Chest Pain, Dyspnea, Right Bundle Branch Block, and False Positive Acute MI

Here’s an interesting case sent to me by Thomas Bernesser of Mint Hill Fire and Rescue.

50 year old male with an acute onset of sub-sternal chest pain and dyspnea. He states he was at rest when the sharp, tight feeling began in the center of his chest and radiated to his left side. A 10 on 10 with the pain. He also remarked of left arm pain and tingling. He c/o of associated nausea and diaphoresis along with the pain and dyspnea. He had taken two of his own SL NTGs prior to EMS arrival without any relief. He had a past history of multiple MIs with stent placement, the last being in October of this year.

He’s pale, diaphoretic, clutching his chest, looks very uncomfortable and anxious. His initial BP was 92/50, a little tachy between 100-110 and a respiratory rate at about 18/minute.

And on to the EKGs, I ran numerous serial EKGs and they were all identical – including the ones done in the ED at the receiving facility. Just based on his presentation alone I was convinced that he was having a significant cardiac event, but the EKG was a little less convincing for me. Each one of the interpretations made reference to ST elevation in the inferior leads and diagnosed an Acute MI. While I do note elevated segments, the EKG just strikes me as odd. I’m not seeing the classic ST elevation above baseline coming off the S wave of the complex. I might be missing something but I found it interesting nonetheless and wanted to share it with you.

0002wm

0001wm

Just so you know, he was worked up in the ER for an MI and sent to the cath lab. He was cathed and came back clean, no signs of occlusion. So, definitely a false MI identification for the Philips MRx.

There’s no perfect solution for patients with baseline abnormalities on the 12 lead ECG. One interesting point for this case is the absence of a definite TP segment as a baseline for ST-segment measurement due to the sinus tachycardia.

1 Trackback

Leave a Reply

Your email address will not be published. Required fields are marked *