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

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68 y.o. male with weakness: “Treat the monitor, not the patient?”
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2015-04-29 12:31:37
The 12 Leads of Christmas: V2
Thank you for your response. By all means, take your time! As for the source of the first figure, I got it from the book "Essential Cardiology: Principles and Practice - 3rd edition" by Clive Rosendorff - Chapter 7, Figure 7.3 (Page 97). It's one of the rare texts where I found a mention of…
2015-04-27 06:52:25
Vince DiGiulio
The 12 Leads of Christmas: V2
Your questions on this topic are some of the best I've encountered—no need to apologize! It makes me very happy to see this post reaching the right people. I'm working non-stop the next two days but I will get back to you soon with my full response. Two things to start: First, where did you…
2015-04-27 05:14:11
68 y.o. male w/ weakness: conclusion – “Treat the monitor.”
Very informative case! Thank you for sharing..... I will be using it to teach our paramedics and residents (if you allow me to)..... Keep the great working going guys!
2015-04-27 03:05:29
The 12 Leads of Christmas: V2
Thank you so much! I wonder why this information is not found in ECG texts. I have a query though. The critical information seems to be the fact that leads V1 and V2; V3; and V4-V6, each are physically located on a different transverse plane with respect to the theoretical electrical center. (Also mentioned in…
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