68 Year Old Male: Chest Tightness – Part 1

A 68-year-old male presents with a chief complaint of chest tightness that started at rest approximately three hours prior and has been constant ever since. He desribes it as a vice-like sensation limited to the central portion of his chest. Nothing makes the pain better or worse and he rates it at about a 6 out of 10.

At a glance the patient appears pretty healthy. He is well-nourished and of normal weight, does not smoke, and feels alright aside from the nagging discomfort in his chest. His skin in warm, pink, and dry and his radial pulse is strong, fast, and irregular.

Vitals are as follows:

  • HR  approx 125 bpm, irregular
  • BP 110/58 mmHg
  • RR 18 /min and unlabored
  • SpO2 96% on room air
  • Temp 37.1 C (98.8 F)

Past medical history is significant for well-controlled hypertension, DVT/PE two years prior, and incidental coronary artery disease noted on a chest CT performed for the PE.

His medications include only amlodipine for hypertension and ongoing warfarin therapy for the prior PE/DVT.


Because of the patient's chest pain and irregular pulse you perform a 12-lead ECG and see the following…


And, because it's the future, you also have immediate access to a copy of the patient's ECG from two years prior at the time of his PE/DVT…


What therapies are you going to implement to treat this patient?

Are you going to activate the cath lab?

See also: Part 2: 68 year old male CC: Chest tightness


  • Chris Touzeau says:

    Critical legion of the left main or LAD.

    The diffuse ST segment depression represents reciprocal change to the STE in aVR.

    This is a STEMI equivalent requiring emergent surgical reperfusion.

    Patients who present with this constellation of symptoms and EKG changes have a higher incidence of mortality if they are treated only medically.

    Neat case.

  • Sanders says:

    LBBB , Afib , anterior hemi block. STEMI ! Cath lab.

  • James says:

    The old left main occlusion.

  • Michelle says:

    I don't see ANY AFIB, I would call this Acute Pericarditis. IV O2 Monitor, Asa, closest appropriate hospital. Monitor him for changes, priority 2 transport….I don't see a LBBB either

  • Jason says:

    I'm thinking CAD with the wide spread depression and elevation in AVR.  Rapid transport to nearest facility.  ASA, O2, IV, possible Fent for pain relief.  Pads on and ready just in case.

  • devkrev says:

    I would treat this as a rate problem/possible new onset A. fib. Vagal, 6mg then 12 mg of adenosine, if no conversion then max of 20 mg cardizem super slow IVP to get the rate around 100, I would take another EKG at that point and see if the ST depression/chest pain improved. Probably some fluid too. If the CP didn't go away at that point maybe consider ACS at that point. I'm not activating the cath lab though. I would probably give him 324 mg of ASA too, for good measure.

  • Chaz Justet says:

    Posterior MI – Diffuse ST depression, flip the sheet and you'll see elevation.  Run posterior leads and your elevation will show up as well.  Yes I would activate cath lab.

  • Steve S. says:

    Acute left main ACS with stenosis which causes subendocardial ischemia. Pt. needs CABG. Not a STEMI

  • Mia says:

    I would get a better history to see if any thing else is going on, like a stressful situation . O2, Asa, monitor,closest facility. 

  • Cathy P says:

    With ST depression acquire posterior ECG treat with MONA inform receiving facility of STEMI and inform cath lab. With patients history and current 12 lead the possibility of posterior STEMI is very proble 

  • Matt says:

    first off, adenosine would not help afib…2nd, the heart rate is only 125…incomplete lbbb…left axis deviation..st depression…ACS protocol would appropriate

  • Scary Medic says:

    Look around back and right side.  Determine where this STEMI shows up then consider nitrates, Beta blockade and alert the STEMI Team.

  • Tommy Watson says:

    I agree with the posterior MI. Diffuse ST depression in all leads excluding the expected aVR. Perform a posterior 12-Lead for confirmation. Activate STEMI alert, O2, IV access, aspirin, fluids, titrate morphine and nitro. 

