69 year old female CC: Shortness of breath, weakness

Here's a case submitted by a faithful reader who wishes to remain anonymous. He has submitted several cases before and they are always excellent so thank you, Mr. Anonymous! 

EMS is called to the residence of a 69 year old female who is complaining of sudden onset of shortness of breath and weakness.

  • Past medical history: Healthy
  • Medications: None

The patient is seen in the emergency department of a local community hospital where she is found to have slight J-point elevation in the anterior leads.

(The vital signs and results of the physical exam are not available.)

Approximately 2 hours later there is a slight change in ST-segment morphology and new T-wave inversion in lead aVL. A cardiologist is consulted via telemedicine at the tertiary care center and the decision is made to transfer the patient.

Concurrently with this decision the patient is given 3 doses of SL NTG with complete resolution of her symptoms.

The transport ambulance arrives and records the following 12-lead ECG.

Several more are recorded en route. Here's the ECG captured on arrival at the PCI-hospital.

Do you think this patient is having a STEMI? Why or why not?

14 Comments

  • Ankit says:

    The ECG does not look good for sure, especially leads II, III, aVF and V5 and V6. Three SL NTG relieved the chest pain is a pointer in the direction of an acute coronary event, but the decision to go for PCI or hemolysis should be preceded by Cardiac enzymes. 

  • Brooks Walsh says:

    Pretty subtle stuff!
    The STE in the inferiors, as well as the TWI in aVL are thought-provoking, but the ST segement in V2-V3, along with an oddly biphasic T-wave make me wonder about the LAD.
    Well, it sounds like she's going to the lab soon, regardless.

  • dr ganesh says:

    no pt nt having STEM. no st elevation of >2mm in ant leads or>1 mm in chest leads

  • akroeze says:

    It would appear that at no point did the patient have pain, just SOB and weakness and combining that with no known history make diagnosis from symptoms alone very difficult, definitely not a classic presentation.

  • Mohamed Wafiq says:

    It is a case of pending STEMI, 1st EKG showing us upsloping ST elevation inferior & Anterior chest leads, although it still Non significant but clinical symptoms of SOB & its improvement by 3 SL NTG, plus the Bradycardic side of her ht rate, all of these give us the motivation to proceede to next step & have a look to her Coronary tree, sure Cr Tr T biomarker also is usefull , & if it is high sensitivity one it will be more appreciating. all the best.

  • VinceD says:

    I'm really on the fence for this one. It would be nice to see that initial ECG and get a feel for just how much aVL has changed, but assuming it's legit, that finding gives a lot of weight to this being an acute process. Still, I wouldn't  activate the cath lab in the field with only these tracings, and my gut tells me this isn't a STEMI. Then again, my gut has been wrong plenty of times, and until proven otherwise, I have to think worst-first. Also, these were done on a pain-free patient, so maybe a tracing when she was experiencing pain would be more impressive. Final call? Not a STEMI if I'm looking at these tracings in isolation. I'll be just as happy if I'm wrong though.
    @Dr. Walsh – I'm thinking a lot of that biphasic appearance in the precodial leads is actually an illusion. The tail end of the T-wave actually never dips below the baseline, but it just looks like it does because of the U-waves that follow.

  • Nick Adams says:

    69 y/o FEMALE (atypical cardiac presentation)……..with a SUDDEN onset of SOB and weakness.  Sounds like an ACUTE cardiac event so far.  No PMH or RX.
    ECG (12):  SB @ 48 bpm, normal axis, no enlargements or hypertrophy.  Slight 0.5mm STE in inferior leads of leads II, III, and aVF,and in V3 with reciprocal TW inversion in aVL, poor r wave progression in the right precordial leads (lead placement?), Biphasic TW's in V1 through V4.
    NTG x3 resolved the symptoms in the presents of subtile ST and TW changess? = cardiac.  I would bet that this pt's cardiac enzymes comes back boarder-line or normal.  This patient is suffering from a proximal LAD occlusion.  It may or may not be 100% right now, but she also needs ASA, NTG gtt, and a PCI center for a PTCA before she is 100% occcluded.
    WELLEN'S SYNDROME

  • KenO says:

    Hmmm… I’m not really seeing the Wellens. I just don’t think I can call those biphasic T’s. If they are it’s reallllly subtle. I do see the inverted T in AVL which I understand is an early indicator of MI, I also see symmetrical, straightened, flattened T’s. Little to no STE in II, III, AVF and no reciprocal changes. I see 1mm STE across the precordium. I’m thinking anteroseptal MI with inferior involvement soon to come. Get Serial ECG’s. And that QTc looks pretty darn long although I haven’t measured it.

