The ECG shows changes suggestive of acute myocardial ischemia, including tall, peaked T waves in leads V2-V4 and possible ST elevation in leads V1 and III. The most important interventions are to give aspirin, heparin, and regular ECGs looking for ST elevation. The man likely needs urgent coronary angiography if ST elevation appears, or angiography soon otherwise, to treat his acute coronary syndrome.

1. A 64 year old man is brought to the ED by friends. He developed
chest pain radiating to the jaw and right arm while playing tennis.
The pain has now been present for nearly half an hour and continues
unabated.
•Describe the ECG
•What are the most important interventions for this man whilst he
remains in ED ?
•What is his likely subsequent treatment ?

3. The ECG shows a number of changes suggesting acute myocardial ischaemia. The T
waves are tall and peaked in leads V2-V4, there is a suggestion of ST elevation in
V1 and III, and biphasic/inverted T waves in leads II and III. Although we
classically look for ST elevation as the signifier of acute myocardial infarction, the
earliest ECG change may be marked T wave peaking. This occurs so early (the first
30 mins) in the infarct that we often don’t see it. This same patient later went on to
develop the classic ST elevation in V1-V4 of an anteroseptal infarct.
The most important issue in this man is to recognise this as an acute coronary
syndrome. In particular make sure he has:
• Aspirin 300mg orally stat (antiplatelet action begins within 30 mins)
• Heparin 5000U IV bolus and infusion to follow
• ECGs regularly (initially every 15 mins) looking for ST elevation
IV GTN and morphine can be given to control his pain but they will have minimal
effect on infarct size and mortality. Clopidogrel or Ticragelor may be indicated but
in this case discuss with cardiology first.
He already meets criteria for coronary angiography. The only real question is the
timing and urgency. Should he develop ST elevation on his serial ECGs then urgent
transfer to the cathlab under a “Code STEMI” protocol is required. Otherwise his
angiography should be soon.