Snapshot Case: 45 Year Old Female–Chest Pain

 

Here is the latest from our "Snapshot" case collection.. 

This ECG was taken from a 45 year old female patient who had "off and on" chest pain for about 24 hours. The discomfort radiated to her left arm, and she complained of some "dizziness".  She denies any associated SOB, or N/V.  The discomfort worsened over the last few hours without relief, so she presented to her PCP.

Her past history is significant for hypertension and uterine cancer, and smoking 1 pack/day.

  • HR: 74 regular
  • BP: 148/86
  • RR: 16 regular, sp02 98% RA
  • Skin: warm and dry

She had received 324 of ASA and NTG x2 from the treating physician prior to EMS arrival.

At about the time this ECG was acquired, the patient stated she was pain free:

ECG1:16x

 

What is your impression of the ECG?

How concerned are you about this ECG?

Would you activate the cath lab?

 

15 Comments

  • Andrew Przepioski says:

    Rate: 75

    Rhythm: Regularly regular, p-wave present, p-waves associated with QRS complex, PR inteval is less than 0.2s (about 0.16s in lead II), QRS is less than 0.12s (about 0.08 in precordial leads). Normal Sinus Rhythm (NSR).

    Using lead V2, QT is 9 small boxes, or 360ms.

    Using lead V2, QTc is 360/((60/75)^(1/2)) = 402 ms.

    Frontal Axis: I and aVF are positive, it's within normal limits. The size of III and aVF makes me believe it's probably about 15 degrees.

    Transverse Axis: There is no R-wave progression. V1 initially has an R-wave, which isn't normal. V2-V5 is about equally biphasic. Based on the frontal axis being normal, don't think this is from a fasicular block. R-wave in lead V1 could be from Right Ventricular Hypertrophy (RVH), but there is no S-wave in V6. R-wave could also be from (incomplete) Right Bundle Branch Block (RBBB), but no S-wave in I and V6, not right morphology in V1. I am very concern about a anterior/posterior infarct.

    Hypertrophy/Enlargement: This doesn't strike me as hypertrophy/enlargement. Too many criteria to test and list here. I really only go through criteria if I suspect hypertrophy/enlargement.

    Q-waves: Insignificat Q-wave in lateral leads I and aVL.

    ST elevation: None.

    ST morphology: Lead V2 is very very concerning for anterior wall infact; looks like beginning of Wellen's Type I.

    T-waves: Inverted in Lead aVL (may be inferior wall myocardial infarct?), inverted/weird T-waves in most precordial leads.

    My overall interpretation is suspected left anterior descending (LAD) occlusion, or anterior wall myocardial infact (AWMI), due to R-wave progression, morphology of ST in V2 (can slightly be seen in V3 too). I would not activate the cath lab yet, but would do serial EKGs to look for changes to confirm what I suspect, and would prefer to transport to a facility with cath lab capabilities. This is a very concerning ECG.

  • Brandon Fortin says:

     Impression :Normal sinus rhythm w/ borderline 1st degree block, normoaxis, anterolateral depression w/ abnormal r wave progression precordially. Nothing to concerning at first glance but if you look a little closer she's quite sick! 

    Concerns: wellens type 1! Very subtle at this point but it's there. Saddleback type t waves in the anterior leads with high and low lateral depression which is very suggestive of a critically stenotic proximal lad! With her symptoms and history and the looks of this ECG I'm thinking the cath lab would be the best place for this patient!

    Cath Lab Activation? Yes! I'm my opinion  the risk factors are there, the hx is there, the symptoms are very suggestive of ACS/CAD and other subtle, the ECG changes are there!

  • P Lem says:

    After having chest pain, persistent biphasic (up then down) T wave in the mid precordial leads is classic type 2 Wellens. While not emergent, pt should be admitted and cathed at earliest opportunity as she is at risk for immient MI.

  • Keith says:

    Don’t forget about inverted T waves. Ischemia

  • Keith says:

    Pt needs an angiogram

  • Keith says:

    Serial enzymes a must

  • Keith says:

    If all negative, stress test is in order

  • Keith says:

    If all negative a 6 month follow up is needed

  • Keith says:

    Also need a CT angiogram, chest. Need to Rule out lung cancer and possible pulmonary embolism. Start with a D-dimer

  • Keith says:

    Daily ASA a must.

  • Keith says:

    Just saying.

  • Alex says:

    Borderline 1st degree AVB with widespread T wave inversion. If she's pain free at the time of assessment, I wouldn't be taking that to a cath lab. 

  • Paul A says:

    Clinically this patient is highly suggestive of ACS. The possible evolving ST elevation and flip T waves in V1-V5 are highly suggestive of AMI. If these changes are new for the patient I could alert the cath lab.

  • Darren says:

    This appears to be a case of Wellen's syndrome.  I wouldn't activate the cath lab immediately in my EMS system, but I would fax my 12 lead to a hospital with interventional cardiology on site if possible and let them make the call whether to activate. Regardless, it is my belief that this patient needs a cath lab as soon as possible, and this is likely a LAD occlusion.

  • Pat says:

    I see a little ischemia. Period. Everybody needs to relax.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Brian Brubaker
59 Year Old Male: Unwell
At a quick glance it looks like tombstones (R on T). At closer look without calipers, it appears to be accelerated ideoventricular rhythm due to complete heart block. Not enough information to go off of, so cardioverting or pacing might just kill the patient quicker than anything. Transport immediately since his sick heart could stop…
2015-07-02 05:49:02
Holden
59 Year Old Male: Unwell
I've only studied cardiology for a few months and have read Dubin's book 1.5 times so I'm not an expert by any means. However, can a possible interpretation be a junctional tachycardia with aberrant ventricular conduction and a STEMI? No P waves and aberrancy causing a slightly wide QRS (but not wide enough for V-Tach).
2015-07-02 00:50:22
James
59 Year Old Male: Unwell
This is a ugly EKG. Wide complex irregular tachycardia around 150's. A-fib and a-flutter are possibilities. He's severely symptomatic. At this point, all treatment is same, electricity. If A fib, it may not want to "shock out" easily. This may be a case where initial cardioversion at max joules would be prudent. Pulmonary edema likely…
2015-07-01 22:00:13
Bryan
59 Year Old Male: Unwell
Calcium has little to no side effects, given the first EKG I think it is reasonable to consider it for first line treatment. Repeat EKG after 5 mins and reassess.
2015-07-01 21:14:40
Mike MacKenzie
The Trouble with Sinus Tachycardia
An absolute must read for all Medics. Great article. I am always trying to tell students to consider referring to these fast rhythms as a narrow complex tachycardia, then start looking for the cause, be it physiologic response or an electrical conduction issue. And as many have stated, I often hear that it must be…
2015-07-01 20:11:34

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