  • Bryan L says:

    Pt is experiencing a acute STEMI most likely LCA, possibly left main.
    - poor R wave progression in the right precordials
    - STE in the right precordials (V1-V3)
    - slight STE in the inferior leads
    - proven new onset T wave inversion in aVL, reciprocal change?
    Add in an elderly female having atypical symptoms (or typical for her!) of weakness and SOB!
    Can someone point me in the right direction regarding some material regarding ST segment morphology in relation to ACS?  I'm totally clueless in this area!   Although the ST segments in the right precordials do seem flat to me in both EKGs, but I don't have a prior reference to compare.
     

  • gman says:

    She is not ACS. Looks like LBBB causing the elevation. Probable pulmonary embolism.

  • Chee Yong Chuan says:

    69 year old lady with no cardiac risk factors presented with shortness of breath and weakness. Index of suspicion must always be high especially among women who present with atypical symptoms like shortness of breath, weakness, diziness.

    ECG shows:
    1) Normal Sinus Rhythm with each QRS complexes preceded by P waves
    2) Axis normal
    3) Narrow QRS complexes with regular R-R interval. Heart rate: 48 bpm(bradycardia)
    4) P wave morphology and PR interval within normal limit
    5) Subtle 1 mm horizontal ST elevation over inferior leads(II,III,aVF) with reciprocal changes seen over in aVL(subtle ST depression with T wave inversion)
    6) Subtle convex ST elevation (1mm) over anterior precordial chest leads(V1,V2,V3)  with straigtening of the ST-T segment and biphasic T waves
    6) Poor R wave progression with mean R wave amplitude from V2 to V4 less than 5mm

    All these features are consistent with actue antero-inferior STEMI. A right sided leads must be done to look for right ventricular involvement(although less likely as lead I has no changes)

    She should be transferred to the nearby hospital with PCI fascility

  • johan theunis says:

    T inversion in aVl
    Wellens V2-V4
    go to kathlab-> LAD lesion?

  • Vince D says:

    Changed my mind again. I'm calling it STEMI. There's too much ST-elevation in V3, and probably V4 if there wasn't so much wander. I also don't like the very slight ST-elevation in the inferior leads.

  • Samuel says:

    Yes there is STE but not enough. I don't see two adjacent leads with STE above 1 mV or 1,5 mV in V2-V3. Also all the ST-T-segments are benign looking. I haven't really investigated the possibility of Wellens syndrome but I wonder if KenO isn't right, that we're really seeing U-waves and not biphasic T-waves. All of the above could be explained by hypervagotonia (which also would result in bradycardia). However, with the poor R-wave progression V1-V3 (which in no way has to be recent by the way) and the recent T-wave inversion in aVL I would suspect NSTEMI/Unstable angina – the troponin levels will decide.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Brian
Rate Related VS. Primary ST-T Changes:
Afib. There is widespread depression in most leads and aVR has some elevation...but I am skeptical about this ecg. If a quick fluid challenge of 500-1000cc did not slow down the HR I would give him some diltiazem (5mg increments is our protocol or 0.25mg/kg) and slow the rate down a bit and see if…
2014-09-19 21:02:48
Michael Schiavone
Rate Related VS. Primary ST-T Changes:
Isolated ST elevation in AVR with ST depression in several leads. Rapid, irregular rate suggests AFIB with RVR. I would provide entry note with this exact description and leave it to hospital whether or not to activate cath lab. My EMS treatment: IV access, 324 mg. ASA, NTG, Cardizem .25 mg/kg over 2 minutes, consider…
2014-09-19 20:30:35
Dayne
Rate Related VS. Primary ST-T Changes:
AF with RVR @167, LVH and prolonged QT. ST depression to I,II and V3-6 and reciprocal elevation to aVR equal to or >1mm highly suggestive of LMCA or 3-vessel disease. High specificity for proximal occlusion. Aspirin, GTN, IV access, Spo2 >95%, Transport to nearest PCI/Cath Lab facility ASAP
2014-09-19 10:52:36
Dayne
Rate Related VS. Primary ST-T Changes:
LMCA/3-vessel disease
2014-09-19 10:42:59
Christopher Watford
59 year old male: chest pressure – Conclusion
Tony, From the initial ECG it appears that the pattern of ST-elevation is suggestive of a proximal RCA occlusion. However, at cath it was instead found to be an LCx lesion. Good question!
2014-09-18 13:20:09

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