73 year old female CC: Chest pain

EMS is called to the residence of a 73 year old female with a chief complaint of chest pain.

On arrival the patient is found sitting on the couch. She appears acutely ill.

Skin is pale and diaphoretic.

Onset: 1 hour ago
Provoke: Nothing makes the pain feel better or worse
Quality: Heaviness or pressure
Radiate: Pain radiates to neck and jaw
Severity: 7/10 and persistent
Time: No previous episodes

Past medical history: HTN, dyslipidemia, breast CA

Medications: Unknown

The patient admits to mild dyspnea but breath sounds are clear.

Vital signs are assessed.

RR: 18
Pulse: 96
BP: 172/72
SpO2: 98 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

Displeased with the data quality, paramedics capture another 12-lead ECG.

What do you think is wrong with this patient?

See also:

73 year old female CC: Chest pain – Conclusion (with angiograms)


  • dr khurram says:

    it is inferior wall mi

  • Justin says:

    Inferior wall mi

  • Dave B says:

    a little problematic i think due to wandering baselines in some of the leads, notably V2, and PR segment depression which is making the ST elevations look larger in the inferior leads than would be if using the TP… however, there are ST elevations in the inferior leads, and it looks like slight st depression in aVL, which would be early reciprocal to the inferior leads. also, possibly the start of pathologic Q waves in the inferior leads…. in addition, the ST elevation looks to be larger in lead III than in II, which is suspicious for RV involvement… also, the pattern in the anterior leads, especially V3 looks suspicious for possible posterior involvement.. i would do a 15 lead for sure. since clear lungs are a hallmark of RVI, i would want to investigate the RV involvement, possibly to hold off on NTG, in case they are indeed relying on CVP for perfusion..

  • Christopher says:

    Appears to be IWMI w/ recip change in aVL. The STD in aVL leads me away from acute pericarditis even though it appears to contain PR depression in multiple leads.

    STE III > STE II, considering RCA, which makes me consider RVI (and as Dave B rocks out, clear lungs!). Right sided 12 lead for certain.

    ASA, early STEMI notification, lines+fluid before any NTG, morphine per protocol.

  • jake says:

    acute MI

  • EMT- I Tech says:

    I am NOt a paragod (paramedic sorry) so technically not allowed to interpret. So first lets start with the very borderline 1st degree block (it is only 202 and cut off is 200 for block) But I see elevation in leads 2,3 AVF in which case I would be thinking of an Infereior M.I also seeing downsloping ST depression in leads v1 and v2,which would be telling me of some angina going on. So plan of action get a V4R if that is show elevation……I would really have to think twice about giving nitro, because in patients with acute inferior MIs about one-third of them are likely to have a concomitant right ventricular infarct. But if V4R is not showing elevation….Pt does also have a systolic Bp of 172 so if nitro did drop the blood pressure, Hopefully she would not become to hypotensive…. Would I give nitro???? Probably, but thankfully we transmitt 12 leads and I can always get medical control. hey if I am wrong let me know cause always tyring to learn

  • Bob says:

    Inferior MI with posterior involvement – >1mm ST depression V1 and V2. Definitely check V4R, check out the P waves as well, P – Mitrale – http://archive.student.bmj.com/issues/01/10/education/fig4.gif. Could be an indicator of right sided involvement prior to V4R.

  • Scott says:

    Sinus mechanism @ ~ 90 w/ axis of ~75. STE: II, III, aVF and STD: V1, V2, V3 and aVL. Inferior wall MI w/ suspected posterior involvement.

    Some O2, 2 large bore IVs, 324 mg ASA, cautious use of NTG being prepared for hypotention, serial 12’s w/ a look at the R side enroute to your dept. approved POE

  • Scott says:

    Forgot to add, that the ST segment in V3 is suspect… It appears isolated but I’d be keeping my eye on it….

  • Gary says:

    Clear elevation 2 3 and AVF, do a quick V4R to rule out RV before giving Nitro.

  • “dammit, i know you’re really sick and all, but STOP MOVING!!!”

  • amir sh says:

    it’s Inf. MI

  • Cyclops says:

    ECG I would call suspect. First the quality is very poor. I think it does show a first degree block and somewhat of an ST elevation that just barely hits the 2 block min. I also notice that the T wave seems to be elevated.
    Of course I would do the cardiac work up, (IV, O2, ASA, Draw Blood). I would hold off on the use of NTG unless there was more pronounced BP problems. With this patients history I would be very suspecious of her medicines and her sodium. This could also account for the wide pulse pressure.
    So I would treat for cardiac with caution, and say that lab work was needed before a diagnosis could be made.

