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Department of Internal Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Suite 2-76, 1825 Eastchester Road, Bronx, NY 10461, United States
An 80-year-old woman with a history of hypertension, prediabetes, chronic kidney disease
(stage 3b), and a remote ischemic stroke without residual deficits presented to the
emergency department complaining of several hours of epigastric discomfort and malaise.
An electrocardiogram (ECG) performed at triage revealed normal sinus rhythm with >1
mm ST elevation in leads V4-6 and lead 1, reciprocal ST depression in aVR, and Q waves
in V1 and V2 (Fig. 1). The troponin I was elevated to 1.66 ng/mL (reference range <0.03). The patient
was loaded with aspirin and ticagrelor and taken directly to the cardiac catheter
lab. Left-sided heart catheterization revealed embolic-appearing occlusions of the
distal apical left anterior descending (LAD) artery and a distal superior branch of
D1, which were not amenable to percutaneous coronary intervention (Fig. 2). She was transferred to the medical telemetry unit for further monitoring.
Figure 1Admission electrocardiogram. Normal sinus rhythm with >1 mm ST elevation in leads
V4-6 and lead 1, reciprocal ST depression in aVR, and Q waves in V1 and V2.
