Today we're presenting a case from our friend Dr. Brooks Walsh of Mill Hill Avenue Command and Doc Cottle's Desk. In fact, this case is being presented both for his readers and for ours! We hope you like it.
You're working ED triage when a 63-year-old man walks in complaining of substernal chest pressure that had awoken him from sleep 2 hours prior. He denied any radiation of the pain, but complained of some mild presyncopal symptoms. His wife reported that he had had intense diaphoresis at home. He reported having a similar episode 1 year ago, but a subsequent stress test was negative.
You obtain a quick history:
- PMHx: HTN, type 2 diabetes mellitus
- Meds: irbesartan, insulin
- Allergies: NKDA
A quick set of vitals are obtained:
- HR: 90
- BP: 145/123 (NIBP)
- RR: 16, unlabored
- SaO2: 98% r/a
The physical exam reveals a patient with mild sweating, but no JVD. His lungs are clear, there are no cardiac murmurs, and he does not have any lower extremity swelling or tenderness.
You obtain a STAT 12-Lead ECG:
The patient is taken back to a bed, 324mg of aspirin is administered, an IV is started, and labs are drawn. The patient receives 0.4 mg SL nitroglycerin and 5 mg morphine, both without relief. Metoprolol is given for the patient's hypertension and a heparin drip initiated. Cardiology was consulted and believed the ECG to be non-specific.
Per the ED physician, an ECG is performed 15 minutes later to assess the right side of the heart. Note that all of the precordial leads were reversed (e.g. V2R = V1):
Due to persistent chest pain, a nitroglycerin drip is initiated and titrated up to 132 mcg/min without improvement in chest pain. A loading dose of clopidogrel is given.
An hour after presentation the ED physician asks for a posterior ECG:
Labs return a troponin of 0.05 (normal is < 0.04). A CBC and basic chemistry panel were essentially negative.
- What does the first ECG show? Is it diagnostic?
- Do the right-side and posterior leads help with diagnosis?
- If this is a STEMI, what coronary artery is likely involved?