EMS is dispatched to a 63 year old male complaining of chest pain.
On arrival you find the patient lying supine in bed, alert and oriented to person, place, time and event. His general appearance is poor. He is pale, but not diaphoretic. Skin temp is normal. His chest pain is substernal 6/10 and non-radiating.
- RR: 12 non-labored
- HR: 68
- NIBP: 97/55
- SpO2: 81% on room air
Breath sounds are clear bilaterally.
Past medical history
- 4-vessel bypass approximately 6 years ago
- End stage renal disease
The cardiac monitor is attached.
What do you think is going on?
This was the first case I ever posted that showed ST-segment elevation in leads aVR and V1 with widespread ST-segment depression.
A recent Twitter poll showed that 72% of the #FOAMed community considered this finding to be a STEMI equivalent (indicating left main coronary artery occlusion) complete with prehospital activation of the cardiac cath lab.
Should STE in leads aVR & V1 w/widespread STD be considered STEMI equivalent w/field activation of cath lab? #FOAMed
— EMS 12-Lead (@EMS12Lead) November 15, 2015
It is probably based on this article.
Rokos I, French W, Mattu A et al. Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. American Heart Journal. 2010;160(6):995-1003.e8. doi:10.1016/j.ahj.2010.08.011.
However, this is controversial (even though I suggested the same thing here).
Stephen Smith, M.D. (@SmithECGBlog) argues that ST-segment elevation in leads aVR and V1 with widespread ST-segment depression really represents subendocardial ischemia, which may represent left main coronary occlusion or proximal LAD occlusion, but it may also represent left main insufficiency, 3 vessel disease, demand ischemia, anemia, CO poisoning, aortic stenosis, or some other cause that requires further workup in the Emergency Department.
The bottom line
Make sure you have buy-in from Emergency Medicine and Cardiology before you start calling this from the field!