The Cath Lab Was Activated, But Something Didn’t Fit

ECG Weekly Workout with Dr. Amal Mattu

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HPI

A 70-year-old woman with CHF, COPD, intermittent atrial fibrillation, chronic pain medication use, and recent poor intake develops sudden dyspnea at rest and is found somnolent and bradycardic in the 30s to 40s. Paramedics obtain a prehospital ECG showing apparent inferior ST elevation and activate the cath lab, but one feature on the tracing makes the receiving physician hesitate before proceeding.

Before watching this week’s workout, review the ECG carefully and consider:

1. 1. What ECG feature seen here in a presumed inferior STEMI should make you step back and consider an alternative diagnosis instead?
   2. What empiric treatment may both stabilize the patient and quickly clarify the diagnosis?
   3. Why might atropine and pacing fail in this type of bradycardia?