63 year old male CC: chest pain

Here’s an interesting case submitted by my friend Lt./NREMT-P Chris B. This is all the information I have, so I won’t be able to answer any questions about the history, clinical presentation, or physical exam.

You are 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.

Vital signs

RR: 12 non-labored
Pulse: 68
BP: 97/55
SpO2: 81 RA

Breath sounds: clear

Past medical history

CABGx4 approx 6 years ago
End stage renal disease

The cardiac monitor is attached and shows this heart rhythm:

A 12 lead ECG is captured.

How sick is this patient?

What do you think is going on?

What is your treatment plan?


  • Tom, I don’t like the r wave progression, nor the depression in the precordials, and the eleveation in aVR is concerning alone with the reciprocal change in Lead II given the rest of the EKG and the signs/symptoms presenting. I would try obtaining a right sided EKG, possibly posterior as well. High flow oxygen, two lines due to presentation and a bolus to see if his skins improve based on his BP, concern lies on his history. Am I close??

  • Tom B says:

    You are close. This patient is very sick, and the story doesn't have a happy ending. I'm glad you noticed the ST segment elevation in lead aVR. Although it's not without controversy, many reliable sources suggest that ST segment elevation in lead aVR (with less ST segment elevation in lead V1) and ST segment depression in 6 or > leads is highly suggestive of either a proximal lesion in the left main coronary artery (LMCA) or severe 3-vessel disease. With this patient's history of CABGx4 approximately 6 years ago, it could be either or both! Regrettably, this patient went into pulseless VT shortly after arrival in the ED and was not successfully resuscitated.

  • walma says:

    Electrocardiographic Prediction of Acute Left Main Coronary Artery OcclusionRostoff P, Piwowarska W, Gackowski A, et al. Amer J Emerg Med 2007;25:852-855. This isn’t new news to anyone that’s been attending advanced ECG workshops (e.g. FHC!) or keeping up with some of the ECG literature, but just one more publication on the utility of lead aVR, the lead I refer to as the “forgotten 12th lead” or the “Rodney Dangerfield lead.” The authors wrote this brief report in response to an article we published in November 2006 pertaining to lead aVR.1 In that article, we discussed that ST-segment elevation (STE) in lead aVR in patients with acute cardiac ischemia has been found to be highly specific for acute occlusion of the left main coronary artery (LMCA). Why should we worry more about ACS with LMCA involvement vs. any other ACS case? Very simple…the literature indicates that when a patient has ACS involving the LMCA, they carry a 70% risk of developing cardiogenic shock or dying, and the only treatment that has been demonstrated to improve outcomes in patients with LMCA occlusion is rapid PCI (or often they will need CABG). No medical therapies have been found to reliably improve the prognosis, including thrombolytics. This is not just applicable to patients with STEMI…it also applies if the patient has an ST-depression ACS. The authors performed an analysis of published data and report that STE in lead aVR during ACS is 77.6% sensitive, 82.6% specific, and 81.5% accurate for LMCA occlusion. These authors don’t specifically comment on what degree of STE is required (0.5 mm? 1.0 mm?), but in our evaluation of the literature there are three patterns that appear to predict LMCA occlusion: (1) STE in lead aVR which is greater in magnitude than the STE in lead V1; (2) STE in lead aVR with simultaneous STE in lead aVL; or (3) STE in lead aVR > 1.5 mm. Also, it is important to bear in mind that these findings only apply when there is evidence of ischemia or infarction in other leads as well, so this is really not applicable to non-ACS patients. For example, some patients with SVT will develop STE in lead aVR, and this is not clinically predictive of LMCA disease. For anyone wondering why STE occurs in lead aVR, apparently it’s not completely clear. The authors cite one theory that “it is caused by transmural ischemia of the basal part of the interventricular septum, where the injury’s current is directed toward the right shoulder” thus producing STE in lead aVR. Sounds good to me. The bottom line is this: when a patient has evidence of ischemia or infarction on the ECG, take a special look at lead aVR. If there is STE there, the first thing you need to do is to get on the phone and find a cardiologist that will take the patient for PCI. And if you have to transfer the patient and have a choice of where to send the patient, opt for a center that also has cardiac surgeons available for CABG. They will often be needed. 1. Williamson K, Mattu A, Plautz CU, et al. Electrocardiographic applications of lead aVR. Am J Emerg Med 2006;24:864-874.

  • Tom B says:

    You’re just a wealth of information! Thanks again, Maciek! Tom

  • SoCal Medic says:

    Interesting literature, thanks..

  • Dr Zeeshan Ahmad says:

    good stuff walma,,very informative,,but he is a pt of End stage renal disease and nobody talked about his Electrolyte Status,,i suspect Potassium imbalance(hyperkalemia)..plus as he has history of Cabg x 4,,surely there might be an ongoing Cardiac ischemia

  • chris t says:

    Man everytime I read one of this sites post and replys I learn so much. Thankyou for taking the time to type, suggest, teach and be taught. I wanna be that good !

  • Hassan says:

    i hate medicine

  • Dodge says:

    As always a very imformative case presentation coming from a service that dose not utilise pre-hospital 12 lead this site as proved a wealth of information so keep up the good work

  • amk-emtb says:

    Thank you for taking time to share what you have researched and learned. I am a E.M.T-B, and have been taught that a good Medic was/is a informed and Great Basic. I am looking to go to school with in the next year to be a medic. There for love reading and doing my own research in the medical feild/EMS. I am very lucky and have a very good mentor that I talk to and he is a very well informed Medic, which is how I have come across this sit. I full understand that doing my own research and reading will not take the place of Medic school, but I hope by doing this I will have a better understanding of what I am learning.

  • Dr.Hafez Al-Ali says:

    this pt have serious attack ,acceralated ischemic crisis most ofTen NSTEMI and because of st elevation of AVR, means triple vessel disease or LM LESION , TO MANGE pt we need URGENT PCI.

  • Cool case, and awesome comments!  More pearls for aVR.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Conclusion to 59 Year Old Male: Unwell
Great discussion on a difficult 12lead! I follow these very closely and based on pt presentation and 12lead tracing, this was a difficult or to treat with impending heart failure, hypotension, and trouble breathing. Thanks for the follow up and look forward to next week!
2015-07-06 20:53:35
Conclusion to 59 Year Old Male: Unwell
Hmmmm, I was fairly close. Sounds like most of the treatment occurred IN Hospital. Love case studies, and that one was good.
2015-07-06 20:28:25
59 Year Old Male: Unwell
There's the point! There is are no P waves, and the rhythm is irregulary-irregular-atrial fibrillation. If you look, it is rsR phenomen-RBBB, BUT there are huge ST elevations on all leads from V1-V5 (that's why the QRS complexes look so broad). I and aVL is clearly ST elevation suggesting STEMI. In limb leads you can…
2015-07-06 10:12:16
Vince DiGiulio
Conclusion to 59 Year Old Male: Unwell
I'll expand on this in the next post but unfortunately I actually wasn't present for this case so I can't give my direct account of how things happened. That said, from the notes I read and word-of-mouth from those involved (which I suspect painted things in a better light than I would have viewed them),…
2015-07-06 04:09:22
Matt King
Conclusion to 59 Year Old Male: Unwell
Hey Vince thanks for the through follow up with this case. I am curious how his rate was controlled since he was hypotensive and maybe an unknown onset of when his A-Fib stated(thinking anticoagulation first)? As you know the wrong approach could be devastating in this PT with risks of further infarction, stroke, or death…
2015-07-05 14:10:57

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