Patient presenting to fire station for BP check proves to be suffering acute STEMI

An 81 year male presents to the fire station to have his blood pressure checked.

He tells the paramedics he had just finished a round of golf and was sitting in the clubhouse when he felt “cold and shaky.” He states that he went out to his car, rolled up the windows in the warm sun, but still felt cold. That’s when he decided to drive to the fire station to have his blood pressure checked.

It’s Saturday and most of the firefighters are outside performing yard maintenance. The EMT who greets the gentleman and assesses his blood pressure does not find the story to be particularly troubling.

His BP is 120/70 and his pulse is 76 and regular; consistent with the other vital signs recorded on his card over the past few weeks. When he left the fire station he did not appear acutely ill.

Two hours later an ambulance is dispatched for difficulty breathing.

The EMT who assessed the blood pressure recognizes the gentleman who greets the ambulance at the side of the road. The patient states that he contacted his physician who was out of town and the on-call physician advised him to call 9-1-1.

The man was helped into the back of the ambulance and undressed from the waist-up. A surgical scar is noted down the center of his chest.

Past medical history: MI and 3-vessel bypass in 1985.

Medications: The patient does not recall the names of the medications.

His vital signs are assessed.

  • RR: 18
  • HR: 80
  • NIBP: 114/76
  • SpO2: 96% on RA

He states that “nothing has really changed” since he was at the fire station.

When asked about shortness of breath, he denies it.

The cardiac monitor is attached.

2010_06_03A_wm

When specifically asked about chest discomfort he states, “Well, I do a little bit of chest pressure, but it’s nothing like when I had my heart attack.”

A 12-lead ECG is obtained.

2010_06_03B_wm

What is your impression?

At first glance the ST-elevation in the inferior and low lateral leads isn’t that impressive, at least when compared to many of the other cases we’ve seen. However, this is an impressive amount of ST-elevation when compared to the small size of the QRS complexes! This is known as the rule of proportionality and it’s critically important when it comes to STEMI recognition!

V1-V3Perhaps more impressive is the ST-depression in the right precordial leads (V1-V3). These are reciprocal changes to posterior extension of this acute inferior STEMI. If this was the only abnormality on this ECG I would still call it STEMI! If you want to get really good at identifying acute isolated posterior STEMI, pay attention to the right precordial leads whenever you have an acute inferior STEMI. These changes will often be present.

Of course, you already knew that the ST-elevation in the inferior leads indicated STEMI. Why? Because of the downsloping ST-segment in lead aVL! This is the “go to” lead to rule-in acute inferior STEMI! It’s so sensitive that absence of this finding should make you question the ECG diagnosis of acute inferior STEMI.

So what happened?

The patient was sent to the cardiac cath lab where angiography revealed 100% occlusion of the right coronary artery (RCA). A stent was successfully placed and the patient is doing well.

Before
Balloon inflation
After successful stent placement

Diagnosis: Acute Inferior ST-Elevation Myocardial Infarction

23 Comments

  • mark olgun fdny paramedic says:

    this is an inferior wall MI,extending to posterior wall-st depressions and deep inversions in V1V2 with reciprocal changes,

  • mark olgun fdny paramedic says:

    this is an inferior wall MI,extending to posterior wall-st depressions and deep inversions in V1V2 with reciprocal changes,

  • mark olgun, fdny paramedic says:

    this is an inferior wall MI, extending to the posterior wall- ST depressions and deep inversions in V1 and V2plus reciprocal changes for inferior wall MIthis pt should have V4R V5R V6R V7R and V8R also to see the RV and the posterior wall…

  • Tom says:

    i concur with inferior Mi with reciprocal changes. Treatment of 02 and ASA at this point. Need to do a right sided before we can decide whether or not to give NTG. Earlier commented deleted for clarity.

  • VinceD says:

    Most everything said already sums it up pretty well. Everyone is getting too good at this stuff lately, and I blame it all on the quality of the teaching information on this site.Anyway, for the sake of my own mental exercise: ST-elevation in II, III, aVF, with reciprocal ST-depression in I, aVL indicative of acute inferior infarct. Marked ST-depression in V1, V2, V3, most likely associated with an acute posterior infarct. I also note ST-elevation in V6, possibly associated with the assumed-STE in the posterior views (Tom, does that make sense?). ASA, o2, and timely transport to a cath-capable facility with early notification. Also capture V4R to rule out right ventricular infarction prior to administering nitro, and V7, V8, V9 to confirm posterior STEMI. Serial ECG's in route to monitor for changes. Tell the guy to get married if he isn't, cause a woman definitely wouldn't let him walk around for several hours with those symptoms.

  • angor animi says:

    Did they perform a 12 lead ECG at the fire station?

