New exertional dyspnea and subtle ECG signs of LAD occlusion

EMS responds to a 76 year old male with dispatch complaint of shortness of breath.

At the time of EMS arrival, the patient appears acutely ill. He is slightly diaphoretic but not overly anxious. He admits to chest discomfort but denies nausea, vomiting, or palpitations. No jugular venous distension. Breath sounds are clear bilaterally.

He reports his past medical history as “healthy” and takes no prescription medications.

  • Onset: While walking (he takes a long walk every day)
  • Provoke: Nothing makes the pain better or worse
  • Quality: Described as pressure
  • Radiate: The pain does not radiate
  • Severity: Started mild and progressed to 8/10 in severity over 30 minutes
  • Time: The patient experienced similar symptoms 2 days ago but symptoms resolved with rest

Vital signs are assessed.

  • RR: 18
  • Pulse: 58
  • NIBP: 155/90
  • SpO2: 98% on room air

The cardiac monitor is attached.


A 12 lead ECG is captured.


Let us assume for the sake of discussion that you live in a rural community.

You are 25 minutes away from your local receiving hospital (no cath lab) and 55 minutes away from a hospital in the next county over that is capable of primary PCI.

Do you bypass the local community hospital?

Should the cardiac cath lab be activated prior to your arrival?


This ECG shows LAD occlusion although it does not meet the guideline requirement of “new ST elevation at the J point in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2-V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads.”

The problem with arbitrary mm criteria is that they do not take into account the depth of the S-wave. This is a violation of the rule of proportionality which states that repolarization is proportional to depolarization.

V1-V3You’ll notice here that the S-waves in leads V2 and V3 are not very deep. In lead V2 they are less than 5 mm! That makes 1.5 mm of ST-segment elevation quite significant.

Also note that the T-waves a disproportionately large because they are hyperacute.

The mean R-wave amplitude between leads V1-V4 is less than 5 mm which essentially rules out early repolarization.

The ST-segments in lead V1 are upwardly convex with terminal T-wave inversion (something I have noticed on many occasions with LAD occlusion).

There is also a flattening of the ST-segments in the inferior leads that probably represents reciprocal changes.

Although the treating paramedics were concerned about the ECG this was not recognized as acute STEMI in the field.

However, the patient was delivered to a PCI-hopsital. The initial ECG in the Emergency Department (which I do not have) was unequivocal and the cardiac cath lab was activated. The patient was found to have 100% occlusion of the left anterior descending artery (LAD).


O’Gara P, Kushner F, Ascheim D et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;127(4):529-555. doi:10.1161/cir.0b013e3182742c84.

Updated 12/09/2015


  • SoCal Medic says:

    Here is what I am thinking, his rate is not that much of a concern due ot his physical well being. My concern lies with how he describes his pain, as well as his skin signs, you cant fake those. With that said, that gives weight to the eleveation noted in V1 through V4 (with respect to the QRS Amplitude) with the T wave morphology in V1. Curious as to how his discomfort has changed since resting from the initial onset of symptoms, as well as any other family history in his past. I am also assuming, for the sake of argument, the two Emergency Departments of choice are opposite direction from each other. I would go Cath Lab to put the patient in the best possible hands. My guess is he has some cardiac vessel disease with his previous episodes of shortness of breath during exertion, which may require a lab anyway for explatory reasons. Would I activate a lab? Not unless I saw changes in the serial 12 Leads performed during transport, every 5-10 min. If the 12 Leads change significantly in a short amount of time for the wrose, fly him.

  • Tom B says:

    Christopher – Do you have the discretion to bypass the closest hospital without a physician consult?If so, do you have to notify anyone (other than the receiving hospital)?If you were en route to the closest hospital (no cath lab) and the ECG changed for the worse (confirming STEMI), would you pull over and wait for a helicopter?I don’t necessarily have a problem with that, but I’m curious to know what would actually happen in your jurisdiction.Thanks!Tom

  • SoCal Medic says:

    In the Valley where I work I dont have those kind of tranmsports. Up in the high desert and the mountains they do, and depending on where they are, the time it takes for the helicopter to get on scene is shorter than the transport to the closest facility (they have a helibase there). With the system I function under, we would have to consult with a Base Hospital, but the ability to actually talk with a physician would greatly depend on which hospital you call, some incorporate their physicians more than others, but a MICN always answers. We would call as soon as possible to seek direction in a case such as this, but we would not wait on that call to begin transport (usually someone is calling while we are loading). I have never had to deal with transports longer than 20 min’s driving emergency. The difference between a local facility and a lab may be 10 min or so depending on location of the call.Our destinations are typically decided by the Base Hospital, but alot of that comes down to good presentation of the case to the MICN, and their comfort with the Paramedic presenting it. We have to call a Base Hospital, but not all Base Hospitals are Cath Labs. In some cases, telephone is played.Assuming I am in the high desert and en route to the closest medical facility, would I stop for a helicopter? It would greatly depend on where I was at in the desert. The three hospitals up there are worse case 15 min apart? But there are some areas where the helicopter can greatly influence your travel time.Now up in the mountains (yeah it is really diverse area), especially right now with the snow and skiers, waiting for the helicopter may be easier/faster/safer for everyone than trying to drive back down the mountain to get to the hospital (also a lab).My system has a lot of variables in it, with a ton of avenues to take with regards to choices. We have in the past traveled away from the closest medical center with patients who presented as a STEMI regardless of their clinical presentation.

  • Bob Jester says:

    If this call were to occur in my little corner of the peoples republic of new jersey the patient would have the option of which ED they are transported to (we have no STEMI diversion guidelines… yet).My job, in part, is to explain the risks and benefits to both fibrinolysis and PCI and to try to get the patient to consent to transport to the ED with an interventional cath lab. Although we have some standing orders we are required to call in to medical control on all calls. I can request the lab be activated thru our hospitals one call system (now being used for all outside referrals). Sometimes the doctor will ask to have the 12 lead sent, most often not. We’ve just completed the first year of STEMI alert and I am proud to say we haven’t had a false alert yet, we’re currently looking at our intervals to see where we can save some time.

  • Shaggy says:

    I work in an urban setting and bypass local hospitals all the time for specialty regionalized centers without having to ask anyone. We seem to insist on our destinations here and patients seem to be at our mercy. Yes, patients get a say but usually within reason for obvious reasons.If I were in a rural setting, I would be tempted to head to the local hospital where they have fibrolytic therapy and could further assess and draw cardiac markers. However, a local MD here named Dr. Brader did a local study and found patients who went to local facilities and were then flown out waited almost 6 hours for PCI, where if the patient drove an hour with activation of the cath lab, the patient got PCI hours quicker. So my option would be to fly the patient, and if no flying, drive to the hospital with PCI capability. Our state protocols state we must contact the destination hospital with PCI to give report and send the EKG to the attending, who will make the decision to activate the cath lab. If the attending does so, the attending will call the one call center to conference with the interventional cardiologist and to call in or alert the cath team.

  • Shaggy says:

    …and from there either the accepting ED attending will make the decision to have the patient come to the ED to be met by the chest pain team and prepped for the cath lab, or bypass the ED altogehter and head straight up to the cath lab. It often depends on the attending and/or receiving hospital practices.

  • Tom B says:

    Bob – Just curious, how do you explain the risks and benefits of fibrinolytics versus primary PCI? Tom

  • Tom B says:

    Shaggy – What state are you in? I actually agree with transmitting the ECG to the PCI hospital as opposed to the local non-PCI hospital for suspected STEMI patients.I’m trying to figure out how this is going to play out in the rural setting.Tom

  • Shaggy says:

    I am from Pennsylvania and our having to contact the PCI facility is a recent addition to our protocols last summer. Why would this be any different in a rural setting opposed to an urban or suburban setting? A large portion of our state is rural and I am sure these state protocols were enacted with those areas in consideration.What roadblocks do you perceive?