  • Bill says:

    I agree with Chaz… Posterior MI

  • Steve says:

    Posterior 12lead is called for, along with ASA and a phone / radio call to the local PCI facility.  

  • DR Cuong says:

    LM OR serve Three branch, CABG not PCI!

  • Dane Friley says:

    This pt could very well have left main disease, but it is really hard to believe that he has an acute left main occlusion. Other than the afib his vs are stable. If this were an acute occlusion of the lmca I would expect dyspnea, labored resp and probably not a sat of 96% on ra. I would also maybe expect fluid in his lungs. He may very well have a posterior infarction. Obtain a posterior view to confirm. this is most likely new onset atrial fib with rvr. At this time rate is not that fast, but how fast was it three hours ago when it started? Could this be ischemia from a rapid hr? He also meets voltage criteria for lvh in lead avL. Again this pt could have left main disease, but I don't suspect acute occlusion. I would expect this pt to be dead already or close to death if it were acute occlusion. I'm very anxious to here results! None the less pt should be treated with acs protocols. If your posterior leads are negative you are going to have a hard time getting cath lab activated at least where I am located!

  • Dane Friley says:

    Pt also has pathological lad so this is very tough call

  • Chuck says:

    Would use ACS treatments, and transport to nearest hospital.  The rate is only 125 not high enough to treat with meds, nor do I see any elevation in any lead but one.  It is all depression at this time, the elevation was probably when it first started three hours ago and now the damage is already done.  He needs evaluated for prevention of further damage, and to develope a care plan. 

  • Dane Friley says:

    Most likely triple vessel disease

  • Lynn says:

    I agree with the posterior MI call… Perform a 15 lead and V4R. In the meantime, treat according to ACS protocols, but hold off on the Nitro til the patient is better situated. I would also treat the patient with a fluid bolus of NS to see if that would help bring the heart rate down and bring the B/P up so that Nitro might be used, but ASA and O2 first. Fentanyl for pain management. I don't see elevation, but I do see depression all over the leads, particularly the ones that would lead to a posterior MI call. Contact Medical Control and let them compare old and new. As far as where to transport the patient-always err on the favorable side for the patient. (And auscultate the lung sounds to see if you can pick up on a 'pleural rub' sound-just in case..)

  • @devkrev
    Why would you choose to lead with adenosine if you correctly identified the rhythm as rapid atrial fribrillation? What would that offer someone with an irregular narrow-complex tachycardia?

  • @Dane Friley
    I just wanted to say that I like where you head is at in how you would handle this case.
    In regards to the high voltage in aVL and left-axis deviation you spotted, there's a specific entity that can explain both of those findings plus the poor R-wave progression seen across the precordial leads. What you're seeing here isn't LVH, though it's possible this condition can hide pre-existing LVH, so we can't rule out it's existence based on the EKG alone (but what else is new?).

  • @Everyone calling LMCA/triple-vessel disease
    Demand ischemia secondary to a rapid HR, as is commonly seen in atrial fibrillation w/ RVR or SVT's, can produce a picture of subendocardial ischemia with diffuse ST-depression and ST-elevation in aVR.
    How do you know that's not the case here? Can you still make the call in light of the patient's tachycardia? Even if the rate was slower and demand ischemia wasn't in play, is diffuse subendocardial ischemia something you are actually able to activate the cath lab for in your region?

  • Greg says:

    Patient does not present with enough symptomotology for STEMI Cath lab activation and would best be treated monitoring and with pain management. Agreed new onset AFC but only symptom is pain. HR and patients mental status dictates his treatment.

  • Jason says:

    There is STE in lead AVR. This does not occur in demand ischemia from rapid afib. As Mark Josephson likes to say, "AVR points to heaven!" This is a left main or proximal LAD occlusion. There is more than enough here to activate the cath lab, especially with that history. This man is relatively yound and active. Would be a shame to sit on his MI. 

  • David says:

    Likely LMCA occulsion; less likely LAD occulsion / 3VD. 

