STEMI at Elderly Age (Part One)

An 88-year-old woman is brought to the emergency department by her family for four hours of epigastric pressure, nausea, and dizziness. She has a past medical history of diabetes and hypertension, well-controlled by metformin and lisinopril, respectively. She lives independently and performs her own activities of daily living. She has had no recent hospitalizations and the past medical history is non-contributory. The patient repeats that she has indigestion and needs something for her stomach.

On physical examination, she is diaphoretic and mildly agitated. Her BP is 100/78 mm Hg in both arms, and the heart rate is regular at 105 bpm. Respiratory rate is 20 breaths per minute. Her weight is 120 lbs. The arterial oxygen saturation is 94% on 4 liters of O2/min administered by nasal cannula. She has jugular venous distention to 8 cm, carotid pulses are brisk, there are bi-basilar rales, and the apex impulse is sustained but not displaced. An S4 is present. Peripheral pulses are symmetric.

Laboratory data: the hemogram is unremarkable, electrolytes are normal, BUN and creatinine are within normal limits, blood glucose is 105 mg/dl and the troponin is 0.28 ng/ml.

The electrocardiogram is as shown in Figure 1.

Figure 1: Admission EKG

Figure 1

Which of the following is the most likely diagnosis?

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