55 year old male CC: Chest pain?

EMS is called to a local urgent care center for a 55 year old male with chest pain.

On arrival, a patient care technician states that the patient is experiencing a hypertensive crisis.

He has already received SL NTG x3 but his BP is still 180/118.

The physician states that he is also worried about changes on the patient’s ECG and he has “already talked to the ED physician”.

The patient is placed on the gurney and he is removed to the back of the ambulance.

He appears to be in no distress.

In fact, he denies having chest pain. He states, “I came in for a sinus infection but I started coughing and when I coughed I grabbed my chest so the doctor thought I was having chest pain.”

The paramedic says, “So you’re not having any chest pain at all?”

The patient answers, “Well, I had some pain in the right side of my chest last night and also along the inside of my right arm, but it went away. But that’s not why I came to see the doctor today.”

Past medical history: HTN
Meds: Lisinopril, Diovan HCT

Vital signs are assessed.

  • RR: 18
  • Pulse: 80
  • NIBP: 188/120
  • SpO2: 100 on RA

Skin is pink, warm, and dry.

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

Much ado about nothing?

Or a very astute urgent care physician?

See also:

55 year old male CC: Chest pain? – Conclusion

23 Comments

  • Dave O says:

    Hx of recent infection, concave ST segments in v1-v4.

    Possibly the beginnings of stage I pericarditis?

  • Christopher says:

    Tough, voltage criteria for LVH is met in I and aVL. Not a fan of the ST-T wave changes in I/aVL and the STD in V6. The elevation in V1-V3 may be normal given the depth of the S-wave. I’m going to want to get serial 12-leads especially since he is pain free at this time.

    His blood pressure is also concerning, trend that. Stroke screen. Consider his weight vs cholecystitis with the right sided pain from the night prior. IV, monitor, repeat 12-leads, and a calm comfortable transport to the patient’s facility of choice.

  • dave says:

    P waves are inconsistent and the fact that he is on several HTN meds puts him at a higher risk of a heart related event. Nitro should have knocked down the Blood pressure. Keep up with the 12 lead snapshots and transport to better eval.

  • Troy says:

    There’s depression in the lateral leads and elevation in V1-V3. Not a stemi criteria patient but definitely one to watch. IV, monitor, serial 12’s, and O2 as needed. He definitely will get watched over in the ER with some serial troponin tests and ECGs. I’m wondering if he’s got some stenosis or stricture of the cardiac vessels.

    Someone should also tell this guy that this is no time to be a macho man and to just admit it if he’s in pain 😛

  • Brandon O says:

    Hmmm. What did his pressure start at?

    Concerned for lateral ischemia… anterior leads look relatively okay, but I don’t like how these “S” waves look suspiciously more like Q or QS. And how about that HTN? I worry about dissection, but the complaint is atypical. Pericarditis (as there is infection)? Not impossible, but the ECG involvement is minimal; a more full physical exam might help here. And does the transient CP last night mean anything — perhaps we have unstable plaques causing stuttering ischemia? Whatever the case he does need prompt evaluation for the intractable hypertension (perhaps ask medical control for additional nitro use), so I’d hit the closest facility. Although he may be okay, he has all the appearance of someone who’s currently doing well but has a significant chance of a major occult morbidity — i.e. an example of “treat the numbers, not the patient”! He can sit at the nearest ED while they screen for bad things, handle the HTN, and run additional ECGs and biomarkers; if necessary a transfer to an angiography facility can proceed after that.

  • DrTor says:

    No PR-segment depression, as one would expect with pericarditis, nor are the STE generalized – in fact they are localized to contiguous leads. The STE in V2 and V3 look sorta benign (“happy smile”), but V1 looks a bit more sinister. The STD in V6 is on the near opposite side from the STE in V1, could it be reciprocal changes? There is also STD in I and II, which are also leftsided leads.

    I would definitely do rightsided precordial leads (V3R-V6R) to rule out (or in) a right-sided MI!

  • DrTor says:

    As for the lack of pain I recently had a patient with a massive posteroinferior MI and Troponin-T of nearly 6200 with no pain at all at presentation (in fact he was actually admitted because of a subacute traumatic subdural hematoma, we just took the ECG as per our routines at admission, imagine my shock when the nurse handed me the ECG!)

  • Dave B says:

    Hmm… well, the voltage criteria for LVH is met in I and aVL, so you could wonder if the ST depression in the lateral leads, and elevation in V1-V3 are related to strain pattern… however, the ST depression in the lateral leads does not look like typical strain pattern, and the amount of ST elevation in V1-V3 does not seem to be proportional to the size of QS waves (which you would normally find in LVH w/strain), which make me suspicious for MI with reciprocal changes.. while slightly concave, the large size of the T wave in V3 and especially V4 relative to the QRS also makes me suspicious for an ischemic event. also, which concave, there are no R waves in V1-V3, and the QTc is a bit long for it to be early repol.

  • rm says:

    Tricky situation! The ste in v1-3 does appear to be proportional to depth of the s wave… But the hyperacute t wave in v3 and borderline std in inferior / lateral leads is concerning/ mighty suspicious.

