73 yom CC: Chest Pain

Here’s a case that was submitted by a reader from the UK.

He’s a new EMT in his first 6 months who has chosen to remain anonymous.

In his own words:

Presenting Complaint: Chest Pain

History of Presenting Complaint: 73 year old male with cardiac history complained of retrosternal chest pain whilst getting out bed in the a.m.

The pain radiated left shoulder, left arm.

The male took his gtn sublingual spray and the pain eventually eleviated after x3 spray’s.

4 hours later male is persuaded to call ambulance to inform of this episode of pain.

On arrival: Patient self mobile to door – nil obvious difficulties.

On examination:

Alert, orientated with good colour – GCS 15.
R/R 19, with good clear bilateral air entry.
Sats 97% on air. Patient communicable.
Good strong radial H/R 85.
Nil chest pain/discomfort.
Nil diaphoresis.
BP – Systolic elevated – 200/83
All other obs within normal parameters

3 lead – see attachment.

12 lead done in situ – see attachment

Past Medical History: Cardiac hx = Angina, Bypass (12 years), valve replacement (u/k which – 1 years)

Allergies – Clopidogrel

Treatment: 300mg aspirin and transport to A&E;

A&E; department ecg – see attached.


 What do you think?


  • Anonymous says:

    I immediately thought A-flutter (Shark Tooth). Interestingly no ALS treatment was done.

  • Point to note guys…Antiarrhythmic Lidocaine was one of numerous drugs recently taken off some Ambulance Trust crews in the UK 🙁

  • Christopher says:

    Quite a high systolic! Pretty obvious A-flutter, gorgeous sawtooths. However, those gorgeous sawtooths make it pretty hard to read the ST segment. I marched out the F-waves in II and I can see it one of two ways: the STE is possibly an F-wave or the beats w/o STE are because the F-wave pulls the ST segment down.Now the monitor claims STE inferiorly, and scoping around it is tough to definitively tell. STD in lateral leads is also possible. I would call ahead to the ED early, notify them that the monitor reads a inferior STEMI but a-flutter is obscuring the view. Recent Hx supports a cardiac event, especially since pt is pain free from self-administered NTGx3.The A&E; 12L cleans up II, III, and aVF enough to where I'm leaning towards IWMI. I and aVL show ST depression.

  • akroeze says:

    Am I totally insane here? There seems to be no correlation between the F-waves and the QRS complexes.Is there AV dissociation?

  • Hillis says:

    Interesting case…The rythm is atrial flutter with left axis deviation. rS in V1 classical pattern for RBBB. There is also the sign of left ventricular hypertrophy. ST elevation is seen in the inferior leads with discrete ST depression in leads I and aVL.. Isolated ventricular ES.. So my Dx- Acute inferior STEMI.

  • Tom B says:

    C.Watford – I agree! Those gorgeous sawtooths do make it difficult to read the ST-segments!I would question whether or not the monitor reads an inferior STEMI. Yes, it says "inferior infarct, possibly acute" but it is not giving the ***ACUTE MI SUSPECTED*** message.Of course this case comes from the UK and it's possible the LP12s there are not programmed the same.I am also concerned about the apparent ST-depression in I and aVL.Tom

  • Tom B says:

    akroeze – I don't think there's AV dissociation but I do see some variable conduction in the rhythm strip (alternating between 3:1 and 2:1) and the QRS complexes do appear to "hit" on different sides of the F-wave depending on whether or not it's 3:1 or 2:1, which is interesting!Tom

  • Tom B says:

    Dr Hillis -I think you wrote RBBB when you meant to say LBBB (rS pattern in lead V1). The QRS duration, while prolonged at 100 ms is < 120 ms, so I'm not convinced we're dealing with a LBBB.However, I do share your concern about the possibility of acute inferior STEMI, mostly because of the possible ST-depression in leads I and aVL and the fact that the R-wave in lead V2 is taller than the R-wave in lead V3.I should mention, however, that the ST-segments are obscured by flutter waves, so it's possible that we're picking up on pseudo-ST-elevation and depression!Tom

  • Jesse says:

    Tom-"I do share your concern about the possibility of acute inferior STEMI…the fact that the R-wave in lead V2 is taller than the R-wave in lead V3."Why is that? Its been my understanding that some of the right precordial leads can occasionally show reciprocal changes from inferior ischemia or injury, but I thought that would present in the ST segments or T waves.Are you possibly referring to a posterior Q wave?

