66 year old male with chest pain and acute STEMI identified with serial ECGs

Here’s a great case submitted by Nick Ciaravella of Grady EMS in Atlanta, GA.

66 year old male presents to EMS with chest pain.

SAMPLE history

  • S – Chest Pain
  • A – None
  • M – Atenolol, HCTZ
  • P – Hypertension
  • L – meal, 7 hours prior to event
  • E – Mowing his lawn


  • O – Started while mowing his lawn
  • P – Provoked while exerting himself, Palliated initially when he sat down to rest
  • Q – Sharp
  • R – Substernal, initially radiating to his jaw, when he rested the pain was only in his chest
  • S – Initially 10/10, upon ems arrival 4/10, en route 8/10, 9/10, and 10/10 upon arrival at ED
  • T – No previous episodes

Vital signs

  • RR: 18
  • HR: 72
  • NIBP: 148/84
  • SpO2: 96% on room air
  • BGL: 103

The patient was placed on 3 LPM O2 via NC, given 324 mg Aspirin PO, given 0.4 mg nitroglycerin SL and 1 inch of nitroglycerin paste. The patient’s pain increased en route to the ED and began to radiate down his left arm en route.

12-lead ECG #1


Sinus rhythm with a rate of 68 and borderline first degree AV block. The R-wave in lead V4 is cut off by the top of the ECG paper. The prominent T-waves in leads V3 and V4 are probably due to early repolarization.

12-lead ECG #2 (15 minutes later)

Now the T-waves in the inferior leads (II, III, aVF) are hyperacute and there is a downsloping ST-segment in lead aVL! There is new ST-segment elevation in leads V5 and V6. There is also new ST-segment depression in the right precordial leads (V1, V2, V3) with “down-up” ST-depression in lead V3. 


The patient was taken to the cardiac cath lab. We do not know the outcome but there is little doubt this represents acute STEMI, mostly likely total occlusion of the circumflex (LCX).

Some ECG machines come with ST-segment monitoring and will automatically print out a new 12-lead ECG when there are changes. Whether the machine does it automatically or you do it manually, it’s important to obtain serial 12-lead ECGs when caring for a patient with signs and symptoms of an acute coronary syndrome (ACS).

See also

82 year old male CC: Chest pain

41 year old male CC: Chest pain

Updated 01/23/2016


  • Hillis says:

    It's really amazing to see the clear changes between both ECGs.. the second ECG shows deep ST depression in the anterior leads with STE in the lateral leads and T wave inverion in aVL .. I think we are dealing here with posterolateral STEMI , no harm to repeat ECG with V7-9.I think it's wise to activate the cath lab for urgent angiography .. I think the leasion would be in the left circumflex artery .. Amazing case , curious about the updates.

  • What a smart crew with their serial ECGs. posterolateral STEMI could indicate a dominant circumflex, or more likely a distal RCA occlusion. Either way, the sharp pain is an atypical presentation. He does have large complexes in Left precordials and heart failure meds, but with the ST-progression and growing T-waves, STEMI is likely.

  • Christopher says:

    Initial 12L unremarkable for STEMI, however, I do note the QRS complex cropping in V3-V6. T wave in V4 seems way out of proportion with the QRS.Serial 12L shows marked changes from prior with STE lateral precordials, II/III beginning to show STE. STD V1-V3. I'm sold on posterior involvement seeing the change from a tiny R to a big R in V3 (upside down Q!).Going to concur with posterolateral STEMI especially considering the acute change in 12L (15 minutes!).

  • akroeze says:

    Out of curiosity, what did the machine interpretation read?Interested if it could make any sense of this.

  • Mark J. Tenerowicz says:

    Looking at the 2 EKGs side by side, I'd guess the 1st shows hyperacute T waves in V4….the second shows the evolution of a posterior-lateral STEMI.

