On the blindside of the ECG lies critical coronary disease

A 46-year-old man presented to the mobile coronary care unit following acute central chest pain radiating to his left arm at rest. He was seen out of hospital 7 min from onset of symptoms. He had suffered from inferior-territory ST-elevation myocardial infarction (STEMI) 3 years previously, with percutaneous intervention (PCI) to the right coronary artery (RCA). His only risk factor was a family history of ischaemic heart disease (his mother aged 42 years had coronary artery bypass grafting). At first medical contact, he was haemodynamically stable [blood pressure (BP) 112/76 mmHg] and clinical examination revealed no abnormality. Twelve-lead electrocardiogram (ECG) had 1 mm STE in aVR, ST-depression in I, II, aVF, V3–V6 and T-wave inversion in aVL (Figure 1a). Concomitant body surface potential mapping (BSPM), utilizing 80 surface electrodes, revealed high right anterior and posterior STEMIs with reciprocal lateral ST-depression (Figure 1b). …