41 year old male complaining of chest discomfort.
- Past medical history: Asthma
- Medications: Inhaler (unknown type)
EMS finds the patient sitting in a chair.
The patient appears acutely ill. His skin is cool, pale, and diaphoretic. Breath sounds clear bilaterally.
- Onset: At rest
- Provoke: Nothing makes the pain better or worse
- Quality: “Heavy” and “unrelenting”
- Radiate: The pain does not radiate
- Severity: 8/10
- Time: The patient has had similar episodes that cleared up after using his inhaler
Vital signs are assessed.
- RR: 20
- HR: 60
- BP: 112/84
- SpO2: 91 on RA
The cardiac monitor is attached.
A 12 lead ECG is captured.
What’s going on here?
*** UPDATE ***
This following ECG was captured en route to the hospital.
Look very carefully at lead V3!
Does this help with the diagnosis?
It’s also worth noting that the initial ECG shows upwardly convex ST-segment elevation in lead aVL with terminal T-wave inversion. There is also a subtle reciprocal change in lead III.
This case was especially difficult because our normal “tricks” to differentiate between acute anterior STEMI and benign early repolarization lead us in the wrong direction!
In other words, R-wave progression is intact and the QTc is not prolonged.
In this case it’s the serial ECGs that save the day.
Remember, there is no “always” in medicine!