54 year old male CC: Chest pain

Here’s an interesting case submitted by Terry Weatherford, NREMT-P.

EMS responds to a report of a 54 year old male complaining of chest discomfort.

O—Sudden onset
P—Nothing made the pain better or worse
R—Radiated to left shoulder
T—Less than 30 minutes

Vital signs:

B/P 110/78
Pulse ox 100% with O2.

S—Nausea no vomiting
M—NTG, Lisinopril, Insulin
P—MI with stents placed, diabetes and HTN
L—Breakfast 1 hr ago
E—Taking a shower

The patient informs paramedics that his pain resolved prior to EMS arrival. He states that he does not want to go to the hospital because he knows they will keep him for 4 to 5 hours and it will turn out to be nothing.

A 12-lead ECG is captured.

The paramedics tell the patient that with his past medical history he should go to the hospital by ambulance for an evaluation. He adamantly refused treatment even with 3 paramedics explaining the possible consequences of refusing care.

Suddenly, the patient’s chest pain returns. He appears diaphoretic.

A second 12-lead ECG is captured.

What is your impression?

See also:

54 year old male CC: Chest pain – Discussion


  • my impression is that the 3 medics nagged and stressed the pt into having a cardiac event.

  • Tom B says:

    Hahahaha! 🙂 Good one.

  • 1. ekg #2 has STE in aVL with reciprocal STD in inferior leads.2. different limb lead amplitudes between #1 and #2.3. T wave changes in all precordial leads.4. left axis deviation in #2.

  • Bob the builder medic says:

    2,3,4,5 elevation. I like what burned out medic said

  • I can see the research paper now…"Efficacy of Paramedic-Induced Cardiac Stress Testing (EPIC-ST) for refractory transport stubbornness"

  • Anonymous says:

    Anteriolateral MI with LAH

  • Brian H. says:

    They left out the tasering…Anyway, inferior reciprocal changes, early septal / lateral changes of ischemia.

  • HybridMedic says:

    Did he self administer NTG prior to arrival, is that what made the pain stop? I'd be tempted to say that he has unstable angina with the strong possibility he is having an anterior MI. I can't really add anything else.

  • akroeze says:

    I'm just finally (I think) getting totally comfortable with calculating QRS axis.ECG #1 I see extreme right axis deviation to the tune of -170 degrees. Which is right on the edge but makes me query if the limb leads were swapped between these two as all of a sudden in ECG #2 we have a left axis deviation but I'm having a hard time putting a number to the degrees.Can someone confirm if my thought process is right here? And can you tell me how I can determine how to use either I or aVL as the isoelectric lead?If it is Lead 1 I put it at -70 degrees and if it is aVL I put it at…. well it can't be aVL can it? The "up/down" method puts the axis in the left but aVL would be extreme right would it not? Or am I over thinking?Sorry if I am going on a tangent here, trying to learn!

  • David says:

    Firstly I'd be asking if his cp has changed over the ladt little while. If he's been having more episodes of cp at unusual times (at rest, while asleep, etc). Someone asked if the pain subsided with ntg use, I'm curious as well. Unfortunately I can't really see the 12 leads well on my phone, but it sounds like there are some interesting changes (will check to see if my employers block blogs :)). My guess, prinzmetals agina.

  • Hillis says:

    Not easy !! But in all cases i do gree with the paramedics the patient needs transport to hospital at least for observation and further evaluation , but after development of the second episode of chest pain i can see clear ST depression with T wave inversion in the inferior leads ( II,III and aVF ). 1 mm ST elevation in aVL , not sure about lead I !! but the history of sudden onset suggest more STEMI than NSTEMI so i wil go for lateral STEMI . Honestly am not sure what will be my decision if i was the treating doctor activate the cath lab or wait for more obvious STE changes !! What do you think Tom!!Nice one Burned- out medic !! it does really happen .

  • Terry says:

    Burned-out MedicThat was funny you really are burned out!!The pt did not take any ntg prior to our arrival. It was amazing at how diaphoretic he got when the c/p came back. I did note the axis and made sure that the leads were on right. Also when the pain came back he did not refuse treatment or tx. He was a willing cooperative pt. Still no feedback from our QA folks but he did go to the cath lab per ER Doc and he was pretty sure that he got his LAD cleaned out.Another side note— 3 medics on scene and the pt survived. Now that's amazing.

  • Hugh Skye says:

    I'm inclined to agree with David on the Prinzmetals diagnosis and I think the patient got worked up by three medics telling him to go to the hospital or he was gonna die. that probably triggered the vasospasm and thus triggered the STE, the fact that he has a significant cardiac hx I think leans towards this theory. I think he'll probably be fine with a hit of nitro, but should absolutely go have a sit down with the ER doc and an interventional cath lab.

  • Steveandannette97 says:

    Antero-septal? Elevation in V4, V3 and V2 with reciprocal changes, depression in limb leads 2, 3 and aVF

  • Nancy Nurse says:

    Left BBB (unable to measure but it sure looks wide)….irregardless of the ST segment elevation, if this is a new onset of LBBB (which may obscure MI), he gets treated like a STEMI (with the chest pain).

  • Andrew says:

    Good jon on the serial 12s. I’ve had a few like this were you see them evolve right in front of you. One of my preceptors in pmed school told me to print a 12 with any change (complaint, pain, presentation). Good advice.

  • Meg says:

    Blocked stent? Perhaps he’s having a problem with his previous stents..

  • The Jarvik 7 says:

    Beautiful case study! Very apropos of Dr. Smith’s recent interview on the EMCrit podcast. Thank you for this!

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