66 year old female CC: Chest pressure

EMS is called to the residence of a 66 year old female who was awoken from sleep with substernal chest pressure.

On EMS arrival the patient is found sitting on the edge of the bed.

She appears anxious and exhausted. Skin is pale and clammy.

Past medical history: Breast CA x5 years ago. Additionally, she has recently experienced the death of a spouse and has been suffering from anxiety and insomnia.

Medications: Paxil, Ambien

  • Onset: 20 minutes prior to 9-1-1 call
  • Provoke: Nothing makes the pain better or worse
  • Quality: Pressure also described as a “heaviness”
  • Radiate: The pain does not radiate
  • Severity: 6/10
  • Time: No previous episodes

Vital signs are assessed.

  • Pulse: 64
  • RR: 18
  • NIBP: 138/79
  • SpO2: 98 on RA

Breath sounds: clear bilaterally

No JVD or pitting edema.

A 12-lead ECG is captured.

The ECG is transmitted to the emergency department.

Should they activate the cardiac cath lab?

See also:

66 year old female CC: Chest pressure – Conclusion

20 Comments

  • Gary says:

    I would hope that they would run a 15 lead if suspected posterior MI, unable to tell from just a single 12 lead. At the min. do a quick V4R, certainly not give nitro, IV extablised and run fluids. If posterior MI loosing preload anyway so fluids always a good thing. Would quesiton if patient had any N/V as well. Some elevation in II. Need more info.

  • 12leadekg says:

    This EKG shows ST elevation in Lateral Leads and in the Inferior leads as well. ST depression also noted in Leads V1 to V4. I would say this is inferiolateral MI along with a Posterior wall MI. Given this patients presentation along with her age and hx I would call it a STEMI. Transmit the 12 lead EKG to our local PCI center, obtain a 15 Lead to confirm Posterior MI and look for RVI as well. 02, ASA, Fluid bolus if RVI present with NTG, Call for orders for Morphine if time permits during transport.

  • Skaw says:

    I see a discreet ST elevation (< 1mm) in two consecutive leads II and III and ST depresion ( mm discordance, ECG shoudl be sent for medical consideration. Not sure if angio lab should be informed…

    Anyone assessed a Fibrinolytic Checklist?

  • Skaw says:

    I see a discreet ST elevation (< 1mm) in two consecutive leads II and III and ST depresion ( mm discordance, ECG should be sent for medical consideration. Not sure if angio lab should be informed…

    Anyone assessed a Fibrinolytic Checklist?

  • Skaw says:

    I see a discreet ST elevation (< 1mm) in two consecutive leads II and III and ST depresion ( 1 mm discordance, ECG should be sent for medical consideration. Not sure if angio lab should be informed…

    Anyone assessed a Fibrinolytic Checklist?

  • Brandon O says:

    There’s a possibility of Tako-tsubo cardiomyopathy. But that’s not the kind of call we get to make, or really anybody does without angio. Yes, activate.

  • 12leadekg says:

    I had forgotten about “broken heart syndrome” I think this is still a STEMI until proven otherwise.

  • Brandon O says:

    Yep… that one’s really in the realm of the academic, unless perhaps it resolves prior to cath.

  • MedicJosh says:

    I’m on the same page as Brandon O. Looking like inferolateral STEMI with posterior involvement. 15-lead and normal STEMI protocol…careful with NTG especially if 15 lead shows RVI. Based on the hx of recent emotional stress this could be a case of stress cardiomyopathy (broken heart syndrome, takotsubo cardiomyopathy, whatever name you prefer) and the pt being post-menopausal fits the common demographic seen in SCM. this is a dx of exclusion, and certainly not a dx we are fit to make in the field. SCM will be dx if cath results are unremarkable, ST/T changes resolve, and echo reveals LV wall abnormalities with apical akinesis and normal contractility at the base

  • Christopher says:

    Brandon O, I think the depression in V2-V3 make Tako-tsubo unlikely, usually you get QS waves in those leads with biphasic T’s. However, I’ve only seen classical EKGs for that syndrome so I guess without an echo to rule out apical ballooning I couldn’t say definitively no 🙂

  • Brandon O says:

    Christopher, you may be right — it’s just hard to avoid “reading into the question” when our Humble Narrator drops in a juicy piece of history like that. Got a good reference for the class regarding the specifics of Tako-tsubo EKG presentation?

  • Rose says:

    I would do another 12 lead with posterior leads and handle the matter as a STEMI. Given the history, I would not rule out the possiblity of Tako-Tsubo however I will handle the patient based on what would be the potential life threat.

  • AlmostJesus says:

    Elevation in II, III
    I also think there is elevation in aVF, if you look at it, the QRS is small, thus you need to consider proportionality, if you look at the ST segment, there is elevation above the isoelectric line proportional to the QRS.
    Reciprocal changes in V1-V3
    Her impression is indicative of an MI too
    I would divert hospitals from my close community hospital to the cath lab equipped hospital 45 minutes away. Enroute, I would give O2 to keep sat >94%, IV before NTG, ASA, and I would consider some Fentanyl. I would activate the Cath lab and call for orders if they want a NTG drip, a bolus dose of Heparin, or a ß-Blocker

  • AlmostJesus says:

    Two things I forgot, I doubt they would order a ß-Blocker, the pulse is already 64, I didnt think about that when I was writing it
    Also, I would also do a 15-lead and possibly an 18-lead if I have time since there is depression in V1-V3, I originally said reciprocal changes in V1-V3 – those reciprocal changes are indicative of a posterior MI. I would say its an inferiolateral with probable posterior involvement

  • Corey says:

    Looking at the 12 that is provided and based off of th ePt current status I would say that I am dealing with a STEMI. Changes of 1-2mm in the lateral leads, some changes in the II and III leads with possible changes in AVF. There is depression in the Antirospetal side of the house. I would need to caputre a 15 lead to see whats going on back side. RVI is possible but I think that the insult is from the LAD and effecting the Inferior side at the terminal end. With VHR & checklist she is a go for Fibrolytics as there is no contraindications in the Pt Hx. Is VHR doc is good with the 12&15 ECG’s push the Fibrolytics or its PCI.

    TX with IV,ASA, O2 via NC@2 lpm, Nitrates if indicated or MS depending. repeate 12 enroute and go.
    I can treat a STEMI but I cant do a thing for Tako-Tsubo so I would get hung up on it.

  • Brandon O. –

    I’m deeply hurt to know you think I’d manipulate you by dropping a juicy piece of history like that! 🙂

    Tom

  • hafez al ali says:

    inferior mi plus posterior

  • Paul says:

    I have nothing to add, other than a field or bedside would easily reveal apical ballooning; not angio. That being said, this patient needs to be taken to the cardiac catheterization lab forthwith as there appears to be an evolving wraparound transmural infarction. Inferior -> High Lateral -> Posterior wall.
    Aspirin, Fentanyl, no fluids, and no oxygen. I would have a weight-based bag of dopamine at the bedside, because if this is Takotsubo, the blood pressure could crap out nitrates or not.

  • Daman Deep says:

    Acute posterolateral MI. Possible LCx involvement as per clinical experience. cath lab should be activated for a primary PCI.

  • alexandra says:

    infero posterior and lateral wall stemi-she needs primery pci' there is rca or cx occlusion or both

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