53 year old male with a suspicious ECG

Here's another interesting case brought to my attention by the one and only David Hildebrandt.

EMS is called to a local medical clinic to transfer a 53 year old male to the emergency department.

It turns out the patient was in for a regular check-up.

He appears to be in excellent physical condition and states that he is a personal trainer at the local gym.

Past medical history: Hypertension
Medication: Atenolol

Vital signs are assessed.

RR: 12
Pulse: 44
NIBP: 132/78
SpO2: 99 on RA

A 12-lead ECG is captured which matches the ECG taken at the clinic.

Why is the physician at the clinic concerned?

See also:

53 year old male with a suspicious ECG – Conclusion

33 Comments

  • billy says:

    STE in high lateral leads and depression in the inferior leads III, and AVF, LBBB, prob. new onset. and 1 degree av block.. which might be normal since hes a trainer. wonder if he has been having any chest pain the last couple days

  • Shalom says:

    The patient is bradycardic(which is probably because he's very fit).
    There is ST elevation in the lateral and anterior leads which seem very suspicious for STEMI.
    because of the widespread elevation and notching of th j-point you might say BER, but the reciprocal depression and t wave inversion in the inferior leads point to something thats seems more serious.

  • Troy says:

    STE in I and aVL with reciprocal changes in III and aVF. Id be a little concerned as well. With his history I would most likely call the STE BER but not with the reciprocal changes. Definitely needs to be checked out at the hospital. Any nausea? Pain? Fatigue?

  • Wes says:

    Sinus bradycardia with a 1st degree av block.  Agree with rate being low due to pt being in excellent physical condition.  Does not seem to meet criteria for BER as the T waves are not large in leads v2-v4 and the ST segment is also not "upward sloping."  Also, there is not a lot of information suggesting BER to cause J point notching and elevation in the limb leads.  Agree with STE in the anterior leads, but there is an inverted T wave in v1 which is non-suggestive of anterior stemi.  Worried about the prolonged PR interval, brugada type 3 syndrome possibly?  Not sure what to make out depression in the inferior leads.  It is reciprocal to I and avL, but the pt has no complaints and is in for  a regular check up.  Therefore I am not too concerned with an MI or ischemia.  I was also curious as to why the pt is on a beta blocker if his only pmh is HTN.  For someone that exercises constantly and trains people I would think most clinicians would start the pt on an ace-inhibitor.  Maybe he's leaving out some information.  Interesting to see a diagnosis.

  • William Ritchey says:

    Agree with Wes..Sinus Bardcardia with a nasty first degree HB. I do see the ST depression but with no cardaic complaints from the patient I would watch it but not be to concerned. Would like rpt 12 lead EKG and would get IV ASAP but other wise O2 and get the patient to a hospital with cardiac capibiites by ground. 

  • Chris T says:

    im with gregory. There are no real differential diagnosis for the clear elevation with riciprocal changes for the High lateral leads. The block and brady easily could be the BB in an otherwise healthy heart. Luck maye to catch this? AMI STEMI until proven otherwise.

  • Ryan says:

    Heartrate may be on the slow side, but, without a prior EKG or history to compare it to, I’ll just call it a 1st deg AVB, with sinus bradycardia. The data quality is crappy on the EMS 12 lead, I would have re-ran it. But ill stick with the AMI for now. I’d like to know if he’s been symptomatic in the past few days, or had any odd events leading up to this presentation today. Any chest pain, pressure, weakness etc…just a good in-depth physical and SAMPLE history. If he is asymptomatic, I’d suggest a silent AMI, treat down the MONA, cardiac protocol route, watch for changes in 12 lead, and overall HR. If improvement is found or seen, continue with treatment. Rapid transport to a PCI capable facility. There is more I’d like to know on this case, but, I’ll stck with silent AMI, which is causing the rate.

  • Chris T says:

    Im a 28y/o overweight male, do not exercise and have hypertension as diet and heredity. Taking a BB. My resting HR the other day was 55. Just sayin. I didnt have my monitor with me though 😉
     
     

  • Clifford says:

    Look at the patient!!!! Ekg’s are great but it’s one of many tools. I would think an appointment with a cardiologist would be more appropriate. Also with these bradycardic rhythms I like to print extra long strips to better see trending.

