76 year old female CC: Chest pain

EMS is called to the beach for a 76 year old female complaining of shortness of breath. Past medical history of emphysema.

On arrival, the patient is found sitting in a beach chair alert and oriented to person, place, time, and event. She does not appear to be in any acute distress.

The patient states that she was out wake-boarding when she fell and “got a mouth full of water.” She coughed profusely and then experienced some chest discomfort.

She denies having experienced any shortness of breath.

She denies any other significant medical history other than a little bit of emphysema and states that she takes an inhaler but rarely uses it.

The patient is embarrassed but consents to further evaluation in the back of the ambulance. It takes some convincing for the patient to allow EMS personnel to carry her off of the beach (she wants to walk the 100 yards to the ambulance).

In the back of the ambulance, vital signs are assessed.

RR: 18
HR: 80
BP: 132/74
SpO2: 94 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

The patient states she feels better and wants to know if it’s really necessary for her to go to the hospital.

What should the paramedics tell her and why?

*** Update 09/06/2010 ***

By request, here are the serial prehospital 12-lead ECGs for the case.

See also:

76 year old female CC: Chest pain – The case for this being an acute anterior STEMI

76 year old female CC: Chest pain – Conclusion (Tako-Tsubo Cardiomyopathy)


  • Christopher says:

    NSR, 12L looks like anteriolateral changes, STE V2-V5, I/aVL. I don’t see any recip changes, maybe some STD in III. I’d like repeat 12L’s and a ride to a PCI capable facility.

  • Jordan says:

    12L STE I,L V2-V6 with poor R wave progression throughout precordium suggestive of anterolateral injury/infarct. Catch another 12L if CP changes

  • RM says:

    STE in precordial leads is reminiscent of BER. However, looks like elevation in AVL and I, and reciprocal depression in lead 3 and flattening of ST in AVF. Serial ECGs please 🙂

  • Geoff says:

    I am also concerned about the STE in I & aVL. I’d like to try to clean up the artifact if at all possible with serial ECGs, but definitely elevated. Could this be an example of STE that doesn’t necessarily meet the mm criteria, but you need to relate it to the size of the QRS complex? I don’t like the depression in III either. Based on age, I’d have to lean towards the elevation across the precordials as being possibly cardiac…T waves look almost symmetrical to me in some leads…hyperacute T waves in V5?…First convince her to go, I would lean towards a PCI center.

  • Medic999 says:

    Right then, here we go.

    Firstly, I have to ask myself does the description and history of the pain sound cardiac and does the patient sound/look cardiac?
    In this case, I would say no for both.

    Now, since we dont look at a 12 lead in isolation without the full patient presentation, it tends to point toward me being more skeptical of an ACS event than the ECG suggests.

    Yes there is a suspicious morphology of the ST segment in I and aVL and there is a slight bit of ST depression in III (but only in one lead). There is also ST elevation in V2, V3, V4 and V5 but in my humble opinion, only V4 looks like it isnt BER (so therefore again, only in one lead).

    So, in conclusion, looking at the overall picture, I would suggest this isnt an STEMI, however, I would still be persuading the patient to attend hospital as I had noticed some abnormalities in the ECG which I cannot rule out as ‘normal for her’. As for the choice of hospital, I would first send the ECG to the normal cardiac unit for their opinion, then if they were at all concerned it would be sent to the PPCI centre.

  • Tom B says:

    Excellent comments, everyone! I really mean that. You guys are all hitting on the abnormalities that had me concerned when I looked at these ECGs.

    The STEMI Alert wasn’t called from the field for this case but the ECG was transmitted to the hospital.

    I’m going to post a follow-up to this case that makes the case for this being an acute anterior STEMI.

    Special thanks to Dr. Smith of Dr. Smith’s ECG Blog for taking a look at this case and confirming a few things that I strongly suspected.


  • saif _iraqi says:

    thanks for this ECG,,,,
    the ECG shows st elevation in the lat. leads also there is st elevation in lead v2-v4 with poor r progression in ant. leads

    so its anterolateral ischemia
    markers and serial ECGs are needed…..

  • Lars says:

    Have you ever had a heart attack , Ma'am? I see some discrepencies in your EKG, but for you it may be normal with your age. I'm not a cardiologist though and I'd like to take you to the hospital now to see one.
    Works every time. Yeah, she'd be going to the cardiac center, not the local stitch and splint.

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