62 year old male: Chest Discomfort – Part II

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:
 
Well Page Him Again - Initial 12-Lead
 
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:
 
Well Page Him Again - Repeat 12-Lead
 
  • 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?
 

9 Comments

  • FB says:

    Wellen’s reperfusion T-waves. Probable prox LAD lesion. Find a mountain, ask him to run up it and see if he goes into V-Tach. Macimum medical therapy, can probably wait for cath lab until the morning as long as his pain doesn’t return.

  • Alex says:

    In itself, the second ECG isn't obviously diagnostic for anterior STEMI either. But, in combination, the changing morphology is highly suspicious and I would be asking for PCI.
    Are we seeing Wellens waves or is it ST elevation coupled with T wave inversion (or biphasic Ts)? I don't know.
    In more general terms, with border line ECGs I tend to fall back on the clinical presentation:
    Cardiac sounding chest pain + borderline ECG = PCI
    Atypical chest pain + border line ECG = nearest emergency department
    That said, changing morphology is enough for me to want to activate PCI. It's highly suspicious and I wouldn't know how to assess whether it needed immediate or delayed investigation so the safe option is to call PCI as soon as possible.

  • Floyd Miracle says:

    Patients dont typically have pain during wellens t-waves. The patient needs urgent PCI before this turns into a anterior stemi. Regardless if it is typical vs atypical wellens I believe that the dynamic changes themselves warrant agressive treatment.

  • Robert says:

    W W W elllllllens

  • Travis K says:

    Wellens waves!!

  • Justin P says:

    I think urgent PTCI is warranted, are we waiting for heart muscle to die before we cath him? yes he may be pain free but the histroy, combined with an evolving EKG, suggest something is happening, Did we dialate his coronary arteries to cause a reperfusion syndrome or is this some type of unstable angina? Either way this guy needs investigation of his coronary arteries and likely stent placement, just a matter of do you think its urgent to transfer for urgent catheterization; I would err on the side of caution and transfer immediately.

  • Ed Shipley says:

    So we decide the guys goes to a room for the night.  He is still at a non-pci hospital.  What happens in the middle of the night when he really goes down hill.  As someone that has been "this patient", I can tell you you may be signing his death warrant.  It takes time (there goes muscle) to get a Doc up to the floor in the middle of the night.  As much respect as I have for MD's, I had one that was clueless about ECG's.  I was showing her my need and begging to go to the Cath lab (I was at an outstanding cardiac hospital with 24 hr cath lab).  I begged to go back to the ER, but that is not allowed once you are on a regular floor.  My wife finally contacted a friend Cardiologist and he got me in.  I heard my Cardiologist giving this floor Doc a lecture about ECG's.  She almost killed me and STILL billed me $300.  In this 62 year old guy's case,they will have to call a transfer ambulance in the middle of the night.  More time, more muscle.  He gets to the new hospital and they do their evaluation.  More time, more muscle. At the very least, this guy should be transferred immediately to a PCI hospital and be put on 24 hour cardiac monitoring.  He should be evaluated by a Cardiologist now.   

  • Erin says:

    LAD coronary T-wave syndrome - Wellens !!!

  • This is particularly interesting because the first ECG has a computerized QTc that is very short (375) for either Wellens’ or anterior STEMI. Then the one with Wellens’ has a more typical QTc (422)

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Ivan Rios
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
Thanks for writing Tyler. They are the same thing. Strain pattern is just the result of increased pressures against the ventricles which alters the way repolarization occurs from epicardium to endocardium. Similar to stepping on a puddle of water. Your show spreads the water away from the area of pressure. The ST segment is slightly…
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Tyler
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
Can you explain how these ST segment and T wave changes can be differentiated from right strain pattern?
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