76 year old male CC: "Possible MI"

Here is a case submitted by a faithful reader from the UK who wishes to remain anonymous.

Call is received into control via 999 from a General Practitioners Surgery. Call is received as 76 year old male with possible MI.

Presenting Complaint – Chest Pain

History of Present Complaint – 76 year old male, nil cardiac history, known COPD, ex smoker, social drinker.

Awoken at 2 a.m by an acute central chest pain radiating to his left arm.
Male waited till surgery opened and made an emergency appointment.
GP had 12-lead ECG done on patient – noticed ST-elevation and administered 1x400mcg GTN spray SL, 300mg Aspirin PO and O2 therapy. Ambulance contacted via 999.

Here is the first 12-lead ECG taken by the GP.

The second 12-lead ECG taken by the GP was after NTG.

Ambulance..
On Arrival – Patient supine on bed, O2 therapy via NRB administered by GP

On examination:
Alert, orientated and communicable (GCS 15)
Slightly pale
Nil diaphoresis

Nil SOB, clear bi-lateral air entry – nil adventitious breath sounds
R/R 20, SpO2 99% on O2

H/R 89 and regular, BP 149/99

Pyrexial 37.7
B.M 10.6

C/O chest pain..
O – Acute
P – Not affected by breathing. Eases slightly leaning forward. Pain++ on palpation of sternum.
Q – Sharp in chest
R – Central chest radiating left arm
S – Pain score 7/10 eases slightly with GTN
T – 11 hours ago
I – No pain intervention sought.

Nil nausea, nil vomit

Meds – Usual COPD drugs
PMH – COPD
Allergies – NKA

Paramedics switched the patient over to their 12-lead ECG monitor.

What’s going on with this patient?

What is your treatment plan?

Where would you transport this patient?

Is there anything unusual about this case?

23 Comments

  • Christopher says:

    Hospital 12L appears to show clear anterior STE w/ somewhat clear recip changes in III/aVF (borderline). Also pathological Q waves in III/aVF. Old IWMI, new Anterior MI.

    I like the post GTN (yay I’m learning British!) 12L, which shows a resolution of the anterior STE, but hyperacute T waves.

    EMS 12L shows anterior elevation again, recip changes in III/aVF, and the T waves are huge compared to the QRS complexes. I’m still sold on anterior MI.

    I would make an early STEMI notification, switch the patient to a nasal cannula, repeat GTN until pain free (GTN paste potentially), initiate a second IV line, safe and expeditious transport to a PCI capable facility.

  • Hillis says:

    Why the patient is feverish ? the saddle STE ( according to me ) is more likely to be due to myocarditis thu i couldn’t appreciate the PQ depression which is quite specific for myocarditis anyway it absence doesn’t exclude it .

    So before activation the cath lab i would like to exculde myocarditis by performing ambulantory ECHO to check for abnormal wall motion.

  • shane says:

    i think it is a new onset of anterior infarct and with there 1st 12 lead it was obvious, and for the second one…the nitro dilated the arteries and masked the occlusion. i would treat him as a level one stemi based off of the 1st and 3rd ekg and direct admit to cath lab.

  • NYCMedic says:

    Given the patients history and physical exam, primarily that the combo of pain relief while leaning forward, change in pain with palpation, and pyrexia, I’m tempted to agree with Hillis, maybe pericarditis or even Dressler’s pericarditis?

  • just another medic says:

    Anterior (anterolateral?) STEMI: STE in V2-5.

    RX:
    O2 2lpm via NC
    NTG SL PRN
    STEMI Alert, transport emergency status, and transmit EKG to closest PCI hospital.
    IV En route, second line saline lock if time permits (most hospitals I transport to seem to want 2 IVs before PCI, so it helps to have two on arrival if feasible.)

    The low grade fever and changes in pain with position and palpation make me suspect pericarditis, but I am going against that Dx because: some pain relief and major improvements in STE after the first nitro spray, and no change in pain with deep breath. I would get a quick listen to heart sounds before we got moving just because it’s on my mind.

  • Brian says:

    My initial thought is an anterior septal wall STEMI. However, pt being febrile and chest pain decreases when leaning forward pericarditits can not be ruled out. I would still treat as an MI and take to a hospital with PCI capabilitiy.

