Discussion for 51 Year Old Male: Chest Pain

Here is the conclusion to 51 year old male: Chest Pain. You may wish to review the case.

Here is the ECG again:

 

There is a regular sinus rhythm at a rate of about 70. The QRS is narrow. The axis is normal, at about 15 degrees.

Let's take a look at the constellation of ST changes:

There is ST elevation in leads I, aVL, V2-V6. There is slight ST depression in III and aVF (and arguably in lead II) with ugly looking T wave inversions. Some of you also noted the suspicious looking Q waves in III and aVF.

Pericarditis and Early Repol were put forth as possibilities. Remember though, that neither of those will have reciprocal changes (excepting myocarditis, which may present as STEMI). Here, we have reciprocal changes inferiorly. If you were inclined to be thinking about STEMI mimics in this case, those changes should put ischemia at the top of the list.  In addition, as some of you pointed out, the ST changes do not look like Early Repol, and the amount of ST elevation here is alarming.

The crew in this case, along with the physician, decided this was STEMI. The patient was given Heparin, ASA, anti-emetics, and Morphine. His condition improved enroute, and his BP climbed to 124/75.

Upon arrival at the hospital, he was taken directly to the cath lab. There was a complete blockage of the LAD.

 

Here is the cath lab image showing the blockage:

Here is the image after revascularization:

 

I don't know about you, but I always find these images amazing. Fortunately, our patient was discharged from the hospital to cardiac rehab a few days later. He was expected to recover nicely. 

Enjoy the holiday!

 

 

 

 

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
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
CB
57 Year Old Male–Chest Discomfort
Given what he was doing (paint fumes on ladder painting) I would first question if the pain is reproducable. Yes his ekg isn't normal but looks like old inferior MI. And he is hypertensive. 02 a must. Def. would give ASA. First would give morphine and see how his cp and bp are. If still…
2014-08-29 11:37:25

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