  • Tom B says:

    Dr. Hillis -I was also very impressed with this case! I also agree that there would be no harm in capturing modified chest leads V7-V9.Definitely a case where I would activate the cardiac cath lab!Tom

  • Tom B says:

    Adam -I'm going to take your comment on a tangent.You said, "What a smart crew with their serial ECGs." Why is it that in medicine, we leave so many things to chance? A "smart crew" performs serial ECGs. A crew that is "not smart" does not.It seems to me that we need to design "smart systems" that are not so dependent on "smart individuals" within the system.All patients with indications for a prehospital 12-lead ECG should receive one with the first set of vital signs.All patients with indications for a prehospital 12-lead ECG should receive serial 12-lead ECGs for exaclty this reason! So we need to educate not just our individual paramedics. We also need to educate our system designers and make sure that "someone is watching" to ensure consistent performance.Tom

  • Tom B says:

    Christopher -I agree with everything you wrote, and it's true that leads V5 and V6 each show > 1 mm ST-elevation.The changes between the two ECGs remove all doubt! But I might perform modified chest leads V7-V9 just to make sure there was no delay inside the hospital.This meets the criteria of an acute STEMI if there ever was one. Tom

  • Tom B says:

    Mark – I think you're correct.Other interesting findings between the two ECGs:* Look at the inferior T-waves! They "pop up" in the second ECG. That's significant! * Look at the downward slope of the ST-segment in lead aVL in the second ECG. That's also significant! * The most impressive changes are reciprocal changes in the right precordial leads. This would be significant all by itself! * Leads V5 and V6 are significant because they meet the actual ST-elevation criteria (which shouldn't even be necessary in the context of the other changes, but nice to have none-the-less).Tom

  • Tom, Couldn't agree more. I guess I am just so numbed by the constant subpar care I bare witness to that I am quick to give compliments when someone does something right. Not extra, just right. If there is an indication to perform a single 12-lead ECG, than there is an indication for the second.

  • Tom B says:

    Adam – I was just playing devil's advocate! I agree with you that good performance is praiseworthy.In this case, the treating paramedic captured a 12-lead ECG with outstanding data quality and then caught an acute STEMI with serial ECGs.That's awesome! I'm just trying to figure out how we as a profession are going to make this an expectation.Tom

  • RobertB says:

    Nobody has commented on the prolonged PRI (anywhere from 0.24 to 0.28) ? Is this likely caused by ischemia, or is this first degree block more likely existent before the onset of symptoms (if there's any way to separate the two ?)

  • malcolm x says:

    sinus rhythm with 1ST degree AV block, acute antero-lateral wall myocardial injury and possible hyperkalemia

  • malcolm x says:

    LAD occlusion

  • rui says:

    Posterior-lateral STEMI >>>>reperfusion theraphy (PCI or if not possible tNK ev)

  • malcolm x says:


  • KeeferTrace says:

    I don’t consider myself an expert, just a regular EMT-P. In the first 12-lead, I see a 1 degree AV block, and hyperacute T waves in V3-V4. In the second, I see clear lateral elevation, early Inferior changes, and obvious depression in the early V leads that I would suspect of being reciprocal changes from the posterior wall. Based on what I was taught as a paramedic in Alberta, I would have done a 15 lead after the 1st 12 lead to look at the posterior wall, and another after my 2nd 12 lead (10-15min later). I also would have left my pt hooked up, and done serial 12s every 10-15min during transport and triage). we routinely use bluetooth technology to send abnormal 12s to to oncall cath hospital, and they chose the tx path of thrombolytics first or straight to the cath lab. We also have had good results with giving thrombolytics in the field prior to or during transport.

    Malcolm X states he thinks the posterior wall clearly isn’t involved, while several others concur that there is posterior/lateral injury. Why the contradiction? I feel I must be overlooking something…

  • malcolm x says:

    the posterior wall is not involved because what you see on v1 is a reciprocal change not an indicative change.with posterior wall infarctions, the preponderance of the current is on the right not on the left.

  • Jon Eshbach says:

    First EKG looks ok. Second shows the progress of the infarction in lateral leads. But depression in v1-v3 concerns me. I would deffinately do posterior 12 lead to check for elevations and transport/treat as indicated.

  • Vijay Balaji.K says:

    Can the 1st ecg also indicate an impending MI.There seems to be horizontality of the st segment. “it seems to hug the baseline”. Can that give a clue to the diagnosis?

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