74 year old male CC: Chest pain

74 year old male presents to EMS with a chief complaint of chest pain.

Onset approximately 1 hour prior to the 9-1-1 call.

No further details of the OPQRST are currently available. I will update the case with this information as soon as it is available, along with the physical exam.

Vital signs:

  • Resp: 20
  • Pulse: 56
  • NIBP: 97/57
  • SpO2: 100 on RA

Past medical history: HTN

Meds: Unkown

The cardiac monitor is attached.


A 12-lead ECG is captured.


What is your impression?

Would you call a STEMI Alert?

Why or why not?

What additional action(s) might you take?

See also:

Update to 74 year old male CC: Chest pain

Cath report for 74 year old male CC: Chest pain (with angiograms)


  • Tor P says:

    Localized ST-depression in anterior leads V1-V3, with minimal ST-changes in other leads is highly suggestive of posterior STEMI.Take posterior leads V7-V9!

  • christina says:

    Agreed. Need to see the posterior leads but would go ahead and start treating for posterior stemi based on what I'm seeing. O2, IV with NS bolus, ASA (unless allergic). Transport to a facility with PCI capabilities.

  • Tom B says:

    I'm starting to wonder if the blogosphere even needs me anymore! :)You guys might be interested in this case from Dr. Smith's ECG blog.Tom

  • Christopher says:

    Agreed, tall R's in the right precordials w/ STD makes me think posterior. (I'm sure this post is not needed, but I feel better going through the motions)

  • Hillis says:

    The rythm is quite difficult to determine .. It's written in the strip that PR is 0,190ms, but i can't see the P wave in all leads!!Also the quality of ECG not that much !!the rate is slow.. Am thinkin about AV dissociation..There is RBBB ( is it new !! an old ECG is so much helpful if available .. if not i would consider it as new RBBB until proven therwise) the heart axis is left which suGest left anterior fasicular block so am thinkinG about anterior STEMI ..Of course it's nessecary to rule out posterior MI so do the posterior leads.

  • Tom, I think you are still needed my man. Think of all the people that read your blog, but don't post. I still refer people to the axis determination tutorial quite often. Ps. I agree with posterior STEMI, big R's in right precordials with ST-depression.

  • arnel says:

    Agree with posterior MI. Yes call a code. R wave in V1/V2 is 0.04ms or more and RS ratio is more than 1 – fits the criteria and ST dep and Upright T. What makes me wonder too – is there an existing AV dissociation? Are those P waves in between the QRS and T in aVL and II,III and I? Would love to see rhtyhm in real time to see the P waves move in relation to the QRS. Tnx for this interesting case.

  • Tom B says:

    I'm not entirely sure the tall R-waves in this case are related to the posterior STEMI.In the first place, this isn't sinus rhythm. The QRS duration is borderline, but with the RBBB morphology, I'm leaning toward a possible AIVR.Typically the tall R-waves in leads V1 and V2 associated with posterior STEMI are not terminal R-waves.Either way, this case is an excellent example where posterior leads V7, V8, and V9 might be very helpful! I'm going to post some serial ECGs captured en route to the hospital. The cath report and angiograms have also been requested.Tom

  • Geoff says:

    I'm going with Posterior STEMI as well. In terms of the rhythm, in Lead II on the initial rhythm, I kind of thought I was looking at inverted P waves right after the QRS complex. In terms of immediate treatment, O2, IV w/ fluid bolus, ASA, and repeat 12 Lead to try to improve the data quality if possible. Also repeat w/ posterior leads.ST Depression, maximum in V2-V3 with the upright T Wave leans towards Posterior STEMI correct?Thanks again for the great post.

  • Tom,Just to elaborate on your statement regarding tall R-waves. Might they not normally be terminal R-waves normally with STEMI because they are actually representing pathological Q-waves through the "rear mirror" view?

  • arnel says:

    I am seeing AV dissociation as I can see P waves about 16 ms after the QRS in I (rhythm strip – small deflections). Thus I am not for AIVR. This coulbe be CHB. Second this can be an RBBB but the upright T wave is against the concept of discordance in RBBB(T wave inversion). Yes tall R waves are earlier in PMI as also with RBBB. Aside from posterior leads it would also be nice to have baseline ECG which is difficult in the real world.

