Methodist ECG Lesson: with a little help from Amal Mattu

So... here is a real case from Methodist. Try to figure out what is wrong...

The case is a young (40's) male with a history of pulmonary sarcoid and diabetes presenting with chest pain.

Trouble finding the abnormality? So did I. Thats why I emailed Dr. Amal Mattu, the EM ECG guru.  Luckily enough, he graciously wrote back with his own interpretation:

Jordan,
Here are some thoughts.
The tall R wave in aVR is a bit unusual, so the first thing I'd do is to recheck to make sure the leads were placed correctly. Assuming the leads are placed properly, I'd interpret as follows.
Normal sinus rhythm, left anterior fascicular block. There are Qs in V1-V2 and poor R wave progression so there's evidence of an anteroseptal MI of uncertain age. There's also loss of tall Rs in the lateral V leads (V4-6 normally have taller R waves than S waves), and that could also indicate evidence of anterior MI of uncertain age. 

There are concerns for acute ongoing ischemia: 
1. The initial portions of the T waves in V2-4 are very straight, and although this could possibly be normal for this patient, I'd want to get an old ECG to see if that's old; or I'd like to get some serial ECGs to see if anything evolves.
2. There's slight STE in V2, and maybe in I + aVL (with T wave inversions in those leads, which could be ischemia). I'm a bit more worried about the STE in V2, given that there's a Q wave and also straightening of the initial portion of the T wave.

We must bear in mind that the ECG must be interpreted in the context of the patient's symptoms. I have seen ECGs showing many of these findings in asymptomatic patients and it's just the patient's baseline. On the other hand, if this patient is acutely having some concerning cardiac symptoms, I would call this ECG an acute STEMI.

So......what's the answer?

Thanks for sharing the case. 
Amal

 

Here is the conclusion: 

This patient spit out a troponin in the ED of 53. He was actively having chest pain and was brought to the cath lab. These are the cath results: 

IMPRESSIONS: -- Significant two vessel coronary artery disease with 99%

proximal LAD and 90% OM2 stenoses with left to left and right to left

collaterals.

-- Status post successful mechanical thrombectomy and PCI of the proximal LAD

with a 3.0 mm x 15 mm Integrity bare metal stent. The first diagonal branch

acutely closed post stent delivery and was unable to be reopened.

-- Status post successful PCI of OM2 with a 3.0 mm x 26 mm and a 3.0 mm x 9 mm

Integrity bare metal stents.