80 year old male CC: Chest pain

Here’s a case submitted by a faithful reader who wishes to remain anonymous.

It’s a great case and destined to be one of my favorites!

EMS is called to evaluate a 80 year old male patient with a chief complaint of chest pain.

On arrival the patient is found sitting on his living room couch. He appears acutely ill and anxious.

Onset: 2 hours prior to EMS arrival
Provoke: Pain unrelieved after SL NTG x5
Quality: Severe substernal pressure
Radiate: The pain does not radiate
Severity: 8/10
Time: Several previous episodes but “never this bad”

Skin is cool, pale, and diaphoretic.

Breath sounds: clear

No JVD or peripheral edema noted.

Past medical history: CABG x3, CHF, angina, renal insufficiency, LBBB

Meds: Numerous but unavailable at the time of evaluation

Allergies: Penicillin

Vital signs:

RR: 20
Pulse: 108
BP: 150/80
SpO2: 99 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

What is your impression?

*** UPDATE ***

Here are the serial 12-lead ECGs.

See also:

Excessive discordance as a marker of acute STEMI in LBBB

80 year old male CC: Chest pain – Conclusion

Discordant ST-segment elevation in LBBB or paced rhythm

62 year old male CC: Chest pain

58 year old female CC: Chest pain


  • Troy says:

    Well……wish I could see the rest of the complexes in V2-V3 but here it goes. According to Sbargossas formula (modified) I would say its a septoanterior MI with reciprical changes in the inferior leads. Treatment would be O2, IV, trended 12 leads, morphine, heparin drip, nitropresside drip (in a seperate iv), and PUHA (Pick up haul a$$). :)

  • Aharon says:

    Clinical it’s look like AMI have a sumsternal chist pain pressure, but we haven’t any idia about her old ACG , but it’s not so necessary ,couse we can give treatment as the patiant feel , un that case I O2 60% not pass 99 setoration , give Heparin 4000IU IV , I give some MO IV around 2 mg , I don’t know the weight of the patiant but we need to be cerfull cuse her age , trasport her to the medical center that can be catheterization her.and in that time I say that she have ACS even we have 2,3,avf dipreation and avl elevation all that couse I don’t have old ACG

  • Christopher says:

    Very interesting QRS morphology in the inferior leads, the slurring is in the intrinsicoid deflection rather than in the S wave like in V1-V4, yet V5/V6 have slurring to the intrinsicoid as well. Regular rate, LBBB, some trouble identifying P-waves but in V5 we have some to fancy. Lead placement?

    We’ve got concordant ST-depression inferior and anteriorly with concordant ST-elevation in I/aVL. Lateral wall MI. “STEMI” treatment and transport with expert consult.

  • Troy says:


    Are you sure your seeing depression and not elevation in the septoanterior leads? Btw I saw the ST elevation in avl but good catch in I.

  • Troy says:

    I’m thinking proximal LCX block

  • Christopher says:

    Troy yeah I reordered things and messed that bit up, thanks. Anteriolateral elevation.

  • Troy says:


    Why did it not even make an attempt at an analysis?

  • Mark says:

    Just to summarize the findings on Sbargossas’s criteria…am I right with the following observations? I want to make sure I’m seeing the right things…

    Concordant ST-segment elevation >1mm – Not present
    Concordant ST-segment depression >1mm in V1, V2 or V3 – Not present
    Discordant ST-segment elevation >5mm or 0.25 of the QRS – Present in V1, V2, V3, V4

    (Last criteria is met)

    Am I wrong to think that, although I see the ST-segment elevation in aVL, this alone does not meet Sbargossas’s criteria of >1mm because the ST-elevation is discordant (rather than concordant)?

  • Tom B says:

    Mark -

    This case is unusual in that the limb leads show a strange QRS morphology for LBBB.

    Typically the main deflection of the QRS complex is the terminal deflection but this case shows that there’s always an exception!

    I discussed this with Dr. Smith yesterday and he uses the main deflection of the QRS complex when deciding whether or not the ST/T is concordant or discordant.

    So he would say the T-waves are discordant in the limb leads.

    I just know they look “wrong”.


  • Hillis says:

    SR ..STE in AVL with reciprocal STD in the inferior leads II,III and aVF ..LBBB with LVH the huge STE in the anteroseptal leads is appropriate due to the above mentioned reasons.. obvious prolongation of QT/QTc beaware of sudden arrythmia.

  • According to sgarbossa criteria :
    There is discordant ST elevation in leads V1, V2, V3 , V4
    So it is LBBB and acute MI
    So, aspirin & plavix and activate the cathlab

  • Paul says:

    LMCA/LAD/LCx occlusion also supported by significant STe in lead AvR. Additionally, significant STe in I and AvL, with extremely suspect reciprocal changes in the inferior leads that are not consistent with LBBB.

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