50 year old male CC: Chest Pressure

We hope you enjoy this case, as always some details have been changed to protect patient privacy.

It's around 05:00 when the tones go off at your fire station for a medical response at a large apartment complex.

You leave the bunkhouse with the engine crew and check enroute. Dispatch relays you are headed to a 50 year old male with chest pain.

Upon your arrival to a first floor unit, you find the door unlocked and the patient sitting in a chair in his living room. He appears anxious, is pale and is holding his chest. The engine crew begins obtaining vital signs and places the patient on the cardiac monitor.

The patient tells you he was awoken from sleep with "some really bad pressure". He'd had the same pain, "come and go yesterday," and that he saw his doctor and was diagnosed with "strep throat".

When you ask about any other history he says he only has high blood pressure and high cholesterol, but denies taking any medications at all. 

  • Pulse: 56, strong and regular
  • BP: 136/94
  • Resps: 22, labored
  • SpO2: 96%
  • Skin: pale, clammy

The patient is placed on a nasal cannula at 4 L/min.

You perform a focused assessment of the patient's chest pain:

  • Onset: yesterday
  • Provocation/palliation: nothing makes it better or worse, not reproducible upon palpation
  • Quality: "Pressure"
  • Radiation: localized retrosternal, does not move
  • Severity: 8 of 10
  • Timing: "went away 8 hours ago, woke me up so I called 911."

One of the firefighters hands you the 3-Lead as your partner is placing the electrodes on for a 12-Lead.

The patient denies any medication allergies and is handed 324 mg of chewable aspirin. Your partner hands you the 12-Lead.

Due to the wandering baseline you ask your partner to work on a cleaner tracing. The patient is instructed to breath slowly and to stay still. After the second attempt your partner hands you the following 12-Lead.

The patient states he feels very nauseous.

You're 10 minutes from the nearest hospital, 15 minutes from the nearest PCI center, and your patient has been to them both.

  • What do you think is wrong with the patient?
  • Is the recent diagnosis of "strep throat" important?
  • Should this patient go to the PCI center or to the community hospital?
  • How would you continue treating this patient?

 

41 Comments

  • Ben says:

    Im going with Pericarditis. The pain is non-radiating for a start, the ecg shows ST elevation in II, III, aVF, v4, v5, v6. I dont see reciprocal changes or ST depression in any of the leads. There is what looks to be PR depression in some of the leads with elevation (hard to tell with the baseline) and the elevation that is there 'looks' curved – the old smiley face sign. I would be tempted to get the patient to lean forward and see what effect that position has on the symptoms – should relieve the pressure in Pericarditis. I would take him to the normal hospital – and probably give him 300mg of aspirin as a just in case lol.

  • SMM says:

    they already gave him the aspirin….ST elevations in II, III, avF (inferior) and V4, 5, 6 (lateral) ….those are true elevations.  I would go to cath lab hospital

    • Dave says:

      We can as intelligent people disagree as to weather this is an AMI or not. There is a limit to what we can know pre-hospital and because of this we should treat this as an MI. If it is not and we treat it as one there is very little chance that it will harm the PT. But if we don’t treat it as an MI and it is one then we are guaranteed to have hurt our PT. The answer is for me to treat as an MI just like I would if the EKG was normal because EKGs are not 100% sensitive,

  • Terry says:

    Pericarditis is a strong differential DX but I would treat him as and MI and take him to a PCI center. The recent strep dx is important and so is his hx of HTN. The strip does show some ste in leads II III AVF V-4—>V-6 which could be an inferior lateral wall MI. But there are no reciprocal changes in V-1 2 or 3. But that still doesn't ro MI. He is also bradycardic and nauseous which is classic inferior MI. I would expect him to be a little tachy with an infection. IV O2 Fentanyl serial EKGs PCI center.

  • Susan says:

    I would say pericarditis.  The only odd thing is that V1 shows ST depression.  Usually all leads are positive in pericarditis.  Thanks Ben – I'd never heard the "lean forward" trick.  I would also go to the normal hospital.

  • Dustin says:

    I would do a 15 lead ecg and see what is showded. However, either way this guy is being treated as an MI pt. As said above the elevation current is an inferior lateral MI.

