spanish language blog.  You can find this case in Spanish at his blog here: https://urgenciasbidasoa.wordpress.com/2015/11/16/caso-201-varon-de-35-anos-con-dolor-toracico-de-10-horas-de-evolucion/

He gave his permission for me to post it here.

A 35 year old complained of typical substernal chest pain:

What do you think? My opinion is below. Notice the computer reads early repolarization.

Here is my response:

Dr. Abecia,

This is highly suspicious for LAD occlusion, though not diagnostic.

Have you used my formula?

ST elevation at 60 ms after the J point in lead V3 = 4 mm

computerized QTc = 405

R-wave amplitude in V4 = 14.5 mm

Formula value = 23.9, which is > 23.4 which is pretty specific for LAD occlusion.

I would do frequent serial EKGs, every 15 minutes, for several hours.

I would do an emergent formal contrast echocardiogram.

If still non diagnostic, consider immediate angiography.

What was the outcome? 

Here is the outcome (slightly limited because I don’t read Spanish very well):

Time zero: Troponin T drawn, returns later at 43 ng/L (= 0.043 ng/mL, slightly elevated)

Serial EKGs unchanged.

Thoughts: myopericarditis vs. early repolarization vs. possible MI

Time 5 hours: Troponin T returns at 151 ng/mL.

Still thinking myocarditis

Time 11 hours: Troponin T returns at 350 ng/mL

Echo shows EF of 67% and no Wall Motion Abnormality

But symptoms persisted, and with the positive troponin, they sent him for angiogram.  Here are the results:

Occlusion of the very distal LAD.  So in this case, it was a small infarct territory. The thrombus was suctioned out and it was stented. Symptoms resolved.

The formula to differentiate benign ST elevation from LAD occlusion worked perfectly, even though it was a small anterior MI.  It outperformed serial ECGs and formal echocardiogram.

One might argue, with good rationale, that such a small MI can wait until the next day for angiogram.  I will not oppose the argument strongly, but the patient did have ongoing chest pain that was relieved by intervention.