62 year old male: Chest Discomfort

This another great case study from Vince DiGiulio, EMT-CC. As always, some details have been changed to protect patient privacy.

It's Monday night and you're working triage in a busy emergency department. The waiting room is full when a very pleasant 62 year-old man presents to the desk with a chief complaint of chest discomfort. You sit him down in a wheelchair while he gets registered and perform a quick "eyeball" examination.

The patient is a well-appearing middle-aged male in no acute distress, who actually appears younger than his stated age. He is alert, oriented, and answers all questions appropriately, with skin that is warm and dry and a strong radial pulse that's not too fast or too slow. His breathing is unlabored and he states that he has been experiencing some minor chest discomfort for around for two days.

You figure that he's not going to collapse in the lobby and leave to speak with the triage RN while he signs some paperwork. The two of you decide to bring him back to the dedicated ECG nook, where the nurse will perform a triage assessment while you obtain vitals and run a quick ECG.

  • Onset: 2 days ago
  • Provocation/Palliation: He cannot describe any provoking factors, but states "I usually rest and it eventually goes away"
  • Quality: Midsternal chest pressure
  • Radiation: None
  • Severity"Not bad at all, maybe a 3 out of 10."
  • Timing: Intermittent, with spells lasting for 10 minutes or so and possibly increasing in duration more recently. The current episode has lasted at least 15 minutes.

Using an automated monitor, you obtain the following vitals:

  • Pulse: 92 bpm
  • BP: 147/88 on his left arm
  • Resps: 20, unlabored, and clear bilaterally
  • SpO2: 96% on room air
  • Temperature: 37.1 C (98.8 F) orally

At the same time, the nurse elicits the following information:

  • Signs/Symptoms: Intermittent midsternal chest pressure x 2 days. No diaphoresis, nausea, vomiting, SOB, or dizziness.
  • PMHx: No significant medical history besides well-controlled HTN and an appendectomy in his 20's
  • Meds"some blood pressure medication"
  • Allergies: NKDA
  • Last In's/Out's: Dinner
  • Events"This discomfort started a couple of days ago. It comes and goes, but my wife wanted me to get checked out and I finally gave in after dinner when it started to return."

You run the following 12-Lead:

Well Page Him Again - Initial 12-Lead

There is no old ECG in your electronic medical record for comparison, and when you walk back to the main department, you cannot find a physician to look at the tracing. One is performing an I&D of a peritonsilar abscess, while the other is probably with a patient somewhere but MIA.

Every room is filled, most of the hallway beds are occupied, and there is certainly a line forming at the front desk while you're wandering around in back.

  • Are you concerned about this ECG?
  • Do you need to pull a physician away from someone else to look at it?
  • Does he need to jump to the front of the queue and get a room right away?
  • If you were in the field, how would you treat and transport this patient?

18 Comments

  • Nicky G says:

    I am concerned, this ECG does not look normal.
    Sinus @ 90 w borderline 1st degree AV block and STE V2/3/4 (anterior STEMI). No reciprocal changes.
    This pt needs to be treated for ACS based on hx provided. Grab a doctor or anyone authorised to start this pts treatment pathway.
    If I was in the field start Rx as per ACS protocol and activate cath lab.
    Obtain serial 12 leads and administer GTN, aspirin, IV fentanyl, IV heparin, PO clopidogrel.
    Maybe there is more to it but seems straight forward…

  • Kurt says:

    V1 concerns me too. I'd say Anteroseptal infarct. I'd page a physician at the very least. Do the same treatments as Nicky G, except we dont do heparin in our system.

  • Don J says:

    I am concerned as well, but the concave nature of the ST segments in the precordial leads without reciprocal changes makes me think more of LVH and not STEMI, but with the current symptamology he moves to the head of the line and I call a doc to the desk for a look. I would definetly get nitro and ASA on board and activate our ER protocol orders for chest pain and expect an admission but don't think he will be rushed to the cath lab without an acute EKG change or a wildly elevated troponin I

  • Jay B says:

    Im a new medic so barewith me, the J point in 4 is on the baseline alittle, although there is some ST elevation in 2 &3 keep in mind the patient has been having on and off sxs x a couple of days of 3/10 severity. I dont think its a full blown STEMI.  But he is symptomatic so he moves up for a bed, I would interrupt a doc to look at the ECG becuase of the pts symptms. I would do MONA but giving morphine/fetanyl only if his pn is where it causes him anxiety and his BP is high enough. I would not call the cath lab. I see a slight 1st degree block also. Lets see what the labs say. Thats it, hope I didnt make a fool out of myself! If I did, teach me!!!!!

  • Travis K says:

    At frist I was considering LVA due to the QS waves in v1,v2 and the appearance of the T waves.  After closer examination I noticed ST-E V1-V5 and AVL (small QRS= small ST-e) and you have your reciprocal changes in the Inferior leads. 
    1) Yes, I am concerned about this EKG for the stated reasons above. 
    2-3) Yes I would
    4) I would call a stemi on this. The reciprocal changes cliniched the DX for me. Pt would get ASA, NTG, and MSO4 as needed. 

