50 year old male CC: Chest pain – Discussion

This is the discussion for 50 year old male CC: Chest pain.

You may recall that the patient started experiencing chest pain during sexual intercourse.

Many of you were appropriately concerned about the possible use of drugs for erectile dysfunction that would contraindicate nitroglycerin! Thanks for pointing that out.

In this case the patient was not taking any medication for erectile dysfunction.

Let’s take another look at the 12-lead ECG.

This ECG shows an essentially regular rhythm with no clearly discernible P-waves and wide QRS complexes (but not > 180 ms) at a rate of about 90.

The morphology of the QRS complexes are somewhat unusual, especially in the right precordial leads. If this is a supraventricular rhythm I would call it a non-specific intraventricular conduction defect or atypical left bundle branch block.

Regardless of what kind of conduction delay is present (even if it’s an accelerated idioventricular rhythm) we know that the depolarization is abnormal. T-wave discordance is present throughout the majority of the 12-lead ECG.

So does anything look like an acute injury pattern? Absolutely!

Let’s take a look at high lateral leads I and aVL.

Here we can see significant ST-elevation that is concordant with (in the same direction as) the majority of the QRS complex. It is also concordant with the terminal (last) wave of the QRS complex.

That’s bad! We have already satisfied one of Sgarbossa’s criteria to identify acute STEMI in the presence of left bundle branch block (LBBB).

Another feature worth pointing out is that leads I and aVL show pathological Q-waves.

Now let’s look at inferior leads III and aVF.

Even taking into account the wandering baseline and artifact we can appreciate concordant J-point depression.

Is this concerning? Yes!

Why?

Because of the ST-elevation in the high lateral leads. In the words of Tomas Garcia, M.D., one must always consider the company an ECG abnormality keeps.

Lead’s III and aVF are reciprocal to leads I and aVL. So the fact that ST-depression (or at least J-point depression) is present in two inferior leads while ST-elevation is present in the high lateral leads is troublesome.

How troublesome?

Troublesome enough for me to call this an acute STEMI.

Now let’s look at the right precordial leads.

Once again we see concordant J-point (and ST-segment) depression in leads V1-V3. Is this concerning? Absolutely! In fact this meets another of Sgarbossa’s criteria.

Finally, we can appreciate ST-elevation in leads V5 and V6 in spite of the wandering baseline there.

I can’t tell you what heart rhythm this patient is in but I feel confident we’re looking at an acute injury pattern.

So what was the outcome?

Unfortunately, this patient experienced cardiac arrest on arrival at the hospital and was not successfully resuscitated (which is more evidence that it was an acute STEMI).

See also:

An unusual case of right bundle branch block

An unusual case of right bundle branch block – Discussion

6 Comments

  • Christopher says:

    The qR in I/aVL/V2, Rs in V5/V6, and general weirdness in V1 were definitely interesting features! I wonder about lead placement (maybe up an intercostal or down an intercostal) changing the morphology on the surface ECG.

    Either way, pretty convincing posteriolateral changes even in the face of IVCD. LCX occlusion seems likely.

  • chris T says:

    Awesome thanks!

  • funny thing about chest lead placement for 12-leads, at least in males… even though everyone only has one 4th intercostal space and one 5th intercostal space on each side, i’ve seen so many different placements it makes my head spin.

  • Stuart Jones, NREMT-P says:

    Sheesh, it looks like his whole heart is dying!

  • at least he went out doing something fun.

  • Ryan says:

    I have seen soooo many people improperly place patches, from medic to ER techs to nurses. The most common response when pointing it out is. This machine will figure it out or this is how I was taught. I wonder how many times improper placement led to misdiagnosis.

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