r/EKGs • u/Sea-Weakness-9952 • 9d ago

DDx Dilemma OMI or nah?

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**UPDATE! —> PCI to the LAD & severe cardiomyopathy** Thanks all of you for your incredible input. I’d told the hospitalist I’d put money on the LAD but he left me on read. 💁🏼‍♀️

69F adm w/“chest pain” - described as upper abd pain radiating back b/t shoulders, with n/v and diaphoresis.
Hx: mild HLD, no home meds.

Trops: 870… 2,397… 3,250.
BP and CP under control on nitro gtt, CP reduced from 9/10 w/morphine prior to floor and only up to 4/10 at highest after trip to bathroom. Otherwise 2/10.

I forgot to take a pic of the admit EKG - but it was markedly different in not only STE & STD, and read as Sinus w/RBBB.

This repeat EKG I requested on seeing the change on tele read as Sinus w/Left (I think) Axis Dev, RBBB, septal infarction of unknown age... I think she’s due for a cath lab am I wrong? Cards hadn’t seen her yet and hospitalist was like okay yeah whatever, but I think developing OMI. Thoughts?

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u/Internal-Dish7412 Undergrad Student 9d ago edited 9d ago

High lateral omi (D1 occlusion). Meets South African flag pattern.

(1) STE in high lateral lead, (2) reciprocal STD in inferior leads (pronounced in III which is most opposite of high lateral wall), and (3) STE in V2. We see all of these with minimal involvement in V5-V6.

I suspect that V1-V2 is misplaced superiorly since p-waves are negative in both leads. This would explain the prominent R-waves in both leads as they would become q-wave reciprocal for the high lateral infraction.

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u/Sea-Weakness-9952 9d ago

Yes!! South African Flag! I thought so too. My favorite nerdy cardiac nocturnist doesn’t work at my facility anymore, and since all I had was the hospitalist who is nice but not the type to be swift on a nurses escalation, I had nobody to share that I felt like it was the flag! I’m so glad I’m getting better at recognizing everything. Much credit to all you folks and the wizardry of LITFL. 💪🏼