For a full discussion of this case, please see this post on Dr. Smith’s ECG blog.
In brief, an older man presented with 5 days of chest pain. Initial hsTnI was 14,114 ng/L and repeat was 12,651 ng/L. Prior to angiography, the following ECG was obtained:
Before looking at angiography, take a moment to consider which vessel you would expect to find as culprit.
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Unfortunately, the angiographer did not appreciate the importance of the ECG and misinterpreted the RCA as chronic total occlusion with LAD culprit. The LAD lesion is indeed quite severe, but it is nevertheless chronic, stable, and not the culprit. The patient received DES to LAD and diagonal with no intervention to the RCA.
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Conclusion: The patient had persistent chest pain post cath. The following day he returned for repeat angiography by a different operator. The second operator interpreted the RCA as acute thrombotic occlusion and wired the lesion with minimal difficulty supporting the acuity. (Chronic lesions are much more difficult to wire.) He placed three overlapping stents restoring TIMI 3 flow.