Snapshot Discussion: 64 Year Old Male–Chest Pain

This is the discussion for "Snapshot: 64 Year Old Male–Chest Pain".

First, let's talk about the patient presentation.What is concerning is the substernal chest pain, radiating to the shoulder and neck area. While this occurred about 30 minutes after exercise, it did not occur during exercise, so that is somewhat atypical. Still, enough red flags in the history to be very concerned.

Here is another look at the 12 lead:

It is a regular sinus rhythm, at a rate of 65. The PRI is on the long side of normal at 200 ms, and the QRS is slightly wide at just over 100 ms. The axis is normal, and there does not appear to be anything causing secondary ST changes.

The question is, do we see signs of ischemia on this ECG?

This is not an obvious ECG, so as we would expect, many of you said yes, and many said no. Is this a normal ECG? We don't have an old ECG for comparison, but I would say this ECG is not normal.

Let's break it down. What jumps out at me most on this ECG are the morphologies in leads I and aVL:

 

 

There is almost 1 mm of flat ST depression in lead I, and a very notable T wave inversion in aVL.

While the T waves look large in leads III and aVF relative to the size of the QRS, there appears to be no ST elevation at this time.

Dr. Stephen Smith, of the famed Dr. Smith's ECG Blog, has written numerous times that depression and/or T wave inversions in aVL will often precede ST elevation in the inferior leads in IWMI.

Also see this recent case by Dr. Amal Mattu for another case on this subject.

Are there any other findings on this ECG that might support these concerns?

There is about 1 mm of ST elevation in V1. Could there be RV involvement? 

At the very least, I would be very concerned about a developing IWMI. The patient's discomfort is diminished, but not resolved. His complaints of "indigestion" are common with IWMI, and diaphoresis is another red flag.

Having said that, would I activate the cath lab based on this ECG? I have to say I would probably not activate based on this ECG alone.

I think this ECG is very concerning, but not yet diagnostic. I would certainly acquire serial ECGs and scrutinize the inferior leads for any subtle signs of change.

Dynamic changes would be a clincher. I would also treat with ASA and NTG, and would divert to PCI center if any changes in the ECG evolved.

This being a "Snapshot" case, we do not have follow up on this patient, or repeat ECGs. 

We run into this in the field often. The spectrum of ACS is far and wide, and we are often presented with borderline ECGs.

I think the best course is to treat based on what is best for the patient, and do serial ECGs!

Thanks for all of the insightful comments on this case!

Any additional thoughts?

 

 

6 Comments

  • Kelly Reynolds RN says:

    As a cath lab nurse, and as a CCU nurse, I fully agree that this patient needs serial ECG's and enzymes.  I would also venture to say, depending on the patient's own prulersonal health history and that of his family he may well be triaged into the cath lab without waiting for much more than initial lab work.  It is not remotely uncommon for patient's with coronary disease to have spasm during or after exercise that resolves relatively quickly, and why would or should we wait for him to "rule out" if he meets other criteria for a left heart cath?  I believe that too often patient's who exercise and eat right are dismissed and treated medically without invasive diagnostics, only to present with a STEMI some time later.  All hail to the EMS workers, you carry the weight of the world on your shoulders, and make some stellar catches every day with your good judgement.

  • Matt134 says:

    Textbook “treat the patient not the monitor” case. There’s a reason for the chest discomfort. Treat that.

  • Wthomas says:

    St elevation would be the mirrored image in v4 v5 v6..curious as to possible posterior event.

  • Kirk Ney - Paramedic says:

    I agree with the above postings, treat the patient and use the 12 lead as a guide.

  • Dr. Mattu states that a T-wave in V1 that is larger than a T-wave in V6 should cause concern, and indicates an AMI.  

  • VinceD says:

    @Adam Thompson – While a new-tall-T-wave-in-V1 can indeed be an ischemic change, it is an extremely subtle sign and has to be used carefully.

    One of the key features is the inclusion of the word "new." There are a lot of people out there with upright T-waves in V1 for a variety of reasons and it can be a perfectly normal finding in some patients. If you have an old ECG for comparison and their T-wave that was previously inverted or shallow in V1 is now upright, that can be quite significant, but one of the toughest features of this case is the lack of a prior ECG for comparison.

    That being said, I agree that in this case it is almost certainly a significant finding, but I would avoid saying that it "indicates an AMI." Nice eye!

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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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