47 year old male: Holiday Indigestion – Conclusion

This is the conclusion to 47 year old male: Holiday Indigestion. Thanks go to a long time reader Nicholas Eisele for this holiday case! Editor's Note: sorry for the delay, it helps to press "publish"!

When we left off, our patient was in the back of the truck with a burning sensation radiating to his back. We had run a 12-Lead ECG and our partner was wondering which facility you wanted him to drive to.

To answer that question, we should look at the 12-lead!

Frightful Weather We're Having - 3rd 12-Lead

This 12-Lead shows a normal sinus rhythm at 70 bpm without ectopy or bundle branch block. A case could be made for incomplete right bundle branch block given a QRSd of ~110ms. Strikingly we have ST-depression in I, aVL, and V1-V5 with ST-elevation in lead III. Anytime you see flat or downsloping ST-depression in aVL you should look for elevation in the inferior leads (typically III). When present, it is almost certainly an inferior wall MI.

Frightful Weather We're Having - 3rd 12-Lead - III and aVL Closeup

Many readers commented that the ST-depression in V1-V5 could be either a sign of a posterior wall MI or a "anterior ischemia". It is important to remember that ST-depression from ischemia does not localize! This concept is so important, I'm going to list it again:

ST-depression from ischemia does not localize.

Traditional evaluation of ST-depression has taught that focal ischemia may cause localized ST-depression, however, this is not the case. Subendocardial ischemia causes diffuse ST-depression and will not be found in a localized pattern. Any time you have localized ST-depression you must consider it to be a reciprocal change first!

In our case, we have ST-elevation in lead III which clinches the diagnosis of an inferior wall myocardial infarction with possible posterior extension. A subsequent ECG revealed evolving ST-elevation in the inferior leads:

Frightful Weather We're Having - 4th 12-Lead

Remember, all patients who receive one 12-Lead should at least receive a second 12-Lead! If you were not comfortable activating a STEMI from the first clean tracing, serial 12-Leads provide improved diagnostic sensitivity. A single 12-Lead may only identify ~80% of STEMI patients.

The paramedics in this case recognized this fact, activated a STEMI alert, and transported the patient to their nearest PCI center. The in-hospital ECG showed continued evolution of the IWMI with the most impressive elevation and depression of the patient's clinical course:

Frightful Weather We're Having - In-Hospital 12-Lead

They achieved an impressive 83 minute first medical contact to balloon time with one stent placed in the RCA.

Frightful Weather We're Having - Cath Pictures

We hope you've enjoyed this case as much as we did, but more importantly this case presents some great teaching points:

  • Sometimes STEMI patients will have atypical symptoms.
  • A single ECG is not enough to detect all STEMI patients, serial 12-Lead ECG's should be acquired on all patients who receive one.
  • ST-depression from ischemia does not localize, localized ST-depression should be considered a reciprocal change until proven otherwise.


  • Alex Kroeze says:

    Quick question Christopher and I thought I'd ask here so others can see, how do I get my monitor to print off the computer measured J point readings with my 12-lead like that?  I work in two services, one with LP12 and one with LP15.

  • Alex,

    The LP12 I do not believe can be configured to print the J-point measurements. As for the LP15, I thought printing of STJ measurements was the default and I cannot find any configuration options to the contrary. Although, interestingly enough, I have a 2008 version of the LP15 manual which does not include STJ measurements, which when compared to the 2010 version of the LP15 manual shows the addition of the STJ measurements.

    My guess is you have an older version of the software on your LP15's. I'm going to get ahold of my contacts at Physio-Control and find out for you!

  • Bradlee says:

    The only thing that I have a question about is why they waited 15 minutes to get the first 12 lead? Other than that, Great job by the crew!!!

  • Ana says:

    The cath image doesn't look like a RCA to me, more like a LCX.
    other than that great case, wonderfully explained.

  • BH says:

    Brandlee- it says "First medical Contact," which would be the engine crew who were jonesing for a refusal.
    I hope the ambulance crew gave them a sound Gibbs-style dope-slap later.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

“Bad heartburn” – 82 y.o. female without chest pain.
I would do a v4r to see if right side involvement as well as posterior v8-v9. Based on the pt not presenting hypotensive this can be RCA occlusion caused by disection of thoracic aortic aneurysm! Debakey type 1 aneurysm! No catch lab however surgical intervention would be required!
2015-10-01 16:47:29
“Bad heartburn” – 82 y.o. female without chest pain.
It's most likely a RVMI because the ischemia/infarction has effected the SA node. IWMI with bradycardia should highly suspect a RVMI. Not all RVMI's are preload dependant. Do a 15 lead ecg to verify V4R elevation. Have 2 IV's established with a bolus of at least 1L of fluid before giving nitrates. If the pt…
2015-10-01 08:55:01
“Bad heartburn” – 82 y.o. female without chest pain.
I kept feading this thread to see how long it'd take for someone to call it as it is 'inferioposterior MI' and the prize goes to iliyas on Sept 11.
2015-10-01 04:08:23
Kevin Dittrich
“Bad heartburn” – 82 y.o. female without chest pain.
S-T (J-Point) elevation in II, III, and AVF are clear. There are no repol abnormalities. There are even reciprocal changes. IV with fluids is a must but beyond that, what else is there. Females, especially, present with atypical symptomologies. Be ready with fluids, but treat with standard AMI protocols. Presentation, ECG, age, sex, it's not…
2015-09-30 13:37:09
“You Make the Call” — 86 Year old Female: Dizzy
There is no LBBB as QRS <120ms. Diagnosing LAHB in a patient with LVH is difficult. ST elevation is appropriate for LVH. 1st degree HB rarely causes symptoms, but when combined with a betablocker could be problematic. I'd want her to have 24 hours telemetry monitoring to rule out cardiac causes of dizziness.
2015-09-29 04:48:04

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