  • Pavlos R says:

    Hello. :)
    SR, 90bpm, no 1st degree AV block ( dont get confused by the U waves), PR is normal. The ST elevation morphology in V1-V4 would posibly make someone think its a normal variant but notice also the poor R progression in V1 to V3 ( actually in V1,2 there is a QS). J point is not very well defined too.
    notice that too : "but my wife wanted me to get checked out and I finally gave in after dinner".     
    He is probably a typical patient who thinks he is ok and wants to go back home quickly, he came to the ER because of his wife. I wouldnt trust him 100%. 
    Its probably an ACS

  • DevKrev says:

    Get leads v7-v9 and check for reciprocal changes.
    A doctor needs to see this EKG, in a hospital setting, usually the docs are the ones that make decisions about EKGs.
    Cardiac Enzymes need to get checked. This guys goes to the front of the line. I can't think of a good reason why this guy should wait.
    Pre-hospital tx:
    Cath Lab activation
    324 mg PO ASA
    IV, 0.4 mg SL NTG q 5 minutes PRN SBP > 100, serial 12 leads, cardiac montior, transport.
     
    The Patient says that he finally decided to come in when the pain came back, it could very well be worst than before.

  • This diagnostic of anterior STEMI. Interestingly, my equation only comes up with 22.45 (< 23.4) because of the short QTc.  However, there is ST elevation and so the differential is normal variant ST elevation vs. MI.  The R-wave amplitude in V2 + V3 + V4 is only 10 mm and this is almost impossible for normal variant.  If there were deep S-waves, one could attribute the ST elevation to that, but there are not.

  • Hugh says:

    Symptomatically I would say that he has a new onset unstable angina, which should get him seen regardless of what his ECG says. That being said, I see a NSR at a rate of roughly 90 bpm, the PRI here does not appear, to me, to be prolonged. I see concerning elevations V2-V4 obviously and a questionable STE in V5 as well. what's concerning to me is that I don't see any real reciprocal depressions that would clinch the deal for me. The ST segments in II, III and aVF that I would expect to see depressed are essentially isoelectric. He certainly gets O2, IV, Monitor 362 of ASA and NTG for pain relief but I doubt if I'm getting a cath lab on this.

  • Ari says:

    New medic here too, but I'm seeing regular sinus rhythm with ST elevations in V1-V4 and I can (but please correct me if I'm wrong) see reciprocal changes in II, III, AVF of about 1mm. Right on the borderline for me, I'd err on the side of caution and certainly get a doc to take a look. EKG like that with intermittant chest pain means he gets a bed in my eyes, as well as O2, IV, Telemetry, ASA, NTG and some blood work to check Troponins. It's really borderline for a STEMi, in the field I'd call a STEMI alert, but possibly in a hospital setting they'd wait for troponins to come back and rule in ACS?

  • Keith says:

    ECG is non diagnostic. This patient definitely needs an overnight stay and a cardiology consult. I would recommend serial ckmb, troponin levels. bnp-t, and d-dimer studies to rule out PE and CHF. Chest films to rule out pneumonia/pleural effusions. That being all clear, a stress test followed by an eco cardiogram. If patient fails the stress test. He’s off for an angiogram.

  • David Baumrind says:

    @Dr. Smith,

    I was wondering if the inferior leads helps you with the diagnosis…There appears to be 0.5 to 1.0 mm of ST depression, but regardless the morphology looks abnormal (flat, slightly downsloping segment).

    Would you care to comment?

    -David

  • Robert says:

    STEMI VS. Ventricular Anareusym. Need prior ecg's to confirm previous changes.

  • Robert says:

    STEMI VS Ventricular Anareuysm.  Need prior ECG's. 

  • Gorton says:

    DevKrev
    How does this help us learn anything?  
    This is what you've chosen to write
    "A doctor needs to see this EKG, in a hospital setting, usually the docs are the ones that make decisions about EKGs."
    I thought the point of this site was to make us (Paramedics) get more comfortable w/ ECG interpretation.  
    Obviously doctors make the descisions in the hospital.  

  • Justin P says:

    I dont see reciprocal changes here 0.5 mm isnt diagnostic for anything, there are no q waves, very subtle r waves in v1-2 becomes progressively larger and 'flips' at v4 that's normal R wave progression. There is also no LVH as evidencesd by the fact that the S+R waves in V1 & V6 are less then 35 mm, R wave in aVL is less than 11mm, etc…. I also dont see any early repolarization or simmilar ST artifacts. So we've ruled out all of those things.. we are left with two possibilites as the previous poster had indicated either normal ST variant or an evolving UA/MI in its infancy. Many MI's dont not present with full blown 8/10 chest pain, diaphoresis, and hypertension. I wouldn't call for a cath lab activation from the field on this but would give my report to the ER DOC not the nurse, and tell them that I have a 62 year old male with progressively worseing intermittent CP, a boarderline EKG AT THIS TIME, and a history/presentation suspicious for ACS.

  • Just noticed David's question.  lead III is suspicious but I don't think you need it in this case.  I'm convinced it is an anterior STEMI with a false negative on my equation.
    I just saw that it did indeed turn out to be MI.
    Steve Smith

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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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