  • Tom B says:

    Jesse -If you look at serial ECGs from an acute inferior STEMI as Q-waves develop in the inferior leads (II, III, aVF) you will see a corresponding increase in R-wave height in the high lateral leads (I, aVL).In this case the prehospital 12-lead ECG shows Q waves 1 or 2 mm deep in lead III and R-waves 3 or 4 mm in lead aVL.In the A&E; department ECG the Q-waves in lead III are about 7 mm and the R-waves in lead aVL are about 8 mm. So the Q-waves got deeper in lead III and the R-waves got taller in lead aVL which is a reciprocal lead. That's not good (assuming lead placement was the same). The R-waves also became taller in lead I.Often with posterior STEMI there will be an increase in R-wave amplitude in the right precordial leads. I assume this corresponds to posterior Q-waves but I've never tested the theory.In this case, R-wave progression is reversed in leads V2-V4. This is a nonspecific finding, but it's concerning in the context of the other findings we've been discussing.Tom

  • Hillis says:

    Thanks Tom for explanation..Well here am just thinking loudly.. I read article posted by Dr. Smith that STEMI best seen in premature vetricular complex,does it help in this case !!In the first ECG there is PVC wih discordant ST elevation seen in leads I,II,III unfortunately the rest of leads are missing..The third ECG shows subtle elevation in lead V1 with PVC in the right precordial leads .. Could it be right vertricular involvment ? V4R will help in the diagnosis . But the patient wasn't in shock, hypotensive or show signs of heart faliure !!. It's interesting .

  • Tom B says:

    Dr. Hillis -That is an interesting observation. With the flutter waves, I can't tell if the discordant ST-segment depression is > 0.25 the QRS complex in lead III.I was surprised to see that the low frequency / high pass filter was set to 0.05 Hz (diagnostic mode) on the rhythm strip! That would be unusual here in the United States.Tom

  • An interesting case Tom.It would be good to know what his "previous cardiac history" was (esp whether he had a diseased RCA/patent grafts) as this might help us intepret his inferior ST segments easier.On balance I agree that he is in flutter with a relatively slower than normal (i.e. <300) flutter rate with variable block. I'm not convinced his ECGs show ST elevation inferiorly and what we're likely seeing is flutter artefact. His T waves are inverted in I & aVL and he may have slight (<1mm) ST depression there as well.From working in UK A&Es; I can almost guarantee that his lead positions were changed when he came into A&E; so intepreting the discrepancy between the size of Q wave in III & R wave aVL is difficult.The only other thing is to go back over his history and the nature of his pain as the last thing we'd want to miss would be an aortic dissection (hypertensive, inferior ECG changes etc.) and I'd have a low threshold for CT Aortogram if the story was slightly worrying.Good case; lots to think about.

  • Tom B says:

    Thanks, cardiologycases! Got a name? Tom

  • Mau says:

    Hello. The rhytm is not atrial flutter, but atrial tachycardia. The "gorgeous sawtooth wave" are not flutter wave but artifacts. The patient probably suffers from Parkinson disease or something like. This wave are too large, too high and too simmetrical to be F wave. They are present only in the peripheral leads and related to rhytmic movement of the hands (probably one). The atrial tachycardia waves are present in V1 in the second EKG. Due to these artifacts the ST is consufed and interpretation is impossible. The QRS in inferior leads evolves through the 3 EKG. The patient had myocardial infarction in the morning.

  • Lucus says:

    Classic LBBB with clear sign of ST elevation suggestive of  Anterior MI shown in lead 1,V2,V3,V4 

  • Jonathan Hagan says:

    Hello Mau. I wonder, if the F waves are artifact, would the height of the R waves be so consistant? The broad PVC in the A&E ECG traces very clean. Would this be consistant with artifact due to tremor? 

  • Jonathan,

    No the F-waves in these tracings are not consistent with artifact.

  • William says:

    I would say Inferior MI

  • Chuck says:

    Does this patient not meet some of Sgarbossa`s critera here!

  • Paul says:

    There is really no doubt in my mind, but the first thing I would do is obtain a good quality 6-12 second trace of the S5 lead to confirm that this is indeed 3:1 atrial flutter, and not musculoskeletal tremors or some other interference before doing anything else.

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