Rapid Prehospital Evolution of STEMI

82 year old male, in good physical shape, stops at a cafe for lunch after cycling for an hour. Witnesses report a syncopal episode lasting approximately 30 seconds. Patient history significant for prior MI requiring 3 stents. No other significant history.

Patient denies any CP, SOB, N/V, lightheadedness. In fact, he denies any complaints at this time, and questions whether or not he should just go home. You do ask whether his cool, soaked shirt was the result of his workout, and he says no.


Here is the ECG1 acquired on scene (T-0):

ECG2 acquired enroute (T+9):


ECG3 enroute (T+16):



ECG4 Hospital arrival (T+21):


At no time during ECGs 1-3 was the patient symptomatic. Unsurprisingly, at the time of ECG4 at the hospital, he was feeling markedly worse.

What changes do you see between ECGs 1 and 2?

In the span of only 21 minutes, the ECG evolved very subtly from non-specific to full blown STEMI.

Perform serial ECGs, especially on high risk patients, and scrutinize the 12 lead for subtle changes. In the field, we have ample opportunities to obtain them. They are not costly or invasive, and may greatly improve the outcome of our patients. 

See more on this case at DrSmithsECGBlog



  • Chuck says:

    Could this been Right sided, and with the recipical changes in V-1 thru V3 possibly Posterior.

  • Josep Serra says:

    I see changes in v5/6 ST elevation>1mm
    Also reciprocal changes at v1 with tall R
    If I see it I think of lateral high acute MI according to Dr Bayes de Luna it is a lateral lesion, not posterior as thought during years
    Then I see changes in inferior leads corresponding to ST elevation
    So extension of ACS STEMI due to more than one coronary territory could be the reason

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