  • Kevin f says:

    Even with ST elevation I agree with Ben no reciprocal changes and big smiley face sign, but more important is a good pt assessment, what do heart tones sound like any rub? Recent hex of strep throat common infection easily spread to the pericardium.

  • Jason says:

    ST elevation in II, III, AVF and V4-V6, history of HTN and hypercholesterolemia, age makes me head toward the diagnosis of inferior/lateral MI. No fever, no tachycardia, no global ST elevation so while perciarditis is still a possibility I would err on the side of caution, treat for an MI and let the hospital work him up for periciarditis on arrival. NTG, O2, morphine and transport to the PCI center.

  • CE says:

    Inferior-Lateral MI. Start IV, titrate SpO2 to >95%, ASA already on board, Morphine IVP. Can I get a right sided ECG? If no signs of right sided involvement, I’d administer NTG SL. Call for a note to the PCI-capable hospital.

  • Chris says:

    I’d say MI! STE in inferior leads as well as 4,5,6. Pt has Discordent ST-T wave in V1 and a possible LBBB, if so he also meets sgarbossas criteria with concordant ST-T elevation >1mm in leads V5 and V6.
    Reason I’m not saying pericarditits is because there’s not global STE and if lead 3 is elevated higher than lead 2 it’s more than likely a MI.

  • Bryant says:

    I agree with the dx of pericarditis given the recent strep infection and non radiating chest pain. I’d be iffy about the non PCI hospital unless i did a posterior 12-lead to make sure there were no reciprocal changes there either.

  • Daniel says:

    i would have to agree with terry on this one. pericarditis is a strong possiblity but i because of the BC and nausea being including as well as him being pale with the severity of pain i would also think MI i would take him to the PCI center

  • Dan says:

    Pericarditis might be the issue but do we diagnose that and treat it?  We don't and making that assumption and not going to the PCI because of it is a really bad idea. Ask your risk manager (evil grin). 
    I would follow ACLS and transport. You could do a posterior 12 lead but do you reall want to spend the time on that when the PCI is only 5 mintues further? 

  • Laura says:

    With the infection he shoukld be tachy. There is depression in v1 with elevation in inferior/lateral leads so I would do a rt sided ekg, tx with ntg (monitor closely due to it being inferior), call a cardiac alert and let the hosp know what you’ve got, and take him to the pci facility. I would alos move my limb leads to different locations on the limbs to fix that crappy baseline

  • shaun says:

    I agree with terry i see st elevation in leads 23 and avf and lbbb cath lab better safe than sorry.

  • Brodie47 says:

    I agree with Dan. While Pericarditis could be highly suspect, I’m not going to diagnose this and transport to an non PCI hospital. Whe blood enzymes with a short turn around time are the next step. At the non PCI facility, there is now an EMTALA transfer issue that will delay 1/2 to 1 hr. time is muscle. For the sake of 5 minutes, go to PCI center. You might be the hero for that patient vs. the incompetent medic that should have known better! Or, always call Med Control, put it on their shoulders.

  • Brad J. says:

    Although, pericarditis did come to mind when I first saw this I feel like everyone is looking past the patients clinical presentation. Just look at his presentation… He is pale, clammy, bradycardic, pressure as chest pain, shortness of breath, and anxious. Then you pair that up with his EKG and it screams MI and most likely A RVI. You guys are saying there are no reciprocal changes, but I disagree. There certainly is depression in I, AVL. It may not be impressive, but that is not a normal ST segment and there is also a DEFINITIVE J point in those leads. V1 is obviously depressed, you could agree small depression in V2, but the T wave is biphasic which is also indicative of an AMI. I can see more reasons to call it an MI than not to. If it were pericarditis then he would most likely be tachycardic, febrile, warm and diapharetic. There is a difference between clammy and diapharetic. Could it be pericarditis, possibly…. Am I willing to risk the patients health and my license, absolutely not. Also to note sore throat is a sign that asymptomatic MI patients present with and is often misdiagnosed as strep or pharyngitis, but days later the block becomes more significant and that’s when typical MI signs present….. With all that being said, I may be completely wrong though :-)

  • Cal says:

    With my department this patient is transported to the nearest hospital with a cath lab and treated with O2, ASA, Nitro, and MS. No thinking just go, with reproducible pain anywhere from nose to naval and pain greater then a six. It takes the thinking away from the medic but we have one of the highest survival rates in the country.

