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Chest pain in a patient with a tall R wave in V1

An 83-year-old man 2 days postoperative from L3 to L5 laminectomy developed sudden onset of chest pain. Initial ECGs demonstrated a tall R wave in V1 and ST-segment depression in leads V2–V5. A posterior ECG was performed, but failed to demonstrate ST elevations. The patient was initially treated as an non-ST-segment elevation myocardial infarction with weight-based enoxaparin. On further review, the patient's ECG was identified as a STEMI equivalent, and he underwent cardiac catheterisation. He was noted to have a near complete occlusion of the posterior descending branch of the right coronary artery (RCA). Bare-metal stents were placed in the proximal and distal RCA, with restored flow distal to the lesions. The patient was transferred to the intensive care unit for observation, and was noted to develop atrial fibrillation. Rate control was achieved with diltiazem, and the patient was started on dabigatran. Medical therapy including aspirin and clopidogrel was initiated, and the patient was discharged home.