Is the diagnosis STEMI or non-STEMI? #ECGChallenge
The present case appears in the journal Circulation. A 60-year-old male with a history of dyslipidemia and smoking habit presented to the emergency department with oppressive chest pain and diaphoresis, which had been persistent for 2 hours. When a 12-lead ECG was obtained, his pain was constant but less severe.

What is the suspected diagnosis ST-segment elevation myocardial infarction or non–ST-segment elevation myocardial infarction? What is the culprit artery?

The feature of the initial ECG was upsloping ST-segment depression at the J point continuing into positive symmetrical T waves in leads II, III, aVF, and V4 to 6, coupled with ST-segment elevation in lead aVR. The emergency physician did not recognize the ECG finding as an ST-segment elevation myocardial infarction equivalent and started initial treatment for non–ST-segment elevation myocardial infarction STEMI, including aspirin and intravenous administration of isosorbide dinitrate and unfractionated heparin.

Although symptoms were getting better after the treatment, his pain did not disappear completely. At 10 hours after arrival, coronary angiography was performed, which revealed occlusion of the proximal site of the dominant right coronary artery (RCA) and Rentrop Grade 2 collateral flows from septal branches of the left anterior descending (LAD) artery. After stent implantation, his symptom completely disappeared (Figure 2).

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