  • Tom B says:

    angor animi – No they did not, and this is exactly why the ED doesn't do "BP checks". Performing these checks at the fire station presents a significant liability, but we choose to do them as a public service.We encourage citizens to seek medical care when they have a chief complaint that would normally warrant such care, or when they have grossly abnormal vital signs, but it's not always obvious when a bystander should become a "patient" with full documentation requirements.Most of the citizens who come in for BP checks are elderly and have complex medical histories. We could find something wrong with just about any of them.Tom

  • Max says:

    Something's up here.We're out with him due to a 3rd party caller that saw a gentleman with "Shortness of breath" on the side of the road… in a jogging suit.CABG X3, and previous MI. Well that would certainly explain the suggestive Q's on II, III, and AVF. Further, given the apparent severity of his previous MI, and lack of Q's anywhere else, I'm going to suggest that perhaps these EKG changes that we're looking at are normal to the patient, and not indicative of an acute MI today.My feeling is that the answer is on the rhythm strip. He certainly has what looks like a wandering atrial pacemaker.Which would to my mind explain the majority of his exertion based complains.

  • J says:

    I'd have to agree with Max on this one. Knowing previous MI that warranted a 3x cabg, not having any reference 12-leads, and the patients presentation with current "SOB" or "feeling different" on activity should still warrant further investigation. V4R+, eliciting current meds and recent med changes, and whether the pt normally experiences this on activity should be some initial questions. (Maybe he just likes the jogging suit for comfort, doesn't jog, and was golfing for the first time in many many years today.)They may also have a differing presentation due to previous MI and CABG. Depending on what if anything was damaged on previous MI, this could very well change the underlying rhythm presentation, and if the abnormality shown on the 3 lead (either 3rd deg, or second type II – looking at small screen at the moment) is "new", it wouldn't be able to compensate as a healthy heart might, and could present with the same S/S and ischemic T-wave deflections. ??

  • Max says:

    Apologies that I can't figure out how to edit my previous.I misinterpreted the dispatch information, and see now that it wasn't a 3rd party caller but the patient that called. Which really, just further cements my suspicion of a more "on exertion" based pathology.

  • Tom B says:

    Max -We're not really sure how dispatch came up with "shortness of breath" although the questions they ask the callers can be quite leading.Tom

  • Christopher says:

    3L shows NSR @ 70bpm. 12L shows STE inferior, recip changes high lateral, STD V1-V3.IWMI, considering posterior involvement as well!

  • CBEMT says:

    I'm assuming no questions were asked about his history at the station.If he'd come walking into mine with those complaints and that history, I think I would try to talk him into a 12-lead right then. I think this crew (and the department, and the city) got lucky.

  • CBEMT says:

    I should have added: I realize it's easy to judge after the fact, but I think we have a responsibility to have the highest degree of suspicion possible.

  • Tom B says:

    CBEMT – It is easy to judge after the fact.To maintain "the highest degree of suspicion possible" would require vital signs, a physical exam, and a 12-lead ECG on every citizen that walks into the fire station.We have a protocol called "12-lead ECG indications" which is very comprehensive and "cold and shaky" isn't on the list.It will be a sad day when we stop providing free BP checks out of fear that we'll get sued for missing something.Tom

  • Christopher says:

    We do BP checks on the industrial fire brigade I work for, but to alleviate the concerns we standardized our refusals to include a section for "BP Check Only" with number ranges to guide the pt. AKA when do you need to go to our clinic, when should you see your doctor, and when everything is 10-4.

  • Tom B says:

    Christopher -That's a good idea, but it wouldn't have helped in this case, as the patient's BP was within normal ranges and consistent with the other BPs recorded on his BP card.Tom

  • Hillis says:

    I see i've misssed alot, but inspite of that i won't miss my opportiunity to share my comments. Firstly thanks alot for sharing the interesting case .. So the ECG here shows ST elevation in the inferior leads II,III ,aVF ( with STE more in the III lead so exclude right ventricualar involvement by V4R )lateral leads V5 and V6..Deep STD in the anterior leads ( do the posterior leads V7-9 ). I think the patient is having combined MI inferolateral and posterior STEMI.. Is the culprit artery in this case is LCX ?

  • CBEMT says:

    It will be a sad day when we stop providing free BP checks out of fear that we'll get sued for missing something.I'm surprised more places haven't already.

  • Terry says:

    Clearly an inferior wall MI. I can understand doing a quick V4R to rule out right ventricular involvement. But this pt needs to be tx rapidly to a cath lab. Doing all the other right side v leads will not help in the treatment of the pt. We already know by just looking at the 12-lead and his B/P around 114 systolic that his right ventricle may be involved. But how do we treat this pt in the field. If we just give him fentanyl we have helped with his pain and anxiety but have done nothing for his MI. If we give him ntg we vasodilate not only the coronary vessels but his other vessels as well and could drop his B/P to such a low level that we make things worse. Our protocols are to with hold ntg if B/P is 100 systolic or less. I would like to see it changed to "and no STE in V4R." Again thanks for the case presentation.

  • Neil Holtz says:

    If this patient has a right coronary dominant posterior system this makes perfect sense. The SVG to the PDA/RCA/LV branch has a stenosis. Therefore this patient has an inferior/lateral STEMI with posterior involvement. The anterior precordial leads show ST depression as a reciprical change for the posterior STEMI. To see it well, turn the ECG upside down and backwards.

  • HillbillyEMT says:

    MI inferior wall.  Do 15 lead and rt. side.  transport, alert cath lab.

  • Eric says:

    I see a few recommendations for administering O2 to this patient. His SpO2 was 96% on RA so we should be cautious with the oxygen and consider omitting it in this case. Studies have shown that O2 administration at high concentrations can increase the size of the infarct.

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