  • Tom B says:

    I’m worried about transmitting the ECG to the local non-PCI hospital for a “mother may I” bypass you for a PCI hospital. It’s not in the local non-PCI hospital’s best financial interest!October 18, 2008: Dr. Jacobs and Dr. Gibson Discuss Mission: Lifeline – The AHA STEMI Initiative Tom

  • Bob Jester says:

    Blogger Tom B said… Bob – Just curious, how do you explain the risks and benefits of fibrinolytics versus primary PCI? I start off by explaining the ECG findings and how that translates to the symptoms the patient is feeling. If we are in the catchment of a non PCI hospital I offer transport to the PCI hospital and explain that while the non PCI hospital is a fine facility (occasionally this requires some acting to remain credible)providing good care when they see the ECG that I’m holding, they are going to offer two options:1- Treatment with fibrinolytics, describing the risks of re infarction, stroke, GI bleeding and the fact that in a small percentage (10 % but don’t hold me to that)the treatment fails to lyse and that PCI might be ultimately required at a greater risk due to the lytic still being in the system. I also give the benefit of it’s an immediately available therapy. I then tell the patient that most likely the ED will call for transfer to a PCI hospital usually in Philadelphia (further away then our local PCI hospital that your family has to drive not knowing your condition) I also mention that transfers take time to set up and that heart muscle is dying during that time. Having given that a minute to sink in I offer direct transport to the regional PCI hospital with pre arrival activation of the CCL team who aagree to be at the hospital in 20 minutes from the one call page ( on call members carry company issued nextel phones and we group direct connect after my medical control doc and the on call interventionist confer). Since competitation is high and we work for the PCI hospital there are always charges of patient steering from the non PCI hospitals, making it a patient decision is our defense. We are just giving the patient the information they need to make an informed decision. So much for the short story, although it does sound better in person, My bedside manner does not translate well into the written word.bob

  • Tom B says:

    It translates very well! Interesting and very detailed. Thanks for sharing! That was helpful.Tom

  • Shaggy says:

    Tom B said…”I’m worried about transmitting the ECG to the local non-PCI hospital for a “mother may I” bypass you for a PCI hospital. It’s not in the local non-PCI hospital’s best financial interest!”Real easy solution. Don’t transmit to the local hospital since they have NO standing in the whole affair. The only hospital that should be notified with EKG transmission is the destination PCI hospital. This should work in rura, urban and suburban areas. Why would anyone send an EKG and report to a hospital that has nothing to do with the patient? Command? That is what protocols are for. Many medics need to just cut the cord and practice without being led by the hand all the time.

  • Chris says:

    IMHO, this is a clear cut requirement for transport to a PCI facility. Regardless of ECG findings in the prehospital setting, his symptoms warrant further investigation by a facility properly staffed to handle the fallout if an MI is confirmed. Apart from AMI,a trip to the Cath Lab may be used diagnostically for this patient given his good health and likelihood of tolerating the procedure well. Since he is relatively stable to begin with, I’d accept the longer transport to the PCI facility with a reasonable level of comfort. This initial transport decision might also save him an expensive interfacility transfer later on when advanced diagnostics are needed that can only be found at a PCI-equipped center.As Paramedics in the current economic climate, it’s important for us to do everything we can to limit the strain on the healthcare system. One way we can do it is to make sure patients are transported to a facility that can provide them the right care, the first time. Then again, what do I know?

  • Shaggy says:

    I am not sure transferring a patient to a specialty facility regardless of assessment findings, ie, EKG. Most chest pains are NOT MIs, congesting the PCI EDs just because…, is not good for obvious reasons, often the local hospital is where the patient goes all the time and where his MD has admitting privelages, so it may be in the best interest of the patient to go there. Not only that, if the EKG is unremarkable, the chances of needing an emergent PCI is very slim and will be unlikely the patient will have to do an emergent transfer. What if the patient has a PE and the crew decides to take the longer route to the PCI hospital and the patient takes a downturn for the worse while enroute? This is one reason we are entrusted with these assessment tools to help evaluate our patient and make clinical decisions.

  • patrick says:

    Well I think you need to consult with a doctor at the closet hospital. There a few things to think about. If the patient is brought to the closet hospital is he going to be there for sometime before he can be transported out to the PCI. If the pt is going to be there for sometime it better to go to the PCI you have to consider that there might be a down turn for the pt but where i work in the summer it can take 45 minutes or so to get to the cath hospital and we are supposed to call the local hospital and consult the doctor first. but i think the best place for this pt is going 55 minutes and i would also that this has been going on for a little while now the pt does not want to be sitting a local hospital waiting to be transfered.

