23 year old male CC: Chest Pain

Here’s a fascinating case submitted by Geoff Dayne.

EMS is called to a VA clinic for a 23 year old male who came in to get checked into the system. Somewhere in the exchange, he mentioned that he had been experiencing chest pain off & on for just over a month.

Onset: Today’s pain came on gradually.
Provoke: Nothing makes the pain better or worse.
Quality: Pain described as “pressure”.
Radiate: Occasionally radiates to the jaw.
Severity: “Mild” (no pain scale)
Time: Several previous episodes over the past month.

The patient denies shortness of breath. There is no nausea and the patient has not vomited.

A 12-Lead ECG is captured at the clinic.

And another.

9-1-1 was contacted.

The patient was given O2, ASA, and NTG at the clinic.

EMS arrives and performs their own assessment.

The cardiac monitor is attached.

The paramedics capture their own 12-lead ECG.

Are you concerned about this ECG?

Why or why not?

Should a STEMI Alert be called from the field?

Why or why not?

Would you bypass the local non-PCI hospital for a STEMI receiving hospital?

Why or why not?

*** Update 03/25/2010 ***

Here are some serial ECGs captured in the field.

Does this help?


  • Well, shoot.I don't like the trace, especially V1 a tthe clinic and the elevation Anterior, but the elevation does not meet the "standard" in my system to ring up a STEMI alert, nor can I transmit it for referral.Rough spot for me is that our local VA is not a cath capable facility so my options are open destination wise and I am choosing a cath capable facility, just in case.The presentation isn't leading me towards an acute event, but I will continue the NTG with OK pressures and LOC to maintain comfort and maybe that V1 will improve with treatment.Hope we can learn the outcome on this one!

  • RobertB says:

    I'll take a stab at Pericarditis, not STEMI, given the history and his age. Diffuse concave ST changes in inferior leads… ?

  • VinceD says:

    Initially this rings very much of BER to me (Benign Early Repolarization as I've learned to term it). The easy signs being the concave-up nature of the T-waves, the relatively increased J-point elevation in V2-V5 (with matching large T-waves) compared to V1 and V6, and the patient's young age, which of course doesn't make MI impossible but still increases the likelihood of BER. Also, V4-V6 feature a terminal notch in the QRS before the T-wave, another sign of BER. Lead II may also show a hint of this, but I haven't seen enough ECG's in my life to say whether that's significant and if that sign applies equally as well to limb leads.Slightly concerning, however, is the elevation in the inferior leads. It's my understanding that you shouldn't see much J-point elevation in BER in any of the limb leads, so I'm not quite sure what to make of that. Also, I'm not sure why the T-wave in V1 flips from the clinic to the EMS ecg's. There are also some small inferior Q-waves, but those are probably normal in a young healthy male.In the end, I'm not especially worried about this as BER is especially common in young, healthy, fit males (which I'm assuming a 23 y/o checking into the VA system is) and he's not showing signs of acute symptoms today any different from the past 4 weeks. Still treat with o2, aspirin, nitro, and in my system, I wouldn't mind taking him to the non-PCI hospital since it's only 5min from PCI-capable one and I'm not seeing any true indications for a STEMI-alert (even though those big, starred, words at the top of the initial ECG's are scary). If in a more spaced-out system, I'd probably defer to the PCI-facility just in-case. Still, monitor in route and record at LEAST one more 12-lead to check for Q and ST changes in my short ride to the hospital, and reassess vitals.

  • VinceD says:

    I wouldn't be truly shocked to find out it's pericarditis, but I'm just not convinced enough to attribute the inferior elevation it it without much going on laterally. Anyway, point of the second post while I'm rambling about BER. It appears, according to the NEJM, it's not to benign after-all. http://doctorrw.blogspot.com/2010/02/early-repolarization-on.html I can't view the article and haven't read the other citations yet, but it's an interesting idea to keep in mind.

  • TOTWTYTR says:

    I'm leaning against MI for a couple of reason. First, I see no reciprocal changes. Not a complete disqualifier, but highly suggestive of not an MI. Second, the HP of intermittent episodes x 1 month leads away from MI. MI pain is generally continuous, not intermittant. Third, a month of episodes would lead me to think Agina not MI. At this point, transport is indicated, but aggressive treatment isn't.

