Fig. 2.

This patient was found to have OMI of the mid-RCA (pre-intervention TIMI 1 flow, 99% stenosis with thrombus), correctly diagnosed on the first ECG by the OMI criteria but missed by STEMI criteria despite 5 ECGs prior to angiogram, with a delay of 21.4 h (cath performed next day due to “NSTEMI”). Although it is not subtle, the ECG does not meet STEMI criteria because only one lead (III) has 1 mm STE, without 1 mm in adjacent leads (II and aVF). The documentation states: “…substernal chest pain and pressure which radiated to the jaw area and found to have ruled in for a NSTEMI via positive cTns. Referred for cardiac catheterization.” This presentation ECG shows all 7 of the above findings (top panel without annotation, bottom panel with). This patient had a very high peak cTnT of 3.74 ng/mL, a new inferoposterior wall motion abnormality, and a newly depressed EF of 40%, but survived to discharge.