54 year old male CC: Chest pain

EMS is called to the doctor’s office to evaluate a 54 year old male complaining of chest pain.

On arrival, the patient is alert and oriented to person, place, time, and event. However, he is anxious and his skin is pale and diaphoretic.

He is on oxygen via NC @ 4 LPM. An IV has been started and is running KVO. The patient has been giving 4 baby aspirin and administered 1 SL NTG spray prior to your arrival.

Onset: 2 hours ago while at work
Provoke: Nothing makes the pain better or worse
Quality: Described as a heavy pressure leaving him breathless
Radiate: The pain radiates up to the neck and jaw
Severity: Patient reluctantly gives the pain an 8/10
Time: No previous episodes

Past medical history: Depression, hyperlipidemia

Meds: Lipitor

Vital signs are assessed.

Resp: 20
Pulse: 72
BP: 118/72
SpO2: 99 on RA

The cardiac monitor is attached.


A 12-lead ECG is captured.


What are your observations about the case?

*** UPDATE ***

A serial ECG is obtained en route to the hospital.


Is this helpful?

21 Comments

  • Christopher says:

    NSR w/o ectopy, STE I/aVL w/ recip changes inferiorly. STD anteriolaterally as well. STE aVR suggestive of perhaps LCX occlusion close to L main? Early STEMI notification, safe and expeditious transport. Since a line is established and BP is favorable it'd be prudent to administer another 1x NTG SL and reassess pain. Serial ECG's to see if the infarct is spreading. Going to keep an eye out for high degree blocks if we get anterior involvement.

  • Tom B says:

    Christopher – Very thorough interpretation! As usual. It just goes to show that paramedics can be trained to interpret 12-lead ECGs at a very high level! Thanks for the comment,Tom

  • Anonymous says:

    Everything comes if a man will only wait........................................

  • Tony Debelo says:

    I see this as an inferior wall ischemia, with lateral reciprocal. I would retake 12 lead every few minutes to see if it does not turn into a STEMI. watch the BP closely, and be careful with the nitrates.

  • Tom B says:

    Tony – Thanks for the comment! I would suggest that reciprocal changes are strong supporting evidence that we're looking at an acute STEMI.However, serial ECGs are always a good idea, and it just so happens that I've got one for you!Tom

  • SoCal Medic says:

    I once read a statement (on your blog naturally) that you can see the reciprocal changes before the elevation occurs. With that said, the slight elevation in aVL with consideration given to the depression and bi-phasic T Waves in the Inferior Leads would add weight to the elevation if it were the only change. That and Lead II is reciprocal for aVR (which also has elevation), just to many changes to be left alone. STEMI activation would benefit this patient for a Lateral Wall MI with possible occlusion in the Left Circumflex, the computer agrees, and in our system locally, you get the activation and transport to a STEMI Center.Second line established (for the lab), Nitro cautiously because of his blood pressure, and diesel medicine, with serial 12 Leads and strips with each set of vitals because of the potential of rhythm changes.

  • Tom B says:

    SoCal Medic – That's certainly often true with inferior STEMI (that reciprocal ST-depression in lead aVL often precedes ST-elevation in the inferior leads).I think the serial ECG in this case will remove all doubt.Tom

  • Maarten says:

    Tom,I'am a dutch paramedic. Today we had s same case as yours. The dispatch send us to a 65years old patient who has trouble to breath. Whem we arrive on the scene;A(irway): Free,Cyanotic,white face.B(reating): Normal (vesicular) breating by auscultation, frequency: 40,hyperventilation.C(irculation):No radialis pulsation,only a carotis pulsation. Very quick freq. Our monitor shows a Ventricular Tachycardia. Patient was definitely in shock. BP:60/20D(isabillity):awake and alert patient. Conclusion: 65yo male, with a VT with a BP 60/20. I was prep. 300mg of Cordarone (amiodaron)and the driver make a EKG. EKG shows: ST elevation: V1V2V3V4, ST depr. II III AVF. So i treat the patient as a septal/anterior MI; I gave the patient: aspergic (500mg iv), Plavix (600mg oral) Heparine 5000 IE. After the medication the EKG changed. There where no ST ele or depr…..Only a negative T in V1V2…But because of the first EKG we went to a STEMI-centre…It look likes a case like yours…In my case; They couldn't say it was a STEMI for sure; Because of the VT you can devellop a KIND of bundle brach block or fasicular block…Because of that reason you can't interpretate the EKG as a MI…On your EKG you have a deep QS in V1…It could be a BBB… It's realy hard to interpretate a EKG…especially in a case like ours…I think you did it the right way, Get the right patient at the right time at the right hospital…you did…in my case they did not do intra vascular intervention (PCI)…yet….the waited for the bloodanalyse (trop-I)…Are you allowd to give other medication during an MI?like anti-coagulation?Or vasodilatators? I hope you can do anything with the answhere…Maarten;Dutch Paramedic

  • obxpilot says:

    Tom, do you know which artery or arteries were occluded?