  • Anonymous says:

    from all the ECG this pt. is bradycardic. it would have been interesting to know the time between the 12-leads in the clinic and the ambulances own. the clinics show st elevation in the inferior and anterior leads, i would probably look at V4R at the least. also looking and V1 in the first 12-lead there looks to be a bundle branch block. the ambulance's twelve lead looks distorted so i might have tried to get a cleaner picture by adjusting things. VinceD and RobertB discuss concave t wave (thanks for bringing that up i forgot to look) and i think the stats behind that are there is an 85% chance that it is benign if t-waves are concave up, but i not going to say your not having a heart attack on concaveness. i agree that this is no heart attack but there is enough on the EKG to make my worry, especially since there is no documented history in the is pt. i am going to treat it as one per protocols for chest pain. So are treatments are all the same really no matter what the 12-lead says MONA (morphine, O2, nitro, and ASA: not in that order of course). as for receiving location, if it takes 5 more minutes to get to a heart hospital then i will take him there cause if this pt. need surgery a transfer between hospital takes more than 5 minutes. if you only have one hospital, then the answer is easy. as for a stemi team activation, i would call the doctor on this one and discuss

  • Sonnet says:

    Moving away from from diagnosis: I like your analysis of pain.Good posthttp://tabibqulob.blogspot.com/

  • Tom B says:

    THM – I have to admit, lead V1 hadn't given me any cause for alarm when I first reviewed this case, since the T-wave in lead V1 can be positive, negative, or biphasic and still be considered "normal". However, it bothers me when the T-wave changes from negative to positive and back again! Check out the serial ECGs.Tom

  • Tom B says:

    RobertB – For the sake of ruling out the STE-mimics, I usually group BER and pericarditis together, since they are similar in terms of notched J-points and upwardly concave ST-elevation.It's not always easy to tell them apart in the field!Tom

  • Tom B says:

    VinceD – I know that BER usually shows up in the precordial leads (and lead V4 in particular) but I have seen this finding in the limb leads before! Again, I group BER and pericarditis anyway.As for the T-wave in lead V1, I initially thought it was explained by differences in lead placement between the clinic and the EMS crew.However, there are changes in T-wave morphology in lead V1 from one prehospital 12-lead ECG to the next, which is certainly cause for concern! TomP.S. I do know that the limb leads were placed on the patient's chest in the clinic and on the patient's limbs by the EMS crew. That's probably why the clinic's 12-lead ECG shows a slightly right axis and a flat T-wave in lead aVL (which was apparently enough to trigger the ***ACUTE MI*** message on the clinic's 12-lead ECG). So for those who think "it doesn't matter" with the limb leads, it does matter!

  • Tom B says:

    TOTWTYTR – Excellent reminder that we need to consider the history and clinical presentation when we look at an abnormal ECG!Tom

  • Tom B says:

    Anonymous – Remember, the QRS duration needs to be at least 0.12 s (120 ms) to be considered a bundle branch block.The serial 12-lead ECGs show better data quality (I'll post them as soon as I'm done commenting).You are absolutely correct in that upwardly concave ST-elevation does not effectively rule out acute STEMI! Not even close.Upwardly convex (non-concave) ST-elevation is suggestive of acute STEMI, but that's more to help rule-in something you already suspect.Tom

  • Tom B says:

    Dr. Sonnet – You must be referring to the analysis by TOTWTYTR. I agree with you! :)Tom

  • Christopher says:

    23yo seems a bit young for MI, going to get a good Hx including familial Hx, any cocaine usage, etc. Granted he's brady, so something like coke seems less likely. His 12L looks a lot like BER. Serial 12L by the medics were unremarkable except for the noted T-wave changes in V1 (not sure what that could be). A right sided 12L wouldn't be a bad call.Trial of NTG, O2, and in my case the normal hospital I'd be taking him to is PCI capable, so it doesn't have to be a factor in my care.Interested to hear the outcome!

  • Andrew says:

    A tall T wave in V1 can be concerning if it is new (need an old EKG) and if it is taller than T in V6. (Amal Mattu, MD lecture)

  • Brian H. says:

    I'll take "pericarditis with PR depression" for $200, Alex. Not uber-prominent, but there.

  • If i was going to treat the monitor a STEMI alert would cross my mind. Fortunately taking the information given along with presentation and some good O'l paramedic detective work would he be considered a STEMI alert. As it stands with given information and lack of some of the basics my answer is no alert. I think this patient would benefit from some simple blood work in a local ER.