  • Hillis says:

    I thought consulting the ED doctor even with clear cut STEMI is mandatory before transporting the patient to PCI facility is only here where i work, but it appears to be like an international guideline !!! it’s wasting time , esp. many paramedics are qualified to recognize STEMI , so why ED doctor should be consulted or interfere , i don’t see any benefit !! I’d love to say immediatly transport the patient to the hospital with PCI facility , but unfortunately the reality says waste the patient’s time and transport him to the closest hospital !!. At least we all agree give the patient the immediate first line treatment with MONA and clopidogrel while transportation.

  • Jesse says:

    Just an off the wall question kinda related to this topic. I recently had an anterior MI new and evolving en route to the ED. Anyways everything went great cath lab and all the bells and whistles but my question was the Doc called the shape of this guys st segment a “sign” of some sort like a name of some famous doctor or something… I just cant remember what he said but I know it has to do with the type and shape being concave or convex or a specific type of st segment maybe only or usually found in anterior wall MI’s. I cant remember what he called it and I have heard it before. Anyone can help me out?

  • Chris T says:

    Tom, I love it! This is exactly why I am working so hard wot learn all I can to be a part of the solution. I have a 30 min tx to a local non PCI and 1.5hrs ground to PCI. So local ED is way to go EXCEPT!! You brought up helicopter. Here is how our area stands right now. Approved services go to a stemi regognition class and are signed off by local EMS doc. With this approval we may request the helicopter from the feild and have the cath lab activated. By air we can get them to pci IN ABOUT 15 MIN. I am right now educating myself and awaiting the medical control doc for our helicopter service to give me the test (as i am one of about 2 active paramedics in one system I have to seek this out on mu own). If I pass the test I will be able to request helicopter and PCI from the field.
    This EKG is very suggestive of MI. Id check posterior leads for depression, The acute T waves and ST elevation in comparison to voltage also very suggestive. The prolonged QTC, and slight Left axis deviation all pretty good indicators. Add that to the patient clinical presentation I am going to pull the trigger on this one. I do not have transmission capabuilities yet but if I did this would be one Id want a consult with just to be sure they agree. Interesting this is LVH criteria and the largest voltage is in lead III. Since Its a go no go decision right now, Im going with go, the lifeflight medics can be my consult 🙂
    Until I get the spacific approval it is recomended by protocol to go to the local ED. I havent had a good enough stemi yet to challenge this though being the strong headed patient advocate I am i prolly would go for it anyways, request the helo and ask for figivness later(easier to ask for forgivness than it is for permission).

  • ARSHAD HASAN says:


  • Chris T says:

    using Dr smiths decision rule 2 I get 3 yes' Very very likely MI. neat because just rule 1 suggest BER

  • – poor R-wave progression
    – large precordial T waves

  • AntiqueMedic says:

    I would definately flight this man to a cath lab.  Since 50% of AMIs don't show up on  12 leads (I think about 83% show up on 15 leads) I would go by symptoms alone.   I expect that very soon we will be doing field troponin, ckmb and myoglobin here in SW Missouri.  Our medical director allows us to make the decision to fly out our patients to the appropriate facility.

  • VinceD says:

    Jesse – was it Wellens' sign?

  • TwistedMedic says:

    It would depend on somethig for me.  Are both of these facilities in the same direction from the scene.  If so, then I would go en route to which ever the pt chooses.  If he chooses the nn cath ready ED and his condition worsens, then bypass and head for cath lab.  My ultimate goal for this pt would be to get him to the "MOST" appropriate place, which would be the cath lab.  Given his current condition, plus the ECG findings, I would not activate the PCI Lab, but rather call ahaed and advise.  Pulling over and waiting for a helo, never even crossed my mind, and never would.

  • Brandon K says:

    I would call this a STEMI and head for the PCI center. In my area (Ada County, ID) we usually don't have transports over 20 minutes and heli's are rarely used but with pt presentation, Hx, and 12 lead I would have a hard time convincing myself this is anything but an AMI. We do have the ability to transmit 12 leads and activate the cath lab from the field. Luckily 3/4 of our local hospitals have 24 hr cath lab services!

  • Jay Lawson says:

    In the area I serve, the closest PCI facility is 45 minutes away. Yeah, I'd call ahead and ask to have a STEMI alert called, and hopefully bypass the ER enroute to the lab.