    Diffuse ST depressions (I see depressions everwhere but aVR [which has significant elevation] and V1). Almost global depressions indicate subendocardial ischemia (producing reciprocal change in aVR) and probably not caused by an isolated posterior STEMI. 

    STE in aVR > V1 favors LMCA over LAD. 


  • Chee Yong Chuan says:

    Interesting tracing you've got there. Here's my 2 cents worth

    1) Not a sinus rhythm. No upright P waves seen in all limb leads preceding QRS complexes. Rhythm is irregularly irregular beating at a rate of about 120beats per minute. QRS complexes narrow. 

    2) Pathological left axis deviation. rS complexes with deep S waves seen inferiorly with qR complexes observed in I and aVL suggestive of left anterior fascicular block. R wave althought tall in aVL(satisfied criteria for LVH) is probably due to presence of LAFB.

    3) Marked ST coving and elevation seen in lead aVR followed by T wave inversion. 

    4) Marked horizontal ST segment depression observed over the inferolateral leads: II,III,aVF,I,aVL,V2-V6. A pattern suggestive of extensive subendocardial ischemia. ST segment isoelectic in V1

    5) No definite sign of infarction yet, no Q waves, QS seen in V1, but a definite R wave is seen in V2

    6) QRS alternans(subtle variation in the height of QRS complexes) common in Afib with RVR

    7) Poor R wave progression in comparison to the baseline ECG

    Impression: Afib with RVR with evidence of severe subendocardial ischemia. The presence of STE in aVR coupled with diffuse ST segment depression over the inferolateral leads may suggest left main disease, severe triple vessel disease or even critical proximal LAD stenosis! 

    Comparing this tracing with the previous one(2 years ago), things which are new:
    1) New atrial fibrillation
    2) New LAFB
    3) Although subtle STE in aVR was already present previously, this time, it is more marked
    4) QS complex in V1 was new
    5) Poorer R wave progression over the anterior precordial leads

    Taking all into consideration. This might be a presentation of left main UA/NSTEMI, very unlikely to be left main STEMI. Patients with left main STEMI usually present with global STE instead of widespread ST depression. And they don't usually survive to the hospital, usually a victim of cardiac arrest en route. Such patients with suspected left main disease should be sent to a PCI capable hospital, as urgent(not emergent) PCI for revascularisation is usually needed and medical therapy is usually futile. Should be managed as high risk unstable angina/NSTEMI

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Conclusion to 59 Year Old Male: Unwell
Great discussion on a difficult 12lead! I follow these very closely and based on pt presentation and 12lead tracing, this was a difficult or to treat with impending heart failure, hypotension, and trouble breathing. Thanks for the follow up and look forward to next week!
2015-07-06 20:53:35
Conclusion to 59 Year Old Male: Unwell
Hmmmm, I was fairly close. Sounds like most of the treatment occurred IN Hospital. Love case studies, and that one was good.
2015-07-06 20:28:25
59 Year Old Male: Unwell
There's the point! There is are no P waves, and the rhythm is irregulary-irregular-atrial fibrillation. If you look, it is rsR phenomen-RBBB, BUT there are huge ST elevations on all leads from V1-V5 (that's why the QRS complexes look so broad). I and aVL is clearly ST elevation suggesting STEMI. In limb leads you can…
2015-07-06 10:12:16
Vince DiGiulio
Conclusion to 59 Year Old Male: Unwell
I'll expand on this in the next post but unfortunately I actually wasn't present for this case so I can't give my direct account of how things happened. That said, from the notes I read and word-of-mouth from those involved (which I suspect painted things in a better light than I would have viewed them),…
2015-07-06 04:09:22
Matt King
Conclusion to 59 Year Old Male: Unwell
Hey Vince thanks for the through follow up with this case. I am curious how his rate was controlled since he was hypotensive and maybe an unknown onset of when his A-Fib stated(thinking anticoagulation first)? As you know the wrong approach could be devastating in this PT with risks of further infarction, stroke, or death…
2015-07-05 14:10:57

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