68 year old male CC: Chest Pain

Here is a great case submitted by a faithful reader who wishes to remain anonymous. As usual, details have been altered to ensure patient and provider confidentiality.

Hurricane Irene has kept your night shift wet, windy, and you've bounced from one stranded motorist call to another. Dispatch chimes in and puts you out on a chest pain call, 68 year old male at a convenience store, no other information.

You arrive to a neighborhood grocery store and see a small crowd in the doorway. An older gentleman is seated on the ground, in no apparent distress.

You introduce yourself and ask what is going on while your partner acquires vitals.

  • Onset: 45 minutes ago he awoke with some chest pain, but went to the store anyways for supplies
  • Provocation: nothing makes the pain better or worse
  • Quality: "it's like somebody keeps punching my chest"
  • Radiation: he localizes the pain to the left side of his chest
  • Severity: increased to an 8 of 10, "sometimes I can't catch my breath"
  • Timing: constant

Your partner turns and gives you his vitals:

  • Skin: cool, dry
  • HR: 130, irregular but strong radials
  • RR: 26, yet unlabored, too windy to hear lung sounds
  • BP: 138/86
  • SpO2: 95% on room air
  • Temp: 36.9 °C
  • BGL: 195 mg/dL (10.8 mmol/L)

Your patient reports a general "cardiac" history and is unable to remember what medications he is on, stating only that they, "are numerous."

With some help from the bystanders you assist the patient to your stretcher and move him to your unit to get out of the elements. Your partner places him on the cardiac monitor while you place him on a nasal cannula and listen to his lung sounds.

You note that his lung sounds are clear and equal bilaterally as your partner hands you the initial 3-Lead. Your patient denies any history of arrhythmias and says at his last checkup he was, "healthy as a horse."

A 12-Lead ECG is acquired.

With Irene still pummeling the Eastern seaboard, it will be at least a 20 minute ride to the closest facility, 30 minutes to the closest PCI capable center. Your partner asks if you'd like him to request a driver.

What is your patient's rhythm and what treatments should your patient receive?

What does the 12-Lead ECG show?

Does the patient need a PCI capable facility, why or why not?


  • Robert (Las Vegas) says:

    12 Lead Interpretation: Atrial Fibrillation w/ RVR, RBBB, Diffuse/Acute Ischemia, Consider LMCA Stenosis.
    Patient has a Irregular rhythm, No discernable P waves, Diffuse Ischemia with ST elevation in avr and avl which is highly sensitive for lmca stenosis.
    Treatment: Bilateral IV's, MONA, PCI Center Asap.

  • Nicola Morabito says:

    Note also possibli digitalis effect.

  • aman says:

    Signa amd symptoms along with ecg are suggestive of Myocardial ischemia……ekg suggestive of Afib with RVR and significant t wave inversion in inferior and anterior leads suggestive of anteroinferior ischemia.

  • Harrison says:

    A-fib w/ RVR, RBBB. Normal axis. Computerized rate of 147. Near-global T wave inversion, and near-global ST depression. I'm calling a cardiac alert to the hospital and will transmit the 12 lead if capable. The patient will go code 3 to the PCI facility.
    The patient is symptomatic with chest discomfort.
    Treat per your protocol for a-fib w/rvr and chest pain. Either way the PCI capable hospital is going to be the better choice for this patient due to capabilities of the hospital and physician staff. Take the extra 10 minute drive and save the patient the possibility of a non-emergency ambulance transfer bill.
    Let's get the patient's med list if possible. Treat the heart first with PRN supplemental O2, NTG bolus + drip, ASA, and morphine/fentanyl. Then let's consider cardizem bolus + drip for the rate after we get all that finished.
    Also, what's up with the driver thing? What happened to the ambulance crew not operating the ambulance? Talk about massive liability!!!

  • Ken says:

    I agree with Robert to an extent……. Particularly the avr sensitivity for LMCA lesion… However, let us consider this. Sense there seems to be global ischemia, maybe this is rate dependent ischemia. I would correct the HR, RVR first (calcium channel blocker) and see if that relieves cp, dyspnea and ischemia????? Just a thought.

  • James M Clary, RN, EMTI-85 says:

    Anyone considering posterior as well?

  • saraswathi thangavel says:

    it s an af with bbb.. seems lbbb also . if new onset lbbb  have to cosider it as an acute mi because he was alright earlier.. otherwise it s an tacchy arrythmia  possibly AF with chest pain better cardiovert  this patient and see once rhythm normalised whether pain subsides. better taken up for angio and primary pci… for me it looks like new onset LBBB just of acute myocardial infarction..   eagerly waiting to know the correct answers  soon…

  • Troy says:

    Elevation in aVR with global depression is sensitive for LMCA Occlusion or 3 vessel disease. I’m betting he’s on digoxin as well. I would control the rate with some diltiazam then go ASA, nitro for pain, and fentanyl. Activate and have a surgical team on standby

  • Ken says:

    rsr’ = RBBB correct??

  • hisham says:

    The ECG shows AF with RBBB this findings in the context of chest pain could highly indicate the possibility of a  high risk Myocardial infarction, a CK-MB and troponin should be done and the Cath lab team should be quite available for an inavsive approach #

  • Stephen says:

    20 of cardizem or 5 of lopressor.  Slow it down and look again.  May be demand changes.

  • Bill says:

    Any chance of this being WPW?

  • marionurse44 says:

    A-fib, RBBB, Poss R side strain patteren, Lung clot? Q3S1

  • TatonkaDTD says:

    Global ST changes
    Unremarkable skin
    Suddent onset
    Unable to catch breath with good respiratory effort

    I'd strongly consider the differentials…namely PE and aortic dissection, both of which could have a similar presentation…

  • Firemedic24 says:


    Global depression and t wave inversion + ST elevation in avr = probable LMCA occlusion.  Transport to PCI center.  Follow CP protocol asa, nitro, o2, and MS/Fentanyl whatever your preference.  Rate control would be one of the last things on my mind.  The patient seems too hemodynamically stable.  I understand the desire to decrease oxygen demand, but I think the heart rate is a result of what is going on, not a cause of what is going on.  I understand that patient's are stupid when it comes to knowing about their own medical problems, but this is a case where the patient history needs to be very thorough.  If he is "healthy as a horse" than he would not be on so many medications he doesn't know what they are.


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