  • David FBGTX says:

    As a rural EMS provider we are always in favor of by-pass or air evacuation in the even questionably acute patient. This patient would fit our criteria for air evacuation and “Heart Alert” with pain described, severity, skin changes and 12-lead findings. Athletes or people that “work out” are notorious for left ventricular enlargement and is the case of a normal variant. The QRS progression appears to be good, but the p waves could be developing into biphasic wave indicating atrial enlargement and or failure not to mention the t-wave abnormality. Our local Hospital has a cath lab, but is exploratory only. If you have the slightest feeling the patient is going to benefit from intervention then by-pass. The other side of this is when a non-interventional cath lab would have been fine, a $15,000 heli ride is hard to explain to the family in terms of “just in case,” or “in my professional opinion.” If it where my family I would thank the EMS crew for choosing to evacuate and or by-pass.
    With this patient yes, I would activate a heart alert. As a patient that has no real history this is a huge change (duh!!). Even the strongest athletes are at risk of heart and vascular disease. The heart and vessels after all are both wearable items. As we all are familiar with the inevitable, our hearts will eventually stop. Our job is to prolong inevitability and care for the patient in a way that will return them to what they consider a normal life post hospitalization. The easiest way to achieve this is appropriate Hospital choice. This in consideration, an interventional cath lab seems to be the obvious choice. A heart alert is a matter of opinion and/or protocol and could be argued either way.

  • I think if the symptom of shortness of breathing is heavy so the first way is still MONA then we evaluate the vital sign and reply the MONA with dose that can make the patian stable n comfort..dont forget the Pantom of ABCD,if the patient have stable then rever to the hospital that have ICU and PCI for ready to use if immediately the patient need it,about cath lab the pathway is we can take the patient's blood n we can rever the blood to the cath lab hospital n the result of value of lab can we call to this hospital.

  • Rick says:

    looking at the elevation in the V2- 6 leads  I would send the telemetry to our nearest pci  unit here in the uk & discuss the patient  with the Staff on the phone. Its  still quite a new thing here  but  we have had some excellent results so far.   thanks for putting these cases  up for us 

  • Pascal says:

    Illicit more history as I do a physical assessment of the patient.  I need to know what meds he is on and a past medical history.   If available an ISTAT should be done.  The 12-lead which is obtained with the first set of vital signs before treatment will be transmitted to the hospital and the ERMD consulted.  I would transport this patient to the hospital.  The decision as to which one will be made after the physical assessment, ISTAT, and consultation with the ERMD.  Two IV sites will be started, oxygen administered and continual monitoring of the 12-lead to see if treatment has caused any changes.    Consideration for IV nitro therapy and analgesia will be made.  Activation of the cath. Lab will be done by the ERMD.  25 to 30 minutes is our average transport time so that is a none important factor in the calculation process.  If once the physician decides after consultation to go to the hospital with a cath. Lab then so it shall be.

  • bob says:

    Speaking as somwone who does provide rurally, yes, this guy gets the ride to the cath lab. He's stable now, and could very well be stable for the next week or so. After that, you may be pumping and blowing. But he still needs a cardiologist TODAY.,

  • Nate McCoy says:

    Great case and ECG! One thing I noticed, though it is not in its usual leads for presentation is the biphasic T wave in V1. Though its normal presentations are V2 and V3, those biphasic T’s closely resemble a Wellens Type A, suggestive of critical stenosis in the LAD. Given the occlusion to be proximal, it would be plausible that V1 would show the pattern and sinch the diagnosis. Other things in the ECG would raise my suspicion, but for me the biphasic T waves put me on high alert. In my area, rural, our protocol states that if the patient is tPA eligible then we transport to our local hospital ( interventional cardiology on site from 8a to 5p so the ones we take to the ED go to our cath lab). Outside of those hours or anyone failing the check sheet is to be flown to a PCI center. I’ve been preaching the need for PCI instead of lyrics for a while and the research and AHA have finally said the same. My rule is if it’s outside the hours of our lab, probably flying it anyway instead of going with lytics. I’ll consult MC and explain my logic and they’ve always agreed, PCI disposition.

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