  • Chris says:

    I’m seeing a possible posterior MI, I run a 12-lead with V-4r, 8 & 9. Transport to a PCI center as precaution, established IV and follow cardiac protocol.

  • rastallama says:

    recent strep with pr elevation in avr, st elevations with no obvious reciprocal findings, strong indicators for pericarditis… id love to listen for a rub but i wouldnt know how or where!!! regardless… treating this as a “suspicious” ecg and treating for acs with txp to pci capable facility is the most appropriate decision… 12 leads are neat and fun, but only a piece of the puzzle…

  • harry says:

    Here’s an Idea. Take THE extra 5 min drive to the local PCI center. He’s pale, clammy and it woke him up. Please let the Dr’s decide and give that Pt the best ACLS care possible. Stop trying to Dx other issues when you have a good 12 lead. T/P pt, treat, and do a 15 lead. We can also explain to the Pt the possibilities of this pain and or abnormal 12 lead in that extra 5 min T/P it took and look smarter to the “PT” if it is or not an AMI. I have been a Medic for 15 yrs and seen some changes but I still stick to my basics and never jump to conclusions. WE ARE PARAMEDICS.

  • Wanted to write in before the 18 comments multiplied more… though having to do so from a car with at best very blurry tracings to look at. I think Brad J is right on! This has to be taken as acute inferolat MI until proven otherwise given the presentation and lack of baseline ECG. Looks like the baseline is Early Repol, which makes assessment that much harder to assess- but severe new onset chest pain in50 yo man makes acute inf-lat mi the Dx until proven otherwise despite the “smiley” sign that I popularized. I agree- some subtle suggestions of abnormal lead aVL and V2 are present – but bottom line is to assume acute mi and transport ASAP until proven otherwise- AND- I bet you WILL know for sure when the next ECG is done on arrival in the ED- because IF our hunch is correct, then there should be “telltale” evolution by then!!! Acute pericarditis usually more diffuse changes, lead 1 looks more like lead 2 (instead of lead 2 looking like lead 3 as occurs with acute inf mi), and the patient is usually younger with pericarditis. The Hx of strep throat suggests angina!!! (strep is VERY uncommon in a 50 yo man). For whoever asked- the cp of pericarditis is often positional- an inflamed pericardium is “stretched”  on lying  down, and feels better when sitting forward. Great case for discussion and I’ll looked forward to seeing good resolution on my computer when home as well as followup on this interesting case!

  • Another look from a blurry screen in a moving car (my wife driving…) – this could all be moving baseline artifact in a patient with nothing acute and baseline early repolarization… But the HISTORY is VERY concerning – so treat his cp, Asa and transport ASAP- and that better quality ECG that will be done on arrival in the ED will tell the tale!

  • Dustin says:

    Also consider paroxysmal nocturnal dyspnea, back to s/s after listening to heart tones and ruling out pericarditis.

  • Sean says:

    I would go with inferolateral MI. I am seeing a trending of slight increasing in ST segment elevation within leads II, II, aVf, V5, and V6. Although the dx of strep throat might make someone want to think viral syndrome leading to pericarditis, his pain is not typical of the sharp stabbing pain that increases with inspiration seen with this condition. Also, the waxing and waning type of pain the preceding day is very typical of unstable angina, with a significant reduction in coronary bloodflow perfused by the right coronary artery (I would almost bet that he as a 99% blockage pretty high in the RCA). His bradycardia is also classic of inferior wall MI (again, not something typically associated with viral syndromes or pericarditis). I would obtain a right-sided ECG since 30% of inferior wall MIs have involvement of the RV branch of the RCA, thus compromising that chamber. I would be very cautious in using nitrates or morphine in this case as both can decrease preload precipitously, leading to a dangerous drop in blood pressure and cardiac output. Absolutely needs transport to the nearest cardiac center with PCI capabilities. Just the cardio-tech’s perspective.