  • Tom B says:

    Maarten – Did you consider synchronized cardioversion? It's true that VT (being a ventricular rhythm) distorts the ST-segment similar to how LBBB distorts the ST-segment. Typically in a direction that is discordant to the terminal deflection of the QRS complex (which is often the main deflection of the QRS complex).In other words, ventricular rhythms are a STE-mimic. Sounds like a tough case! I hope the patient did well.Thanks for the comment!Tom

  • Tom B says:

    Jeff -This is actually an older case but I might be able to find out for you! Might take a little while though.Tom

  • Geoff says:

    This is my first reply, so please go easy. Looking at the first 12 lead, like was mentioned earlier slight elevation I, elevation aVL. I also thought I saw a little bit of elevation in V1 & elevation in V2. Depression in II, III, aVF, V4, V5, V6.Noted the elevation in aVR. Quick question for those of you who use LP 12s. I saw on another site an aVR elevation STEMI that wasn't recognized by the computer, does the LP 12 recognize this as STEMI?I'm not trying to go against the manual interpretation point of this blog, but just curious. Thanks again for the great info. Any 12 Lead books that people recommend? I have the Garcia 12 Lead Art of Interpretation, but was looking for another. Any out there that explain the physiology behind some of the interpretations like Axis Deviation, etc…?

  • n3uea says:

    Anterolateral MI with septal involvement.

  • TammyCEPFF says:

    Sounds like an anterior wall MI with Inferior wall and poss. lateral involvement. That said, the reasoned I commented are because I would cont. to give nitro SL up to 3 then hang a nitro drip,if BP allows for cont. nitro. I would administed Morphine to decrease pain and anxiety. New studies have shown that MS doesn't cause as much vasodialation as once thought So that with slight hypotension MS would still be given. As we all know most hypotension as a result of MS is almost always releived by elevating pt's legs. If it's not we can always give narcan.My 1st post so go easy on me.THX Tammy K.

  • Tom B says:

    Tammy K. – Welcome to the Prehospital 12-Lead ECG blog! Even if I thought you were wrong I wouldn't rough you up. That would be counterproductive to what I'm trying to accomplish.I envy that you're allowed to use nitro drips. Limiting paramedics to 3 SL nitros with an acute STEMI is an odd practice that appears to evolved from mythology.I've heard that the hypotensive effects of morphine are histamine-mediated and can be counteracted with 12.5 mg IV diphenhydramine. I'm aware of at least one flight EMS system that routinely gives both drugs together.I'm aware of other EMS systems that have switched to fentanyl. It would take some profound hypotension for me to reverse an analgesic that I myself administered!Tom

  • Hillis says:

    Well the case is amazing.. This time i woud comment firslty, to not influenced by the other opinions!! Any way in the case i would say that patient is having anterolateral STEMI the last ECG was so helpful in showing the hyperacute T wave in lads I,aVL, V2and V3 with the reciprocal changes in the inferior leads II, III, aVF and posterior leads V5 ,V6. Honestly it took a long time for me to interpret this ECG !! Anyway i will now check my collegues respond!! Many thanks

  • medic1008 says:

    had a somewhat similar case the other day. wish i could figure out how to upload the 12 leads. 80y/o F w/ only hx of tia 2 years ago. only med, ASA 81 mg/day. c/o mid sternal chest pressure, left arm heaviness and pain, pain down the left side of her back from shoulder to almost waist. onset 6pm the night b4. Now 10am. states couldnt sleep all night with the pain and heaviness and her arm. admits to sob worse on exertion and dizziness.sitting in chair,warm,pink and clammy. slightly anxious. denies recent illness. no n/v/d. FF got initial b/p of 126/70 in R arm.Pulse palpated was 72 and irreg.Thought maybe new onset afib.ls clr bilat.o2 sat 97%. quick look taken. no obvious ectopy. had p waves (sinus arrythmia) o2 n/c 3 lpm and packaged to the truck.B/p R arm was 110/60, L arm 90/50. partner started iv. 12 lead done. really expected elevation…she had “the story”. found inverted T’s in leads 2,3,avf,v4-v6 and marked depression in v1-v4. Her rate was varying from 70’s to 100 but had as low as 60’s and as high as 127. Did a V4 R just to check the right side. no change. My gut said that i was seeing the reciprical changes from the injury posteriorly.3 more baby asa givin. held on the nitro secondary to the b/p. actually bolused and got 500ml into her pta and got b/p up. We were already enroute and unable to acquire the posterior 12 lead. Called into the hosp and presented the story w what was suspected but w/o the post 12 lead, unable to call a pci. Lucky for her, the doc listened to us and she went to the cath lab…circumflex ! i do have the 12 leads( serial w no evovlving) but like i said, need to find a way to upload.

  • Nathan C says:

    I’d like to see V4, V8 and V9 for possible posterior or right involvement, especially before giving more nitro. Medic 1008 giving a bolus and holding the nitro is the path I would travel.

  • Troy says:

    Evidentally we all agree there is a STEMI. I’ve been reading on aVR STE and the first ECG fits the criteria (aVR STE with depression in II, III, aVF, V4-V6) for a Proximal MLCX occlusion which would be grounds for CABG.

  • Aharon says:

    That case is very simple to teatment from the begining , maby you as why? so the answer is that we treatment the pation and not the medical instruments , so the case story is enough , to give a tretment like he have ACS.the big question is how the pation look like. as Nathan say I would like to see the right chest leeds and the posterior one , right is more importent in this case. the treatment is usual to ASTE MI if we haven’t also right MI

  • Paul says:

    It also fits to SI-QIII-TIII (at the beginning), its a bad condition to miocardium, so it get infracted (LV). Proppably im wrong becouse of my inexpirience, so do not criticize me.

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