Is there anything about this ECG (other than the poor data quality) that interests you?
The patient was a 90 year old male, fall with injury. Also complaining of pain between the shoulder blades.
*** UPDATE ***
This ECG caught my eye because it satisfies one of Sgarbossa’s criteria for the identification of AMI in the presence of LBBB. Specifically, the concordant ST-segment depression in lead V3 is a highly suspicious finding.
As a stand-alone finding, concordant ST-segment depression in a right precordial lead gives this ECG a score of 3 out of 10 (probability of AMI 66%).
I personally don’t think it’s necessary to score the ECG. As far as I’m concerned, an ECG that meets any of the criteria should be considered equivalent to an ECG showing acute STEMI, especially when you consider the depth of the S-wave in leads showing discordant ST-elevation (see previous posts on this issue).
So was this patient experiencing an acute STEMI? Here’s what I found out.
Patient (90 y.o.) arrived via EMS from XXXXXXXX after falling; there was no LOC, but did complain of back pain between the shoulder blades and diffuse abdominal pain. Extensive PMH: AAA, non-operable, HTN, CAD, CABG, LBBB, anemia, cardiomyopathy and dementia. The ED physician spoke to the daughter extensively who did not want her father worked up, but did consent to a thoracic x-ray and stated she only wanted him to receive pain medication and return transport to the XXXXXXXX and did not want any further diagnostics noting that his dementia worsens when he is out of his environment. He has a living will /advanced directive on file and with him a DNR order.
He was given pain medication in the ED, the thoracic film showed no acute injury and a prescription for Lortab was written and he was sent back to the nursing home. He did not have an EKG performed on this visit or any other diagnostics. The patient was here for an admission in 6/2009 and it appears that the EKGs are very similar.
When designing a STEMI program you have to make difficult choices when it comes to exclusion criteria like age, DNR status, and neurological status. Was this patient experiencing an acute thrombotic event in an epicardial coronary artery? I guess we’ll never know.
It’s possible this ECG finding was old and it’s possible it was secondary to aortic dissection or aneurysm.
58 year old female CC: Chest pain – Conclusion (meets all 3 of Sgarbossa’s criteria)
62 year old male CC: Chest pain (LBBB with ST-elevation > 0.2 the QRS complex)