A 72-year-old woman with a history of depression, atrial fibrillation, congestive heart failure, and coronary artery disease (CAD) is brought by her daughter to the emergency department with a 10-day history of generalized weakness and decreased oral intake. The daughter states that over the past day her mother has gradually been getting worse, and she now “just looks terrible.” The patient is not the best historian, but admits to being short of breath, weak, and “sick.” She denies chest pain, abdominal pain, fever, vomiting, or diarrhea.
On exam, she is afebrile with normal vital signs and pulse-ox. Her head and neck exam is only notable for dry mucous membranes. Her neck is supple without mass or a thyroid scar. The lungs are clear without wheezes or rales and the heart is regular. Her abdominal exam is benign. Her lower extremities are notable for 1+ symmetric pitting edema, which, according to the daughter, is actually better than it usually is. Her neurologic exam is non-focal, but she is noted to be somewhat lethargic.
Labs are sent off and IV fluids are started. Her ECG is shown here.
Is this case an atypical presentation of an acute coronary syndrome (ACS) or might it be something else?