Hereâ€™s an interesting case submitted by a faithful reader who wishes to remain anonymous.
EMS is called to a 26 year old male complaining of chest pain.
On arrival patient is found sitting on his living room couch. He appears anxious and acutely ill.
The location of the chest discomfort is in the center of his chest and slightly to the left.
- Onset: After a “coughing spell”Â while riding a bike
- Provoke: Nothing makes the pain better or worse
- Quality: Difficult to describe but with prompting the patient calls it â€œpressureâ€
- Radiate: Left side of jaw and left arm
- Severity: 7/10
- Time: No previous episodes
The patients skin is pink, warm, and moist.
The patient denies shortness of breath. Breath sounds are clear bilaterally.Â He is nauseated but he has not vomited.
Past medical history: Healthy
Vital signs are assessed.
- RR: 22
- HR: 98
- NIBP: 140/84
- SpO2: 98% on room air
The cardiac monitor is attached.
A 12-lead ECG isÂ obtained.
Sinus rhythm with a rate of 94 and first degree AV block. There is subtle ST-segment elevation in lead III with reciprocal ST-segment depression in lead aVL. There is also ST-segment depression in leads V1-V4.
The 12-lead ECG was deemed suspicious by the treating paramedic, but STEMI seemed unlikely due to the patient’s age.
AÂ second 12-lead ECG was obtainedÂ just prior to arrival at the hospital.
There is slightly less ST-segment elevation in lead III. ST-segment depression in leads V1-V4 is now more pronounced and shows the classic “down-up” pattern of acute posterior STEMI!Â
Remember that ischemia does not localize! Therefore, ST-segment depression that is localized to leads V1-V4 is far more likely to represent acute isolated posterior STEMI than “anterior ischemia” which is a misnomer!
You can use modified posterior chest leads V7, V8, and V9 to shore up the diagnosis. Just know that when these leads are negative, it does not rule out an occluded artery!
After consulting cardiology the patient was taken to the cardiac cath lab and had a 100% occluded circumflex artery (LCX).
Remember, young patients can and do experience acute STEMI!