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Diffuse ST depression, and ST elevation in aVR. Left main, right?

Dr. Smith's ECG Blog

This ECG was recorded on a middle-aged male with sickle cell disease and diffuse pain. found that such ECG findings only represented left main ACS in 14% of such ECGs: Only 23% of patients with the aVR STE pattern had any LM disease (fewer if defined as 50% stenosis). Ischemia b. ST depression: is it ischemia?

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What does the ECG show in this patient with chest pain, hypotension, dyspnea, and hypoxemia?

Dr. Smith's ECG Blog

The flutter waves can conceal or mimic ischemic repolarization findings, but here I don't see any obvious findings of OMI or subendocardial ischemia. The rhythm is 2:1 atrial flutter. The QRS is around 100 msec wide (narrow), but with very abnormal morphology including a large R-wave in V1, deep S-wave in I, R-wave in aVR.