58 year old female CC: Chest pain – Conclusion

This is the conclusion to 58 year old female CC: Chest pain.

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

Remember, ST-elevation needs to be explained, and if the etiology involves myocardial infarction, urgent time-sensitive decisions need to be made.

In this case, we have ST-elevation in leads V1-V5, which suggests the possibility of acute LAD occlusion.

This finding is all-the-more concerning when we consider that R-wave progression is poor (absent) and the QTc is prolonged at 481 ms. Both of these findings point away from benign early repolarzation.

It's all too easy to dismiss a patient like this as having a mere anxiety attack. We need to keep an open mind and careful not to stimatize our patient.

How else might we explain the ST-elevation in the precordial leads?

We can consider the possibility that the ST-elevation is "old" or from a previous MI (the ECG finding we sometimes refer to as left ventricular aneurysm).

However, when we measure the T/QRS ratio we see that the T-waves are far more acute-looking than we would expect with left ventricular aneurysm.

The T/QRS ratio is 0.45 in lead V2 which is way above our threshold of 0.36.

Another possibility that some of you very astutely pointed out in the comments is Tako-Tsubo (or Takotsubo) Cardiomyopathy. I found that suggestion particularly interesting because it does seem to tie together all of the elements of this case.

In this case, the treating paramedic wasn't sure what to make of the ST-elevation in the precordial leads so he transmitted it over the LIFENET to the receiving hospital.

The two ED physicians weren't sure what to make of it either, but to be on the safe side they called a "Code STEMI".

The following 12-lead ECG was captured en route to the hospital.

The differences between this ECG and the previous ECG are not dramatic, but if you scrutinize the two you will see that there are differences in QRS, ST and T wave morphology.

By the time the patient arrived in the emergency department her chest pain was completely gone.

After a discussion with the cardiologist she consented to cardiac catheterization.

There was an acute 99% occlusion of the LAD which was successfully stented.

Diagnosis: Acute ST-elevation myocardial infarction.

See also:

81 year old male CC: Palpitations

76 year old female CC: Chest pain

10 Comments

  • Christopher says:

    I really enjoy the discussion around Left Ventricular Anuerysm, Tako-Tsubo, and Anterior MI because the reality of the situation is field providers don't have the specificity in the field to differentiate between them without activating a Code STEMI.
     
    We rarely have prior ECGs to compare for LVA and it can be problematic for providers to apply the more quantitative criteria in the field in the face of signs and symptoms suggestive of ACS. If the receiving facility lacks a prior ECG, you can almost bet the patient would be heading to the cath lab! Although, sometimes the LVA is obvious given a small enough T/QRS ratio; but sometimes it is not. Definitely room for discussion on this topic.
     
    For Tako-Tusbo differentiation you could use ultrasonography or a ventriculogram (hmm and that's part of a cath). However, given the prevalence of AMI and the relative rarity of Tako-Tsubo, you can almost bet on the patient heading to the cath lab!

  • ryan says:

    The other item that was missing from the diagnosis of taka-tsubo was the fluid backup. Seeing a taka-tsubo is caused by weakening of the left ventricle, EF,  goes way, way down. Had we been seeing the elevation as presented, along with the history and had CHF presenting symptoms without relief from normal routes of care, I'd suspect taka-tsubo. Which, with a dose of ativan, could potentially relieve all symptoms once PT is calmed down. Along with that, she'd need an LVAD to properly recover. The only problem is, taka-tsubo normally presents in young females under consistent duress less than 25 years in age, not 50+ year olds, and her BP is not indicating LV failure, or a poor EF due to taka-tsubo.
    Had I commented on the original post, I would still have treated it appropriately down the STEMI route.

  • Chris T says:

    Great case. Learned a bunch- AGAIN

  • Ryan -

    Did you click on my previous case of Tako-Tsubo Cardiomyopathy?

    It was a 76 year old female who experienced a near-drowning and she didn't need an LVAD to recover.

    Tom

  • Sherry says:

    You could conclude that this patient has hyperkalemia based on the elevated ST segmant which can lead to arrhythmia if not treated. 

  • it takes some balls for crews to dismiss it as anxiety, yet crews do it all the time.

  • ryan says:

    Tom-I did not.
    I've had one case in my career, and after speaking with the cardiologist he informed me that an LVAD was required to appropriately allow the LV to recover appropriately, and essentially reverse the myopathy to prevent re-occurence. Granted, each, is a case by case basis. The patient in question I had was 19. and under a fair amount of duress. Seeing as it had happened once before and she was worked up as an anxiety attack, nobody had determined it was taka-tsubo. When she presented again with similar symptoms, and essentially CHF, she was diagnosed with taka-tsubo, and the LVAD was placed for about 60 days. She made a full recovery.
    LVAD's are becoming very popular in my area of the country, we've got one of the top caridac facilities in the nation on our proverbial doorstep, and, perhaps that is why we are seeing a large amount of LVADS being placed.

  • Brandon O says:

    Ryan, do you have any literature to support that epidemiology (mostly young women with chronic stress)? I hadn't seen anything that makes a claim that strong.

  • ryan says:

    Brandon, I read it in a journal some time back, and after finding it and re-reading it. I was incorrect. So, my apologies. Though, speaking with the cardiologist at our local heart center, he explained to me, that while it's acute stress that may trigger an event, it's consistent stress over a period of time, say, 7-14 days that really seems to cause the big issues. Here is one of the articles I found.
     http://www.hopkinsmedicine.org/press_releases/2005/02_10_05.html 
     
    I'll do some more research tonight, and post what I find. This is a very intriguing event, and science.

  • Brandon O says:

    Thanks Ryan! I think it's interesting as well, although prehospitally (and likely in the ED) usually moot, because I very much doubt that anybody has the wisdom and testicular fortitude to rule out AMI in favor of Takotsubo. The patient's gonna get cathed, and rightfully so; even if they come out clean, it was the right decision to make.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Jewel
53 Year Old Male: Severe Leg Pain
Hmm it appears like your site ate my first comment (it was extremely long) so I guess I'll just sum it up what I wrote and say, I'm thoroughly enjoying your blog. I as well am an aspiring blog writer but I'm still new to the whole thing. Do you have any helpful hints for…
2014-08-31 17:51:28
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14

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