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ECG Review-An ECG the Day After

Clinical Scenario: The ECG shown in the figure was obtained from a 51-year-old man who was seen in the office one day following an episode of nausea and near-syncope that occurred following physical exertion. The patient denied chest pain. He was previously healthy. He came to the office at the urging of his wife. In view of this history, how would you interpret this tracing? What would you advise the patient?

Interpretation: The rhythm is sinus and fairly regular at a rate of between 65 and 70 beats/min. All intervals are normal. The axis is approximately 0°. There is no evidence of chamber enlargement. The most remarkable finding on this tracing is the presence of inferior Q waves (that are deep and wide in leads III and aVF). In view of the above history (an "episode" a day earlier, and suggestion by the spouse of patient denial), there are several signs that should make you suspect possible recent (1-day-old) myocardial infarction. These include slight (residual) ST segment elevation in the leads with Q waves and subtle coving of the ST segment in leads III and aVF. Support that these findings are real and probably indicative of recent acute infarction is the presence of equally subtle ST segment depression (reciprocal changes) in leads I, aVL, V₄, and possibly V₅. The patient was urged to admit himself to the hospital. Cardiac enzymes confirmed a large acute infarction that was still in the process of evolving.