Scenario: This 12-lead electrocardiogram (ECG) was obtained from a 75-year-old man who arrived at the emergency department with chest pain and shortness of breath. He had been bedbound for several weeks because of his symptoms. He has no history of coronary artery disease, but has significant risk factors including: diabetes, hypertension, and cigarette smoking. Clinical findings include: blood pressure, 222/109 mm HG; respiratory rate, 24/min; brain natriuretic (BNP), 1866 pg/ml (reference < 100); troponin I, 0.073 ng/mL (reference < 0.04); ejection fraction 45%, and elevated blood urea nitrogen and creatinine. Before admission, the patient was taking daily; aspirin, insulin, β-blocker, ACE inhibitor, and diuretic.

Sinus bradycardia with T wave inversion in the left lateral leads, lengthened QT interval, Q wave present in V1 with poor R wave progression in the anterior leads plus the presence of fragmented QRS (fQRS) complexes in the inferior leads, suggesting prior infarction. The...

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