  • Thomas NREMT-P says:

    I agree with Sean. Morphine and NTG dangerous in an inferior event, confirmed by II, III, AVF ST elevation. ASA and Sublimaze or Fentanyl a good idea. If he was tachy I’d give him 10 labetolol, but he’s not. Let’s assume MI because we don’t treat pericarditis. But think about this, let’s get a SAMPLE history because a history of HTN could mean he takes a beta blocker hence the bradycardia, but he could have pericarditis. Or its an inferior lateral wall MI. I don’t know, because I don’t diagnose ! Treat the symptoms.

  • Brad J says:

    @ Harry this is suppose to be a educational discussion about what we think it is and how would we treat it. If every discussion was ended in “just drive to the hospital and let the dr’s figure it out” then we would never learn anything. This case was posted because the author knew that pericarditis would be suggested and for it to be discussed. Relax…..

  • Mike Sherriff says:

    To be clear, Sean said he would "obtain a right-sided ECG" looking for involment of the right ventricle because there is an association (of up to 30-50%) between inferior MI's (of the left ventricle) and right ventricular MI's.  IF the right ventricle is involved, THEN the pt is more likely to suffer from vasodilatory medications which drop the preload. 
    So yes, caution is warranted in an inferior event, because they are associated with right ventricular events.

  • Trish says:

    Treat as MI and go to appropriate ER to handle cardiac, esp one that can handle heart cath.  It is so much better to be SAFE than SORRY.

  • Agon says:

    Pericarditis don’t have depressions , here Avr and V1 is depressed so maybe not pericarditis.

  • Agon says:

    not damn Avr lol just V1

  • Megan says:

    I couldn’t agree more with Harry! Last time I checked I didn’t go to med school so I’m not going to play around with someone else’s life and blow off what is or isn’t wrong. Plan for the worst!

  • Dr. Grauer asked that I pass this along:

    Hi all. Back on firm ground – and finally able to get a good quality image on my computer … This remains an EXCELLENT teaching/discussion case – and I strongly believe that NO definitive answer is possible based on the tracings we have available to us. As per my 2nd comment above – the "tale" will be told after this patient gets to the ED and has a repeat good quality tracing done. IF there is acute STEMI in progress – then there SHOULD be some evolution by that time. And perhaps an old tracing might be available by then …. BUT – you cannot deny the sudden onset of 8/10 CP in a 50 yo man – so with that Hx, this must be taken as a potential acute STEMI until proven otherwise. As to the tracings – the differential is 3-fold, and possibly a combination of two of the 3. Tracing #1 was done at 5:12am and Tracing #2 was done at 5:14 am – not really enough time between them for meaningful evolution (20-30 minutes often needed – but not necessarily more than that … ). Thre is just too much baseline wander to tell. Regardless – I think there is baseline Early Repol (classic "smiley" shape ST elevation in what looks to be infero-lat leads with classic "J-point notch" in at least V5). There IS some ST elevation. Leads aVL (at least on the 5:12 tracing) and V2 are not totally normal – but I'm not convinced these qualify as true "reciprocal changes". V1 is allowed to have T inversion – and especially in view of what looks to be a significant amount of T peaking from baseline Early Repol, V1 could clearly be this patient's "normal". I can NOT rule out the possibility of some new acute ST elevation due to acute STEMI in evolution on the basis of these tracings without any prior ECG for comparison – and given the history one has to act on this as a possibility by RAPID transport, asa and acute pain relief. The ECG in the ED should tell if something is or is not evolving.  Steve Smith makes the additional excellent point that early repol tends to have a relatively short QT – and that clearly is present here – but we KNOW there is some baseline early repol – with the real question being whether or not there is some acute ST elevation on top of this or not …. Finally – re acute pericarditis – there should be diffuse ST elevation in Stage I of acute pericarditis in all leads BUT the "far-away" (=right-sided leads) – which are leads III, aVR and V1 – so the T inversion (I don't think there is real ST depression) that we see in no way excludes pericarditis. I put pericarditis way down on my list (not ruled out, but way down) because: i) the age of the patient and history just don't sound like it; and ii) I don't get a sense of as diffuse ST elevation as I'd like to see with acute pericarditis (really not up in lead I, aVL, V2,V3 … ). This of course would change if one heard a pericardial friction rub which would be diagnostic …GREAT case! – and hopefully there is follow-up and a subsequent ECG that you will be showing us to prove what the answer turned out to be !!! – : ) 

