Perplexing Electrocardiogram in a 50-Year-Old Male with Chest Pain

A 50-year-old male chronic smoker and diabetic presented to the emergency department with complaints of retrosternal chest pain for 3 hours duration. He did not give any history of angina or dyspnea on exertion in the past. On examination, his pulse rate was 75 per min, and his blood pressure was 130/80 mmHg. Cardiac and chest auscultation were within normal limits. Troponin I was elevated. Echocardiography showed lateral wall hypokinesia with an ejection fraction of 45%-50% (Video 1). An electrocardiogram was performed, which showed J point depression, with downsloping ST-segment depression in leads V2-V4, prominent upright T waves originating below the isoelectric line. Leads V5-V6 showed downsloping ST-segment depression, and leads II, III, aVF showed T wave inversion (Figure 1). The leads V7-V9 did not show ST-segment elevation. This electrocardiogram (ECG) pattern appeared to be a variant of the ECG pattern described by de Winter et al, 1 de Winter RJ Verouden NJ Wellens HJ Wilde AA Interventional Cardiology Group of the Academic Medical CenterA new ECG sign of proximal LAD occlusion. N Engl J Med. 2008; 359: 2071-2073 Crossref PubMed Scopus (246) Google Scholar in which there is J point depression and upsloping ST-segment depression with prominent T wave, which is typically described in occlusion of the left anterior descending artery (LAD). The patient was advised to undergo an immediate coronary angiography. However, he was not willing to undergo any invasive procedure at that time.