A 12 lead ECG showed sinus tachycardia at 112 beats per minute (
Figure 3). Axis and PR intervals were normal. The QRS interval was prolonged (>120 ms), and there was a dominant S wave in V1, a broad monophasic R wave in lateral leads (I, aVL, V5-V6), absence of Q waves in lateral leads (I, V5-V6), and a prolonged R wave peak time (>60 ms) in left precordial leads (V5-6), consistent with an LBBB diagnosis.
6 (
Figure 1) Evaluating according to the modified Sgarbossa criteria, there were no ST segment elevations in the same direction as the QRS vectors in leads V1, V2, V3, and V4 (negative criterion). There were no ST segment depressions in any leads (negative criterion). The ST/S ratio was not less than −0.25 in any leads (negative criterion). In short, this patient did not meet the modified Sgarbossa criteria for an MI. Before laboratory test results were available, the patient was placed on bilevel positive airway pressure after failure to raise oxygen saturation with nonrebreather mask. Furosemide was given intravenously for suspected acute congestive heart failure and fluid overload. A chest radiography showed central vascular congestion and bilateral small pleural effusions (
Figure 4). Laboratory test results showed a white blood cell count of 17,700 K/cmm (reference range,
10 4000-11,000 K/cmm) with a high percent neutrophils at 86.4% (reference range,
10 50-70%). Reflex lactic acid was 2.3 mmol/L (reference range,
10 0.7-2.1 mmol/L). Blood urea nitrogen was 43 mg/dL (reference range,
10 8-20 mg/dL) and serum creatinine was 1.67 mg/dL (reference range,
10 0.70-1.30 mg/dL) with estimated glomerular filtration rate of 39 mL/min (reference range,
10 90-140 mL/min). B-type natriuretic peptide was elevated at 27,218 pg/mL (reference range,
10 <100 pg/mL), confirming congestive heart failure; serum troponin I was mildly elevated at 0.187 ng/mL (reference range,
10 <0.04 ng/mL), suggestive of myocardial injury. Nitroglycerin, aspirin, and clopidogrel were administered for suspected myocardial infarction. After consultation with the receiving hospital, the patient was started on a heparin drip and transported to a tertiary center for advanced cardiac work-up and management. The patient was taken directly for cardiac catheterization, at which point an acute coronary occlusion was confirmed.