  • Andy says:

    I would have to agree with most. Inferior wall MI as evidenced by ST Elevation in II, III, and aVF with ST Depression in aVL, V2 and V3. I would also suspect RV Involvement and use great caution with nitro. Mabey a nitro drip is in order so you can have more control over dosing than SL or Paste. 2-3 IV access points large bore, IV Fluid running and high flow oxygen therapy. Treat continued pain with increased nitro if B/P holds and morphine. Heparin 5,000u Bolus IVP is no contraindications. Serial EKGs and transport to PCI Center.

  • Andy says:

    I forgot a Right sided EKG or atleast V4R if not enough time.

  • Cameron Stracener says:

    Treat the patient’s s/s over equipment, rapid transport to closest appropriate facility, high flow O2, ASA, IV, NTG with caution, MS, MCP consultation

  • Caleb says:

    15-Lead EKG please? Inferior MI suspected, possible right side/posterior involvement. ASA, Oxygen, IV. Lung sounds? Depending on 15-lead EKG findings, consider IV Nitro instead of SL nitro to avoid possible pre-load failure. Depending on pain reaction to nitro, consider 2-10mg morphine IV, titrated to pain. Early notification to receiving facility. Rapid transport to appropriate facility.

  • Nick G says:

    Sinus rythm at 90 with elevation 2,3,avF. Pr depression and wandering baseline make it difficult to determine mm.
    However I would call inferior STEMI with posterior involvement. Not sold on RVI but would do v4r.
    Rx 02, aspirin, morphine….. 1xgtn post iv access….. I am happy to give GTN with the wide pulse pressure but will have fluids ready. Serial 12 leads enroute. If BP holds maintain GTN.
    Just curious why 2-3 IVs?? In my Ems system (queensland australia) one is normal, 2 appropriate for Stemi as long as it is enroute and not wasting 2mins on scene.

  • arnel says:

    SR, STE III>II, STD aVL>I, STDV3/STEIII <0.5, V1/2 STD reciprocal changes. Inferior MI and by this configuration the culprit artery would be RCA and less likely LCA. Less likely having RV infarct component since BP is elevated and no STE in V1-2 though if time permits a V4R will help.

  • Hillis says:

    Am not impressed about the RVI in this case no signs of shock and the blood pressure is in the higher side.
    I know inferior MI usually associated with RVI, but this in case of right coronary artery occlusion ,but in this case i think the culprit artery is left circumflex artery which cause the inferoposterior STEMI . Am so curious to know the result of angiography.
    Interesting case indeed.

  • Hillis says:

    PS! I do agree with the rest by doing 15 leads ECG and V4R to be more sure , of course if that won’t delay the treatment.
    Thank you !

  • Patrick says:

    I agree with all so far. I would go for O2, 325 mg ASA, and consider some pain management if I thought appropriate. I would probably end up withholding nitroglycerine regardless of v4R results. My nearest PCI center doesn’t trust our V4R reports much at all and will order us to withhold nitro on all inferior wall MI patients.

  • RoseD says:

    I agree with past posts noting inferior wall and possible posterior involvement. I also agree on doing a V4R and posterior leads. I understand the dyspnea, if this is new onset there may not be fluid build up yet but it is happening which is why she is having breathing difficulties.

  • Martyn Widnes UK says:

    Seems there is more STE in III than II so more likely circumflex occlusion rather than RCA.

  • Martyn Widnes UK says:

    Apologies for my typo above…

    Should read… more STE in III than II so more likely RCA involvement than circumflex.

  • Tom B says:

    Thanks for the comments, everyone! I will be posting the conclusion shortly.

  • Chris T says:

    Confidant STEMI inferior wall with riciprocal depressions, initial 12 leads and vitals less suspicious of Right Sided involvment for this pt. Standard cardiac tx for AMI, ED STEMI activation or lifeflight with medical control direction, none of the systems in my area use thinners or inhibitors such as heparin or treatment beyond ASA and Nitro. Hopefully one day it will be added to our box. My transport times average 20mins to a non cath lab ED. Right side ekg if time permits-prolly will for me, may be more agressive with BP based on that.

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