    Prehospital treatment to inculde. IV enroute, Second IV with saline lock, 02 via Nasal cannula, additional nitro SL(morphine IV after third dose of nitro) if pain returns, Serial 12 lead EKG’s that are transpmited to hospital.

  • ashraf says:

    acute pericarditis

  • Dave B says:

    Things that make me think of pericarditis: pt feverish, and pain eases slightly when leaning forward (classic pericarditis)… on ECG, pt waited approx 11 hours (T: 11)… would not expect hyperacute T waves of MI after that long.. also, while it can be hard sometimes to really see PR depression, i like to look for PR elevation in aVR, and it appears to be present (0.5mm), which also favors pericarditis.
    also, relatively low amplitude QRS, diffuse ST elevation in precordials with NO ST depression also favors pericarditis.

  • Dann EMT-I says:

    Judging by the symptoms….we obviously look for the horse (MI) and not the zebra (ie, Pericarditis). I am still doing full cardiac work up. Oxygen NRB 15 LPM, transport, 12-lead every 5 min or so, vitals 5 min appart, ASA, NTG, IV, 100mcg of fentanyl. However, looking at the EKG i am seeing more of a fishook-like wave for a j wave which indicates pericarditis. This still would cause chest pain.

  • Tubbs says:

    The symptoms most certainly paint the picture of Pericarditis. The ST changes are also quite diffuse in the initial in hospital ECG. I wonder if he has any history of recent surgery or heart problems.

  • Dave C says:

    Sharp pain, eased on leaning forward and S1Q3T3 i am thinking a PE. O2, positioning, ASA, transport.

  • Aharon says:

    I think the treatment is O2 , nitro , aspirin , and I don’t give that patiant Hepain couse maby she has precardities , and trasport her to PCI capable hospital

  • Medic-Minx says:

    Slight STE in I, avL as well as noticeable STE V2-V6. PVC presumed due to irritation; ischemia (inverted T) in III. STE in 2 or more leads meets STEMI Alert criteria. First off, determine how patient is presenting in conjunction with stated level of pain. I’d also obtain a left-sided 12-lead. Treat with O2 (4L via nasal cannula), ASA, PRN SL NTG (or GTN) every 5 min (max of 3). If his BP is maintaining I’d even consider Tridil drip; en route, serial 12-leads, trend vitals, establish (2) bilateral IVs and emergent transport to a cardiac facility. If pain remains significant, pressure holding and he appears anxious, Morphine to decrease oxygen demand, preload and for anxiolytic effects – start 2mg (titrate in 2mg increments).

  • Mark says:

    What’s unusual is that the guy was able to make an appointment with the doctor’s office without the staff screaming, “Sir, hang up the phone NOW and call 999 for your chest pain!!!”

  • Matthew says:

    With the information given, I would treat the patient as a anteriorlateral wall MI, Yes I do agree with the pericarditis as a deferential diagnosis.

    Treatment: 02, 2-IV Lines, 12 Lead, Pain Managment if needed, 15-Lead, NTG. Only After Transmisson. Notify Hosp. Of STEMI. Reassess Vitals and Lungs.

  • Paramedic Pete. says:

    I thing the ECG is indicitive of Pericarditis. There is evidence of ST elevation in every grouping of leads. Ergo every coronary artery should be occluded and yet the patient is sitting up. This is not physically possible. Assess for signs of Pericarditis- pericardial friction rub, positional pain changes. Treat the patient as a cardiac patient as pericarditis is still potentially fatal. Notify hospital and transport to cardiac centre for further assessment/ treatment.

  • Tom B says:

    Paramedic Pete –

    If anything the inferior leads look reciprocal to me. Keep in mind, the standard 12-lead ECG doesn’t look at every anatomical area of the heart!

    Tom

  • those are some really big T waves.

  • Mark says:

    this is clearly pericarditis, diffuse st eleavation, febrile, pain decreases with change in position forward. This does not change your treatment o2 12 leads, iv, pain management transport and notitication,

  • nba says:

    ac pericarditis…

  • Colette botha says:

    I am always still learning, and am curious as to why so many changed the NRB O2 mask to a NC? Personally I’d stick with NRB in this patient. Rest of my treatment would be the same.

  • Beau says:

    Anterolateral stemi. poss. Hyperacute t's on serial ECG's from reperfusion from nitro,"correct me if I'm wrong." Transport to closest er for monitoring or re-occlusion.

  • Ed D says:

    Dave C, I agree!

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