  • akroeze says:

    Is anyone else seeing what could be U-Waves in I, II, V2, V3, V4?  Subtle but I think they are there.

    Is ther any possible, crazy, obscure way that HypoK could be causing everything?

  • just another medic says:

    I also see what I think are U-waves.
     
    Poor data quality, like others said I would run serial 12 leads and get a clean copy to start, as well as a nice long rhythm strip.
     
    A more thorough history I think is in order.  Did he come in for a regular check up that was scheduled months ago, or make an appointment because he hasn't felt well?  Seems there is a risk of this type of Pt. denying or minimizing symptoms (I'm in perfect health, I couldn't have a heart attack!)
     
    IV lock/O2/ASA/serial 12 leads/safe transport to PCI facility.  Nitro if further history elicits any suspicious symptoms.
     
    My suspicion is that the anterior STE is not represtative of ischemia.  The inferior ST depression is reciprocal to a high lateral infarct, silent MI.  Lucky catch or he came in for symptoms that he is denying?  Either way, my treatment above is not going to harm the patient in any way that I can see.  I think the slow rate and first degre AVB is secondary to physical fitness and beta blocker use.
     
    Question:  could someone explain the QRS morphology in II, III, and aVF?  Is it an IVCD?

  • Chris T says:

    I too thought i was seeing an extra wave, it didnt march out as p waves, and some are burried in or on the t wave seems odd to find one there so i figured it was artifact. As a trainer is he taking any crazy suppliments that would effect labs and or potassium i wonder.
     

  • just another medic says:

    Three things I forgot:
    1:  Hypokalemia can cause t-wave abnormalities, u- waves, and st-depression which would explain many of the changes we see here and are likely depending on what he's taking, his diet, etc.  Thanks Chris!
    2:  I am not as good as I'd like to be at evaluating t-wave symmetry, but I would say that there are no symmetrical T-waves in this ECG, leading me away from pathology.
    3:  I am approaching this from a field perspective where labs are unavailable and I will treat for the worst possible outcome in this patient (silent MI) even though I don't strongly believe that's what is happening.
    As always, can't want for the labs/cath/outcome!

  • Brandon O says:

    I think this sort of thing is a nice Rorschach test on the provider. Should you freak? Is it nothing? Did your mother show you enough affection? Hmm…

  • Robert (Las Vegas/Student) says:

    12 lead interpretation: Sinus Brady, 1st degree av block, IVCD, LAD, BER
    .
    Analysis: Sinus rhythm is based on upright P waves in leads I, II, III, AVF, and inverted p wave in avr. The differential diagnosis for global ST elevation are acute stemi, BER, acute pericarditis, and LVH. There doesn't appear to be pr segment depression excluding pericarditis. Based on the concavity in leads v2,v3 as well as the fish hook appearance in I & avl, I would assume it's BER. The only problem is the st depression in the inferior leads.
    Never the less, there is some doubt that exists given the patients age, cardiac history, and reciprocal changes. But given the patient doesn't have chest pain and has completely stable vitals I would be very weary of an Acute Stemi.
    Treatment plan: Serial 12 lead EKG's en route, looking for evolving patterns. In addition, I would get a hold of his primary physician for comparison EKG's.
     
     

  • Jaguar says:

    I beleive the primary concern of the Physician is the ECG findings which is SInus Bradycardia, with 1st Degree AV block, which may be precipitated by atenolol, and I,AVL 1mm ST Elevation.
    And eventhough his patients V/S and Hemodynamically stable, and denies any cardiac complaints, he considers ED facility and expert consultation which is not probably available in a clinic set up. That any any moment a patient migth crash without warning.

  • Rose says:

    Just a bit confused, I was told that U waves are just showing the repolarization of the Perkinje fibers.  Is this incorrect and why would the presences of  U wave be a bad thing.

  • Chris T says:

    My understanding is yes your right, and also can be found on ekg in hypokalemia more pronounced and merging with T wave as potasium drops lower. This will kill them, eventually 😉
     
     

  • Chris T says:

    Goes with my other two favorite lines that arent apropriate right now but not innapropriate ever.
    -All bleeding stops, eventually.
    -I helped my patient into the most stable rhythm I known, asytole.
    (I joke of course) kinda
     

  • zhao says:

    sinus bradycardia with 1 degree av black , LBBB and Lateral MI (you can see LII AVF AND LIII OF ST segment depression are not on baseline ,which mean it is LBBB and )

  • NYCMedic says:

    I think Robert is right on the money here. Everyone is getting very caught up in the ECG and forgetting that clinically, the patient is symptomatic with very little history and is in excellent shape. Yes, there could be something going on here, but if any of us actually had this patient, I hope we wouldn’t be rushing for “2 large bore IV’s with 1000 bags prepped to go!” (I’m always amused by this sort of response on here) or be concerned that the patient will crap out any minute. And I assume no one is going to activating the cath lab.

