A 79-year-old male was brought to the emergency department by emergency medical services (EMS) with retrosternal chest pain radiating to both shoulders. The pain started 2 hours ago while he was working in his garden. His medical history included hypertension, hypercholesterolaemia and a transient ischaemic attack. Physical examination showed tachypnoea, 37 breaths per minute, without abnormalities at pulmonary or cardiac auscultation, a heart rate of 88 beats per minute, a blood pressure of 111/73 mm Hg and unremarkable findings on abdominal examination. However, the patient looked clammy and grey. Nitroglycerine (GNT) administered sublingually relieved the pain. A partial electrocardiogram was performed by an EMS nurse (Fig. 1). Which abnormalities raise your concern?

Fig. 1
figure 1

The anterior electrocardiogram leads at presentation performed by emergency medical services

Full size image
  1. A.

    A new left bundle branch block

  2. B.

    The negative T wave in leads V5 and V6

  3. C.

    The ST depression in leads V2–V4

  4. D.

    The irregularity of the cardiac rhythm

Answer

You will find the answer elsewhere in this issue.