  • Hillis says:

    Thanks Tom for this interesting case , i read the link posted by Dr. Smith.. But still confused !!Does the patient in this case had already a known history of RBBB becouse the interpretation of ECG may totally differ according to this !! don't you agree with me or does not matter whether new or not the diagnosis of posterior MI was only based on the degree of ST depression which is more than 2mm ?!What about the LAFB and the heart axis ?? The ECG of this patient shows the classical picture of the LAFB, which is the most common type of intraventricular conduction defect seen in acute anterior myocardial infarction, and the left anterior descending artery is usually the culprit vessel !!! What was the result of his angiogram ?? Looking forward to hear from you..Thanks again for the great post .

  • Tom B says:

    @Geoff – Yes, I think this ECG points toward acute posterior STEMI for the reasons you mention.@Adam – That is my understanding, that the tall R-waves (R/S ratio > 1) represent a sort of "reciprocal Q-wave". I have also noticed with acute inferior STEMI that as Q-waves develop in leads III and aVF, the R-waves will get taller in leads I and aVL.@arnel – I also see P-waves after the QRS, but I'm not sure it's AV dissociation! However, I am leaning toward a ventricular rhythm.@Dr. Hillis – This could be a junctional rhythm with RBBB/LAFB, but I think it's just as likely to be a ventricular escape rhythm originating in the left posterior fascicle of the left ventricle, which would present as RBBB in lead V1 and LAFB in the limb leads.Either way, whether it's RBBB or a ventricular rhythm with RBBB morpholoogy, the ST-segments are clearly abnormal in leads V1-V3, and especially leads V2 and V3! I agree with all of the previous posters who suggested modified leads V7-V9 to aid in the diagnosis of acute posterior STEMI.In this case, that step was not taken, but if you look at the update, there are changes on serially obtained ECGs.Tom

  • Jon says:

    Discordant RBBB

  • Susan says:

    Junctional rhythm (P waves after qrs), RBBB, st depression v1 to v3.  I would do a 15 lead, to check to the posterior leads.  If patient has chest pain, I would administer ASA, start an IV then consider 1 subligual nitro.

  • Lynn says:

    Initial red flag should be the Hx of HTN and he's hypotensive and bradycardic. Definitely a pump problem. Perform V7-V9 to assess for posterior involvement, administer O2 and ASA while assessment continues (if no allergy to ASA). Assess lung sounds prior to fluid bolus-if clear, initiate bolus. Stabilize pt and proceed to tx. If no elevation is found, we can't call STEMI. What we can do is to advise the receiving facility of the assessment findings as soon as possible. P waves behind the QRS complexes and the new onset of a RBBB (if it's not old and we don't know that) have to be treated aggressively. Pt's already unstable due to CP. It's our job to try to stabilize, 'spot' the problem and 'stop/slow' the symptoms. Administration of NTG (post bolus if successful for stabilization) will help some w/pain mgmt. Careful w/Morphine administration for pain mgmt due to vasodilatory properties. Maintain stabilization after it's achieved. Always be prepared for any changes that occur and get this guy to a PCI facility. (Get the pads out and put them on the seat  beside you just in case you need them if his condition deteriorates)

  • Soozey G. says:

    I would absolutely activate the cath lab based on this presentation and strong suggestion of posterior MI.

  • Tom,
    This looks like a left bundle escape (not quite AIVR, which comes from still lower down). Thus the RBBB morphology. As you say, the tall R-wave has nothing to do with posterior MI, but everything to do with the delayed RV activation. Furthermore, you don’t see large R-waves in posterior MI until the infarct is well developed or completed. The ST depression very likely is indeed posterior injury (STEMI). Looking forward to followup.

  • Nick says:

    Probable posterior STEMI. Do posterior leads to verify. There’s a big difference in how they treat a patient with Septal Ischemia vs Poterior MI. The Septal Ischemia will stay in the ED while they draw enzyme levels and then be moved to the icu and scheduled for a stress test or cath the next day…..while the posterior MI will be rushed to the cath lab. I’ve never seen the ED do posterior lead placement…..so we need to do it prior to getting to the ED. Time is muscle.

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