  • VinceD says:

    Tough situation to be in (since the doc seems very worried and I’m not), but I’m very much leaning towards the ECG showing nothing acute, definitely not meeting criteria for a STEMI-alert. It’s likely LVH with secondary ST and T changes. Of course do a good workup with serial 12-leads and a good exam, checking for neuro deficits, feeling for equal pulses (arms AND legs), and listening for any new murmurs. I’m not worried about the HTN with the story thus far; a patient with no signs or symptoms does not warrant the term “crisis” in almost every case, but I’m curious what his presenting pressure was at the urgent care. You almost never want to drop their pressure more than 25% if they’re acutely ill, less if they’re not. If they have chronic hypertension (which this pt does), you can cause far more harm by lowering their BP too quickly than if they spent a few weeks slowly lowering it to a more reasonable level. Depending on transport time I’d consider calling the receiving physician just to see what’s on his mind and if he wants anything (hopefully not).
    It’s very easy to do nothing when the patient’s not in front of me, but I’m really not a fan of lowering BP unless there is really a compelling reason (i.e. likely dissection).

  • VinceD says:

    Also, there’s a reason our BP manometers go to 300 mmHg, 180/118 is nothing without concurrent encephalopathy or dissection.
    Even with acute stroke the movement is towards much less BP fiddling these days.

  • VinceD says:

    Sorry for three posts in a row, but on that topic…
    http://erstories.net/archives/3665

  • Jack says:

    pulmonary hypertension? some but not all criteria met.

  • STD: I, aVL
    STEish: V1-3
    biphasic P: V1
    loss of anterior forces/R non-progression/tall T: V3-4

    badness lurking.

  • Chris says:

    I read this as a developing anteriorseptal MI. I would strongly consider this as acute STEMI activation or at least let the hosp know my assessment. The ST elevation in v1-v3 seems diagnostic in the face of the overall ekg. This would be a good one to check with posterior leads. and serial ekgs for changes to prove this is acute. I disagree with paracarditis. No depressed P-R interval and no consistant elevation throughout ekg.

  • Tom says:

    Definately worth a trip to the hospital for cardiac follow up. The previous night’s discomfort could have been an ischemic event that will probably return.

  • AJCalhoun says:

    He’s verging on hypertensive crisis. Manage this while watching, serial EKGs and check troponin levels. While it is not exciting to me, it does warrant aggressive BP management and observation for a few hours at least; maybe offer admission for nuc scan stress test if everything stays as is or varies only slightly toward the positive. Just had this very thing happen to me and found EKG changes were consistent with the past 2-years (normal abnormalities) while rt. arm pain could be duplicated by very specific supine posture posing. Will follow up outside the hospital, but appears to be a nothing. Then again my BP was 120/74, and is never a problem. Rt. sided arm pain is often (and in my personal experience again, too) associated with spontaneous RCA dissection, but by then there are classic STEMI signs all over the place. Make him comfortable, reassure, treat for high BP, give him option of nuc scan stress test, everybody relax but look in on him often. Again, not too excited about this one, but just been there myself. Weird.

  • Butchie PA-C says:

    I’m not overly concerned about this….It’s probably voltage related. If there are no s/s of CVA, one could lower his BP with lopressor IV. Check some enzymes…When they’re negative, admit him for obs, control BP, and nuclear stress him in the a.m. I doubt that this is an acute process. I agree with the right sided EKG just for giggles.

  • RNBSNCCEMTP says:

    Astute urgent care physician or not… When you hear Chest Pain at urgent care, 9 times out of 10 there is a call for transfer; however, more complete investigation is needed regarding history and risk factors. We already have one, (at least right now – Uncontrolled HTN) Because he presented with a sinus infection/cold – Did he take something OTC that may have exacerbated his HTN? Previous cardiac events? Family Hx of Cardiac Disease? Smoker? What was he doing when he had the pain? Is it reproducible? A prior EKG if available would be helpful. The subtle changes already mentioned by other posters could indicate a lot of possibilities, or absoultely nothing (could be his baseline). We’re all trained to treat cardiac and work backwards. There have been many times people seek medical care for X problem that is unrelated, and then you find oh by the way, you’re having problem Y and/or Z. If enzymes are negative and this isn’t truly acute, definitely an admit or obs for later stress. Heck, depending how agressive the cardiologist is, if there are more risk factors skip the stress and go straight to a diagnostic cath.

  • Butchie PA-C says:

    Didn’t I just say that?

  • Butchie PA-C says:

    Furthermore, why would someone prescribe lisinopril and Diovan HCT together…ACE and ARB combinations do not work and you’re flirting with hyperkalemia

  • Aaron says:

    Some anterior st elevation, but "smilling face" waves and no reciprocal changes. It doesnt seem to be ischemic CP. Has hypertensive crisis been considered as a cause of CP? send the 12 lead to ed and call for medical control. they might advise a med to lower the bp (since 3x ntg) has already been tried.

  • Jeff Bess says:

    I see First degree AV block ans ST elevation,, Definetly MI,,,   Cath lab ASAP

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