Serial ECG recordings are essential: paramedic makes a great call!

This case was sent by Andrew, an Intensive Care Paramedic from Melbourne, Australia.


We were dispatched to a female in her 50’s who had been experiencing L) sided, intermittent chest heaviness, radiating to her L) arm for the past ~24 hours. 
She had a past Hx of IDDM, hypertension, high cholesterol and was an ex-smoker. She had called the ambulance today as the pain was more severe and persistent than it had been previously. She had never experienced symptoms like this in the past.
When we arrived, she was c/o 8/10 pain and was mildly diaphoretic, but not looking overly unwell. I recorded this ECG.

I read this as normal

The pt was given 300 mg aspirin and 300 mcg sublingual GTN, with the pain reducing to 5/10.

A few minutes later, her pain then increased to 7/10 and she appeared a bit more diaphoretic. I took the following ECG.
Now there is new ST elevation in V2-V4, with tiny new Q-waves
was concerned with the 1mm STE she developed in V2 and 0.5mm in V3-V4 as well as the presence of small Q waves. The T waves also looked bigger and fatter to me when compared to the initial ECG. Unsurprisingly, the computer interpretation failed to recognize these changes.
Her pain then reduced to 3/10, which prompted me to record another ECG. 
All the segments have returned to isoelectric, the Q waves and T waves also appear smaller and are consistent with the initial ECG.
Based on the presence of dynamic ST segments and T waves, I chose to bypass two smaller hospitals and transport her to a PCI centre with a STEMI notification. 
Throughout the transport to hospital, there was no change in the ECG from #3, but upon arrival at ED, she was pale and profusely diaphoretic, and still complained of 1/10 pain post IV analgesia.
The ED consultants were skeptical of my read.
About an hour after our arrival, she became agitated and hypotensive and the final ECG was taken.
Obvious Anterior STEMI
The pt was taken to Cath Lab where her LAD was stented. There was minimal rise in her troponin and CK and she was doing well the following day.

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