  • Geoff says:

    This patient ended up having a repolarization abnormality according to the ED. Also, the clinic had the arm leads on the chest wall.

  • Macgyvermedic says:

    I would have taken pre-cordial catch syndrome with a side of re-polarization for 500 had I stumbled upon this last spring. 🙂

  • 12leadekg says:

    I am going to call this Early Repolarization,  ST segment is concaved.  QTC is < 425ms which i believe tends to lean toward Early Repolarization.  Inferior ST elevation but no T wave inversion leads me away from Stemi as well. 

  • medicdad says:

    Coranary spasms anyone ?

  • 12leadekg says:

    Also noted mean R Wave is leads V2-V4 is around 9.3mm which also favors Early Repol.

  • Doc Cottle says:

    What is with the Marquette interpretation software? It's scarin' the bejsus outta people.
    Had a very similar ECG a little while ago, and it got me to thinking about how STEMI alerts are usually activated –  either a certain absolute amount of elevation in whichever leads (2mm in V1, but 1mm in II…), or just based on the computer interpretation. I hope that more systems start to rely more on the judgement of educated prehospital providers.
    If you care to, check out my post at Mill Hill Ave Command for a thought-provoking pair of EKGs.

  • Ben says:

    Little elevation of inferior lead on first EKG. Possibly some for anterior. Seems after the Nitro, ASA, and O2 was given EKG changed to NSR and Sinus Brady. Would transmit all EKG you obtain and contact doctor to see what his/her say is. I would transport this pt to PCI capable hospital if available if doctor agrees.

  • Charles Phillips says:

    Given his recent history of chest pain relieving itself (stabile angina) and then showing up at the VA with his current symptoms, I'd lean toward getting him to a STEMI Center. Once the cardiologist(s) could look at his EKG's, run their own and any stat labs, they could make a decision. The EMS EKG really didn't show much ( was the patient diaphoretic or needed to be shaved? Lots of 60 cycle interference!). 

  • EmtMom says:

    Nothing mentions his physical description, as in size, weight, athletic? 

  • Michael Ruff says:

    Is there somewhere that you can turn off the interpretation verbage on these machines.  I find that many of my co-paramedics will look at the interpretation before they look at the EKG itself.  
    They already have their mind made up that it's an MI from the interpretation alone.  
    Turn off the words and make the medics or the docs read the darn ekg first and then maybe reprint the same ekg with the words.  Sort of a check your answers kind of thing.  

  • Nancy says:

    My guess is that a 23 year old at a VA clinic is most likely a soldier, and at that age the PT requirements will get you a very fit individual, so even though is heart rate is below 60, it might be quite normal for an athletic guy.

  • S j g says:

    Prinzmetal angina, I have seen and treated before.  Treat it as s stemi   It. Is a vaso spasm of the coronary arteries.  Vessels clamp all the way down and occuled causing a " momentary stemi". In a cyclic pattern.   Can lead to cardiac arrest given long enough or right location in heart

  • John Handlebar, D.O. says:

    It's early repolarization….much less likely is pericarditis…. Come on guys…He's 23 for Christ's sake…

  • Paul says:

    BER. Give him 30 of Toradol, 5/325 Percocet, 5 of Diazepam and maybe a liter of LR and see how he does. I’m going with musculoskeletal injury/costochondritis, and treating as such. I wouldn’t have even called 911 if I were the base clinic physician. I would have done a Chem-7 and a CXR to look for pneumonia/atelectasis which I think would be a lot more helpful than what was done for him.

  • Mike says:

    Medic up and do a 15 Lead on this pt. He is showing slight elevation in the inferor leads. I would want a 15 lead hold the nitro. Just my thoughts.

  • Lisa says:

    Hx of viral illness? Ask him if pain is postional? Treat the monitor or the patient? I'm leaning toward pericarditis.

  • Gusepperm says:

    STE appears and disappears, i do belive it's not a pericarditis/miocarditis and not a BER (QTc is not unnormal). It could be prinzmetal's angina. During the episode of pain ECHO could be done. It could be also  kind of structural heart disorders of miocardium or valves. 

  • Igor says:

    New tall T wave in V1 ! St segments in V2 changes to a small amount od STE – which is normal specially in a young man – to a complete isoelectric ST segment!

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