    The doc is concerned because he has a bradycardic patient with STE… but is it real STE? Probably not in my opinion. I’d call the receiving facility and let them know I have an asymptomatic patient with an abnormal ECG, start a single IV enroute (maybe), but likely wouldn’t bother with MONA. He’s not a diabetic, he doesn’t have a lot of comorbidities, his only risk factor is HTN, so why am I giving MONA to patient that isn’t likely to be having an AMI?

  • Christopher says:

    Sinus bradycardia with 1AVB, isoelectric or minimal STE in I/aVL (with a fish-hook), STD in III/aVF. STE (with a fairly low angle for BER) in V2-V3.

    A cold read of the ECG, with STE and reciprocal changes makes this highly suspicious for STEMI. However, given the patient is pain free and appears without distress, I'm going to run serial ECGs and give a good early notification. If III/aVF had normal T waves I'd be fine with the ECG, but not as it stands.

    Tough case.

  • not a good ekg with reciprocal changes.

  • Mark says:

    Looking at the 'Patient' and not just an ECG in isolationBER. First degree. Sinus brady. Non-specific IVCD (? moving towards incomplete RBBB). LAD. "Athlete's ECG" Pt is well, congratulate him on his fitness, advise that as this is the first time he has had an ecg done it has some findings that are likely benign but need follow-up as we cannot exclude some more serious possibilities in the field. Transport to A&E, no notification, IV (just in case). When (assuming) he gets all clear, hope he carries a copy of his ECG with him for future reference. 

  • Ben says:

    Bradycardic sinus rhythm. 1st degree heart block, LAD – meets all criteria for LAFB. If the physician has old ecgs then easy to find out if its new or not! With the reciprocal changes in the inferior leads and the minimal (1mm) STE in the lateral leads I would be highly suspicious of something bad happening.

  • Greg says:

    Tom- We ever going to get the conclusion to this. Its been like 4-5days now

  • Sergio says:

    Am I the only one that thinks it odd that a very healthy, athletic middle age man just happens to be having a silent MI while at a routine physician's check-up? Lets treat the patient and not the monitor for a second. He has no predisposition for a silent MI. He feels fine. Now looking at the monitor, I personally see a Sinus Brady w/1st deg AVB, and inverted T's in III and AVF. There is not enough QRS widening for me to say it's a LBBB, and I don't see any suspicious ST segment elevation. I'm willing to bet he had a cardiac event in the past, and brushed it off as being part of his workout. I'd REALLY like to see an old EKG of his. If requested by the gentleman and the physician, I'd take this guy into the ER ALS, but no aggressive ACS treatments along the way.
     

  • suhial says:

    may have old ischemia?should be refered for further investigation&evaluation!!!

  • alvin halpern says:

    in a symptomatic patient, a pathological left axis deviation + 1degree heart block= diseased heart (lookout for heartblocks)… having said that, st elevations in the anteroseptal leads  V2 V3  and the lateral leads I and aVL  is a  STEMI (anteroseptal MI with lateral extension)…

  • Brandon says:

    Definately a STEMI, anteriolateral w/ reciprocals in inferior leads. Theres not many differentials that are going to be presenting like this on a ecg. Clear elevation is anterioseptal and high lateral leads. Serial Ecgs, id personally alert the cath lab.

  • Brandon says:

    The qtc is normal which goes against stemi so definately a tough one but id think stemi

  • Georg N says:

    Sinus bradycardia with I° AVB + BER; wrong limb lead placement. Green/Red interchanged. 

  • darren says:

    1st degree AV block.
    Left Anterior Hemiblock (rS waves in II, III and aVF, Left Axis Deviation -45 degrees QRS < 0.12).
    ST-changes I and aVL (concave rather than convex but suggestive of possible high lateral injury).
    Requires cardiologist referral.

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