This is part two of the three part series, 62 year old male: Chest Discomfort. As before, clinical details have been altered for educational purposes and to protect patient and provider privacy.
When we left our patient, he was experiencing the latest in what had become a series of episodes of minor chest pressure. A 12-Lead was acquired, and is given below:
He looked pretty good, but as most of you noted, his ECG was at best borderline, and at worst, diagnostic of anterior STEMI. We'll hold off on our interpretation until the conclusion. So what happened next?
The tech who ran the ECG had the good sense to make this patient a priority and quickly got a physician to lay her eyes on the ECG. Like many of you, she was concerned about a STEMI, but not convinced. There was, however, one important thing she was sure of: even being suspicious of STEMI was cause enough to warrant expedited care.
The patient was immediately brought back to a room, placed on a nasal cannula at 2 L/min, and attached to the cardiac monitor while IV access was obtained and labs were drawn. The physician continued her evaluation and completed a thorough history and physical examination.
However, after leaving the room, she was torn. The patient had a history consistent with angina and a worrisome ECG, but during the previous activities his pain had disappeared yet again.
She put a page out to cardiology, but knew ahead of time that it was going to be a hard sell. It was evening and the facility where the patient presented did not have PCI capabilities on-site. Inter-facility transfer and calling in the cath-lab team would be an extra hurdle if she really wanted to push for that pathway.
When cardiology called back they didn't seem too anxious to come in right away. He didn't have any strong risk factors, the ECG sounded non-diagnostic over the phone, and he was now pain free. They would see the patient, but it would be on a non-urgent basis later in the evening.
So, worried there was more going on than stable angina, the treating physician ordered a repeat ECG. The timing was just about 30 minutes after the first, lead placement was identical, and the patient was pain free without additional intervention:
- What does the patient's 12-Lead show now?
- This 12-Lead was acquired while the patient was pain free, are they in the clear?
- What are your next steps for this patient?