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
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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