  • harry says:

    @ Brad J. I didn’t say “just drive” read it again please cause I think I mention a 15 lead and talking to our PT. I am aware of the discussion but as I recall….1 the only thing I have to treat Pericarditis is Full Fowlers Position (sitting up) and a Calming Voice. 2 Follow basic ACLS for CP and treating Pericarditis isn’t in there… Its M.ON.A. That’s what I was getting at. Yes it may be Pericarditis or as Dr Grauer said Early Repol. It doesn’t matter cause if WE go to a basic Hosp and it is an AMI then who looks ……well you know! I am just saying please as a Medic treat Basic Findings on your 12 Lead and Don’t take a pt at that age with those Signs and Symptoms to a Normal ER. I am reading these comments and some of them are just like WOW!!! Sorry to sound like an A++ but this is what gets Medics in trouble and a bad name I have seen it over and over again.

  • harry says:

    @ Megan thank for reading and understanding my comment.

  • Brad J says:

    @ Harry, I understand now….. I wasn’t trying to attack you or be rude so I apologize if I came off that way. I completely understand what you’re saying bc I too cringed at some of the responses and was pretty thrown back as I’m sure you could tell from my initial comment. Definetly load and go scenario and w/o a doubt transport to a facility that has interventional cath. I don’t pretend to know it all, but I’m shocked at how many would just write if off. Anyway, thanks for responding and no harm meant.

  • Adam EMT-P says:

    I agree with the above I would treat as an AMI and start our STEMI protocol. ASA, O2, (Skip Nitro), Heparin bolus, and start a heparin drip and take to the cath lab. (which unlike this scenario is 1.5hrs away unless flown in my area.)
    Our STEMI protocol is: ASA, O2, SL Nitro -> Nitro gtt titrated, Heparin Bolus 5000u–> Heparin gtt 1000u/hr, and metoprolol 5mg q5min x 3 total 15mg.
    Obviously no Nitro due to inferior, and we cant start the metoprolol if the pt's rate is <60 or if SBP <90. To start the Heparin we have to due a thrombo checklist. Due to the possiblity of PC I might consult prior to starting the STEMI protocol just because I may not have thought of all the possiblities, but if I am unable to contact OLMC I would start it.
    Feedback welcome…

  • MJ says:

    The absence of reciporacle changes in the high lateral leads makes it vanishingly unlikely that this is indeed an inferior wall MI. Pericarditis sounds plausible although those elevations look to me like benign early repolarization.

    As for treatment, still going to treat him as a rule out MI (asa, NTG). Let cards deal with it.

  • Jason F says:

    I hate to say it but I think I will be in disagreement with a lot of you when I say Iwould go ahead and give the sublingual nitro. The key here is that you would want to make sure you had your IV first and hooked up to a saline bolue if needed. It has always been the saying “give nitro to an inferior STEMI and kil them”, but there is only so much someone’s blood pressure can bottom from one spray. Consider that with the half life of the nitro in your system, and it makes a good case to try it. Just like with being able to use adenosine as a “diagnostic tool” in this situation the nitro would prove to be a great one. Improvement in pain with significant decrease in the blood pressure would likely lead you more down the path that it is truely an inferior MI as opposed to an interesting presentation of pericarditis. Just remember to be prepared to dump fluid into the patient and have the ability to place them in trendelenburg if needed. Otherwise though vitals/presentation, I’m going with an inferior wall STEMI anyway. Good news is with the previous pressure 8 hr prior to calling 911, one can be assured that at the ED you will have positive cardiac enzymes if this is a STEMI, takes a couple of hours to make the enzymes really show up.

  • Bob Shumate former paramedic says:

    Pericarditis can cause an MI so a good listen to his chest for a friction rub most likely on the left sternal border. Morphine will ease the pain a bit and get him to a PCI, comfort him. /could be a zebra but better to be on the safe side because Pericarditis untreated can lead to some serious problems. some asprin will help as well. been a very long time since i have even looked at one of these things. i still miss it. patient care.

  • Travis says:

    Anything with st elevation should go to a pci you people are crazy you can never rule out MI completely without bloodwork. Chest pain + crappy 12 lead even if pericarditis should got to a PCI facility period!

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