The Patient:   This ECG is from a 63-year-old man who complained of epigastric pain for three hours. The pain was sudden in onset, burning in nature, and accompanied by nausea and palpitations.  The patient is a heavy smoker, diabetic and hypertensive with a long history of non-compliance to his medications. 

He was given crushed aspirin, loaded with clopidogrel and heparin, given high-intensity statins, and rushed to the cath lab. 

The ECG:  The rhythm is normal sinus, a bit fast at 90 bpm.  The intervals, frontal plane axis, and R wave progression are normal.  This ECG shows a very dreaded pattern:  ST segment elevation in aVR and V1 with widespread ST depression, seen here in all other leads.  This is an ECG sign of GLOBAL ISCHEMIA.  There are several possible causes, all bad.  The most common causes of this pattern are:

·        Severe triple vessel disease, with significantly decreased flow in the left anterior descending, right, and circumflex arteries.