67 year old male CC: Chest Pain

Here’s a case study submitted by a faithful reader named Brian from Southern California.

This patient is a 67 year old male with a cheif complaint of chest pain.

Upon arrival EMS found the patient is found sitting in a reclining chair. He is alert and oriented to person, place, time, and event. He appears calm and his skin signs are pale but otherwise normal.

The patient denies having any shortness of breath or nausea/vomiting. There is no JVD or pedal edema. Lung sounds are clear bilaterally.

History: Pericaditis several years ago and open heart surgery to remove the infected tissue.

Allergies: None
Meds: Carvedilol

Onset: Sudden after an argument with his mailman
Provoke: Nothing makes the pain better or worse
Quality: Severe substernal pressure
Radiate: The pain does not radiate
Severity: 10/10
Time: 20 minutes prior to EMS arrivial

Vital signs:

BP: 140/80
RR: 16
Pulse: 110
SpO2: 97 on room air

The first 12-lead ECG was taken on scene.


What do you think is wrong with the patient?

What is your treatment plan?

You are 25 minutes from a STEMI Receiving Center and 5 minutes away from the local non-PCI hospital.

19 Comments

  • Patrick says:

    This ECG looks like a lateral wall STEMI to me. I see ST elevation in leads I, aVL, V4-V6. I also see what looks like the beginnings of reciprocal changes in III and aVF. I would treat with oxygen, IV, nitroglycerine, ASA, and transport to the STEMI center.

  • Dave B says:

    Patrick, i saw the same… i would also had, that i believe there are elevated ST segments revealed in the PVC’s in the right precordials V1-V3, which would imply anterolateral STEMI…
    i wondered about pericarditis as well, had a hard time clearly determining ST segment in II due to wandering baseline, but the ST elevations appear to localize, and the patient presentation seems more ischemic than pericarditis.

  • lateral STE with subtle reciprocal inferior STD. ignore PVCs for purposes of ST deviation. stemi center.

  • Dave B says:

    burned-out, why ignore PVC’S for purposes of measuring ST deviations?

  • Scott says:

    Dave, I too noticed the STE in the PVC’s in V1-V3. If, for only the fact that it’s so obvious. I didn’t put much stock into tit though. I’m sure Chris and Tom will be able to tell us that because of that specific finding, the patient ate zebra meat back in 1972 or something like that ….

  • Joe says:

    Yeah, looks like lateral wall STEMI. PVCs are significant, but its probably easy to say that they go along with the MI. Would like a little more history though.
    Treatment I would go for is:
    O2, ASA, SL Nitro q 5min with either paste or infusion after the 3rd. Due to 10/10 pain, I might opt for 2-4mg of MS, being cautious with the SBP. I would probably do some Lopressor as well due to the HR, again watching the SBP. Most importantly EKG transmission with Cath Lab Activation, local protocol dependant.

  • Christopher says:

    Lateral STE suggestive of an AMI, however I’m a little worried about the tachycardia. PR elevation in aVR or it could be baseline wander. The tachycardia and PR-elevation is suggestive of pericarditis, although I would think this pt would have had a less sudden onset of the s/s.

    So treat for the one that is more likely to kill him: STEMI. Temp (keeping pericarditis in mind), ASA, NTG, etc etc. Spend the extra time to head to the PCI capable facility. Transmit the ECG if possible.

    Good case.

  • Tom B says:

    “I’m sure Chris and Tom will be able to tell us that because of that specific finding, the patient ate zebra meat back in 1972 or something like that…”

    I am amused! 🙂

  • Christopher says:

    I missed that comment, I guess he’d like the literature to back it up:

    Perkins, Richard M. Multiform premature ventricular contractions associated with ingestion of Equus Zebra meat. Am J Cardio (1977) 18: 1118-1121.

    🙂

  • Tom B says:

    Dear Editor: My colleagues and I read with interest your latest article by Perkins regarding multiformed PVCs and ingestion of Equus Zebra meat. This is no doubt an important topic for emergency cardiac care. However, we would like to bring to your attention a mimic of Zebra meat ingestion first described by Stewart and Collins…..

    Dear God we are dorks.

