58 year old female CC: Chest pain

Here’s a case study from a faithful reader who wishes to remain anonymous.

Presenting Complaint – Chest Pain

History of Present Complaint – 58 year old female, nil cardiac history, mild smoker, social drinker and overweight.

Complaining of acute central chest pain @ rest. Awoken by pain.

On Arrival – Sat upright on settee (Editor’s note: One of you Brits will have to interpret that for me!)

On examination:

Alert, orientated and communicable (GCS 15)
Pale, cool dry skin.

Nil SOB, clear bi-lateral air entry – nil adventitious breath sounds
R/R 19, SpO2 99%

H/R 68 and irregular, BP 125/74

Temp 36.8
B.M 7.2 (Editor’s note: B.M. is BGL measured in millimoles. 1 mmol/L of glucose is equivalent to 18 mg/dL. Hence, this patient’s sugar is about 130).

C/O chest pain.

O – Acute. Awoken from sleep.
P – Nothing makes pain better. Not affected by breathing
Q – Non specific compressing type pain
R – Central chest pain radiating left arm
S – Pain score 6/10
T – 30 mins
I – No pain intervention sought.

Slight nausea, nil vomit

The cardiac monitor is attached.

A 12-lead ECG is captured.

How would you treat this patient?


  • Dan says:

    Alright, here it goes. I am going to say probable inferior-lateral AMI, even though there is evidence of a LBBB, if that is new (as a patient with "nil" cardiac history would have) then that is another indicator. I say inferior because of the ST elevation in II, III, AVF, and Lateral because of V5-6. I know that a BBB can confound elevation/depression, but my guess is that the presumably new LBBB and ST elevation in 2 contiguous leads (in 2 different places) are 2/3 criteria you are looking for… I look forward to being corrected! Is it criteria for R sided involvement? As far as treatment, I would start O2, monitoring, serial 12-leads to look for progression, a Right sided 12 lead/15 lead, heck, maybe even an "18 Lead" to check the posterior while I am at it. BP and HR seem a little low for someone in this much pain, (so is the conduction system also affected?) so I would probably give a fluid bolus before any nitro as there is no evidence of pulmonary edema, especially if there is evidence of R sided involvement. Aspirin, and fentanyl for pain management, rapid transport to a PCI capable center.

  • Going out on a limb here but would the three criteria be:1) Concordant ST elevation in II, V4, V5, V6.2) Concordant ST depression in V1, V2, V3.3) Discordant ST and T waves with ST elevation > 0.2 depth of the S wave in III and aVF.Seems like this one definitely meets STEMI criteria in LBBB.Treatment includes IV fluids and 15 LPM O2. Seems like this has inferior involvement so I would hold off on Nitro. 324 mg ASA and morphine or fentanyl for pain management. My protocol calls for 600 of Plavix in confirmed STEMI so I'd probably be dropping that as well. Right now vitals look ok but I would be keeping a close eye on them during transport. Call ahead to the cath lab would also happen during report.

  • Hillis says:

    The diagnosis is straight forward inferolateral STEMI ( typical presentation of the chest pain + typical ECG changes) the culprit artery is the LCX . Don't forget to rule out Right ventricular involvement by V4R ..Treatment is as for all STEMI with Aspirin , Clopidogrel , O2, be careful when using GTN or morphine and Beta blockers since this type of infarction tend to be complicated with hypotension, heart failure or AV block and of course PCI as soon as possible.

  • meets all 3 of elena sgarbossa's criteria

  • Geoff says:

    I'm going to say inferio-lateral STEMI based on the criteria already outlined. I would like to do a right sided ECG as well, but I'm trying to figure out how V4R should look w/ a LBBB. If the left bundle is blocked, conduction is cell to cell causing the wide QRS. It seems like the "normal" LBBB I am familiar with has a negative complex in V4 w/ a discordant T wave. The normal 12 lead ECG seems to have a positive complex in V4 and if you do a V4R, the complex is negative because the vector is going away from the electrode, right?. This complex looks positive already, so what should be expected? Am I thinking too much into this?

  • Christopher says:

    Inferio-lateral MI. Meets criteria for ST elevation in the face of a LBBB (STE >20% of S-depth, concordant STE in V5/V6). Concordance bad!

  • Tom B says:

    Thanks for the comments, everyone! You guys are all on track. One small comment, because this point is often misunderstood. The ST-depression in the right precordial leads (V1-V3) is actually concordant because it's in the same direction as the terminal deflection of the QRS complex.Tom

  • Anonymous says:

    Tom, I was wondering with the ST depression in v1,v2 and v3 whether or not there's a possibility of posterior involvement ?DaveO.

  • Tom B says:

    Absolutely! That's exactly what the ST-depression in leads V1-V3 corresponds to! Good point.Tom

  • akroeze says:

    Ok so the reason we consider depression in V1-3 as a positive STEMI is that it is a presumed posterior one, why do we need that rule? Wouldn't the other two rules apply to the posterior leads?In other words, wouldn't the standard adage of "Anterior depression can be posterior elevation so check the back" apply here making things even MORE sensitive (checking for posterior elevation vs. anterior depression that isn't a reciprocal change)?

  • Tom, I think you may have started a revolution of MI identification in the presence of LBBB. I dare say that you have provided more information on this topic than anywhere else I have seen. The days of “its a LBBB, unreadable” are hopefully over!!! Now, if you can get the ER docs on the same page, you’d make some real headway.

  • William says:

    Pretty clear cut inferior lateral MI with a LBB block. Treat it as you would any MI..I.e. MI, ASA, Nitro, and Morphine per protocol. She needs a cath lab pretty bad.

    Also note that the 12 lead “interpatation” completely missed the MI. You CANNOT trust it most of the time.

  • Christopher M T NREMT-P says:

    Adam, I want to also give that suppot. My first STEMI call in the feild had a borderline LBBB .10-.12 somewhere. The changes had me concerned and so did the doc that refurred me to the PCI hospital 45 min out after the crew used the monitor to send the ekg to the nearest medical control doc. I ended up in trouble because the only thing found was the borderline BBB. Hx even made it likely to be new. I have been loving Dr Smith and education given on this. thankyou for you time!

    You provided the diagnosis above article, so here is the my Tx until i learn something new. v4r, o2 maintain spo2 98-100% 2 lpm NC, ASA, Bilaterall large bore IVs,caution with NTG -nitro drip (on pump)titrate for pain b/p 100sys, fentanyl 25mcg titrate prn for pn not relieved by NTG/02/ASA and bp greater than 90-100 sys, serial 12 and right sided. if time permitted posterior leads but i know whats there from my 12 lead, NS 250-500ml bolus then titrate down to maintain bp above 90-100 sys. LS remain clear up to 3 L NS if needed. Early notification of STEMI. This area is not PCI but too far fron PCI to bypass ED treatment ( Note pci: 1hr 45 by ground, about 20 by air.). Check status of lifeflight. Meet in route to Local ED as indicated in protocol. D/C nitro if unable to maintain BP as it will almost immidiately wear off unlike SL dose.
    Love feedback!! Sorry this one is so lone wanted to thank you.

  • Troy says:

    Anyone for a right-sided 12 lead? I am!!!

  • AD says:

    15l of O2 for somone with MI, saturating well? Have a look at the AVOID trial.

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