  • Matthew says:

    I am doing this from my phone and I do not get the best in pictures. So when I first looked at the 12 lead, there is a wondering base line, I would do another 12 lead and make sure the patient is still as he can. After the repeat 12 lead I would look for any changes with comparing it to the 1st one. I was able to see the PVC’s, which are important to a point. I did notice in lead V-3 elevation, but do to my phone I was not able to get a good look at the other V-Leads. Treatment Plan: IV, Oxygen, Obtain a V-4R, and a 15 lead. If the other EKG’s show nothing out of the ordinary,Pain management. If the serial 12 leads would change Hold of on the NTG, Transmit to the hospital that is able to handle a stemi. Considering the patient has had a history of pericarditis I am sure there has been some damage to the heart, and pericarditis can alter the ST segment. I would not be to overly concerned, I think this patient is having a angina issue, considering he just had an argument with his postman. Again, I am doing this from my phone and I have limited pic. Capabilities, so I might have missed something with not bie
    ingiaq i44

  • Troy says:

    Well Well Well…… We got ourselves a lateral MI. I would do a V4R to make sure he didn’t involve the right ventricle. Obviously go to the PCI center. ASA, Nitro or Bolus (depending on RVI), MS or Fentanyl (depending on RVI), trending vitals and 12 leads, bilateral IV’s, and titrate O2 to 94-98 sat. As far as the PVC’s, I wouldn’t worry too much about the ST segment PVC’s, but more that the PVC’s are there. There’s no research I’ve read about ST segments being used to diagnose PVC’s, just zebra eating 😛

  • dave b:

    the short version is that because PVCs can take different morphologies, it’s more difficult to determine what is deviated, what is not and consequently what each of those categories means. (i suppose you can apply sgarbossa in a similar manner to PVCs.) whereas in most cases there is only one underlying, intrinsic rhythm and from there you can in a more standardized, conventional way measure deviation.

    of course, tom may tell us that some ekg tracings are black and white because of zebras or something.

  • Dave B says:

    burned-out:

    i believe that PVC’s are subject to the same rules of appropriate discordance as other wide ventricular complexes… Dr. Smith references interpreting ST elevations and depressions in his book often, and i would also refer you to his blog post dated November 28, 2009 titled “STEMI best seen in PVC”.
    There may be disagreements in interpretations of course, but STEMI can be seen in PVC’s, and because it may be subtle or not well known does not mean it is a zebra. an abnormality is either present or it is not.
    of course, i may be incorrect in my own interpretations, but i am not incorrect when i say that PVC’s have been used to diagnose or help diagnose STEMI.

  • Christopher says:

    Dave, the only PVC that was concerning that I saw was localized to V1 w/ the RBBB morphology. Looks like there is concordant ST-elevation with that PVC, possibly not good! Otherwise the rest of the PVCs “look ok” based on the criteria. Usually you don’t have enough PVCs or each lead for each PVC in order to make a diagnosis.

  • harrison says:

    Lateral MI, and I would bet money on it. Likely originating high lateral due to I and aVL.

    Anyone else notice the Q in III and aVF?

    Typical MI treatment of MONA. Alert the STEMI facility and take the patient there lights/siren

  • Ben says:

    can we have a definitive answer on this one please??

    For what its worth in my local guidelines we wouldnt have gone to the PCI centre – not enough ST elevation/no obvious reciprocal changes. I would have tried GTN and reevaluated the pt on route.

  • Kyle says:

    Interesting Ben.  I'd probably be talking to med control if necissary to avoid local transport on this one.   I would have three issues with local on this case.   1, the patient has had myocardium tissue removed.  Depending on what tissue and how much,I would think this could alter the presentation of the 12 lead in very unpredictable ways.   2.  The patient is having 10/10 substernal chest pain.   In my limited experience, people who complain of 10/10 pain that have had things like this patients surgery, are less likely to call us over anxiety.  3.  There are abnormalities on this (albiet low quality) EKG that could be consistant with ischemia.  I assume your system requires 2mm elevation or reciprocal changes?

  • Looks like a Lateral STEMI.
    Do right and posterior leads to see if there is either extension of the lateral ST elevation or reciprocal ischemia in the right side.
    Standard pre-hospital STEMI care.
    Take patient to PCI center.
     

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