88 year old male CC: Chest pain

EMS is called to a 88 year old male with a chief complaint of chest discomfort.

On arrival the patient meets EMS at the front door. His skin is slightly pale and moist. He appears anxious.

  • Past medical history: "Cardiac", pacemaker, hypertension, dyslipidemia
  • Medications: Numerous, unavailable at the time of EMS evaluation

Paramedics lead the man to a chair and the assessment begins.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Nothing makes the pain better or worse
  • Quality: Poorly localized pressure
  • Radiate: Does not radiate
  • Severity: 7/10
  • Time: Admits to previous episodes but unable to give details

Vital signs are assessed.

  • RR: 18
  • Pulse: 70
  • NIBP: 140/92
  • SpO2: 90 on RA

Breath sounds: Clear in the apexes, diminished in the bases.

No JVD or pitting edema.

The patient is placed on the cardiac monitor.

A 12-lead ECG is obtained.

The patient is placed on oxygen via NC @ 4 LPM and is removed to the back of the ambulance. An IV is initiated and the patient is given 0.4 mg NTG spray SL.

The pain subsides to 3/10.

En route an additional 12-lead ECGs is obtained.

And one more just prior to arrival.

Do you see anything here to be concerned about?

See also:

88 year old male CC: Chest pain – Conclusion


  • Prehospital RN says:

    Lateral STEMI … very slight in the 1st two 12 leads but much more obvious in the 3rd where the complexes are paced

  • john Clemente says:

    .it would be helpful to know for  the assessment process what was the patient doing before the on set of angina…don't you think?

  • New Medi says:

    Patient history he has a pace maker which is probably on demand which means the elavation your seeing is from the pace maker firing. I would be concerned because the patient has a cardiac history and how the patient presented. Some ischemia which was resolved with oxygen so I wouldn’t be overly concerned there either.

  • Mohamed Wafiq says:

    Infero-Lateral STEMI

  • High lateral MI and possible posterior. I’m going to guess posterior lateral. But def there is something to be concerned about here.

  • Richard Lynch says:

    Pacemaker firing in last ECG
    first full ECG looks like a possible Wellen's syndrome

  • NewMedic217 says:

    It looks like "atrial" flutter and "ventricular" pacemaker

  • dr sanket patel says:

    its prinzmetal angina

  • Prmedc says:

    Maybe I'm missing something, but I don't see much on the 12 lead. Atrial fibrillation with demand pacing.  I'm fairly certain that the non paced complexes are "normal" with the demand pacing explaining the abnormal complexes.  Unless the pacer isn't functioning and it's some sort of ventricular escape rhythm…but most likely not due to how regular the wider complexes are.
    Of more concern is the patients clinical presentation with rapid relief following 0.4 nitro.  If this was my call I would treat with further nitro (drip) and narcotics if unable to achieve complete relief with nitro.  However the ECG doesn't appear to be worthy of cath activation.
    It'll be interesting to see what the conclusion is on this one.

  • Firemedic24 says:

    I don't see a STEMI.  It seems that every single qrs complex with depression or elevation is a result of the demand pacemaker.  I would still treat it like acs until proven otherwise, but I don't think it warrants a cath lab activation.  I would also keep electrolyte abnormalities in the back of my mind.  Mainly hypok or hypomag.

  • Firemedic24 says:

    Also looks like the underlying rhythm is accelerated junctional.

  • STPEMTP says:

    Rhythm: Aflutter varible conduction, with occasional paced beats (flutter wave best seen in V1)
    Lateral STEMI (3rd EKG V5 an V6.  excessive discordance of ST segment compared to QRS.  very small QRS and very large ST segment)  compare lead II QRS to ST segment vs V5 qrs to ST segment as example)
    initial QT interval borderline long, 2nd ekg QT longer yet ( ? pacer artifact versus actual finding, throwing out 3rd EKG QT due to large amount paced) 

  • Dan says:

    Appears to be Atrial Flutter w/ demand pacing. This is not a STEMI. Nonetheless, 324 ASA, Nitro, consider some morphine. I'm not calling the cath lab. Just my thought : )

  • arnel c. says:

    For me this is an interesting case. Typically RV pacing will have RBBB morph but not here. Second for me hard to deduce the criteria for MI in pacing coz they were describing it for LBBB/RV pacing. If we deduce discodance on inf. wall may not reach 5mm so prob not inf wall problem. What makes suspicious is the morp on V5/6. So ill be conncerned on this one. Combined with clinical and lab then decide on it. Will wait for outcome of the case. Nice… Anyway – VP, intrinsic AFl, suspect MI lateral wall.

  • Stuart Cox says:

    What’s his code status? Walking time bomb.

  • BigWoodsMedic says:

    Yeah this is a tough one. I didn't see any ST changes until I read the comments, then also was pointed out in the first 12 lead what looks like RBBB with the pacer spikes. I now notice the changes in V5/V6 but do they apply to a RBBB morphology? I was told no. I look forward to the analysis of this case study. If I had this patient in real life, I'd go with O2 to 95% SPO2, IV, aspirin, nitro, and send the 12 leads to my local PCI capable hospital, which is where we're going just in case. 

  • fd3941 says:

    Not seeing a STEMI here. Seeing the pacer firing. There are no reciprocal changes related to the elevated ST segments in any of the 12 leads. I would continue with MONA ( minus the morphine, due to proxemity to my hospital, less then 5 mins) and perform a continuous reevaluation on the pt, VS, serial EKG’s. Etc. We have the option in my county of directly activating the Cath team from the field based on our findings. This would only result in a pri2 notification to the ER staff and no activation. I would make a point to state my findings in the EKG related to his pacer and relief with the nitro.

  • Roger says:

    This is a demand pacemaker that is sometimes firing. I would still be concerned though, due to the fact that pacemakers can hide ST elevation. The pacemaker appears to pace and the quit as the heart rate goes above the intrinsic rate set for the pacemaker. It still looks like the underlying rhythm is a-flutter. I would still treat the chest pain per protocol.

  • Nick Adams says:

    12 Lead:  U/L A-Flutter with a 4:1 conduction mostly and an Occasional 3:1, which would explain a HR of 75 bpm.  Pathological LAD 2* to LAFB (-49 QRS axis), Changing to a -79 degree axis with the paced beats. No seen left ventricular hypotrophy, or ectopy (other then the paced bts).  U/L 12 lead looks like he has normal ST segments (nothing alarming), but the paced beats in leads V5 and V6 are suspicious for a STEMI in the lower left lateral wall.  Given his history and symptoms, I would treat this as a STEMI and transport to a Cathlab.  If it walks like a duck and talks like a duck….it's probably a duck.

  • Mdelgado says:

    Trully one that makes you review all you taught you knew ! With st changes on anterior leads you would think a posterior with lateral involvement. Also the pacer with poss demand or falliure to capture.

  • Jeff says:

    I don't see any conclusive signs of a AMI.  Every one of the complexes showing "ST elevation" is what I would consider to be a paced vetricular beat due to his demand pacemaker.  Upon inspection every lead is showing a narrow complex  in at least one of the three EKG's with no ST segment elevation or depression.  The last EKG is a prime example of this in v4 and v5, the complex is much wider then it was in the previous EKG.  I would treat with chest pain protocol but not activate cath lab or call it a STEMI. 

  • Jpjprich says:

    My advice is ” treat the patient” not the monitor! Pale diaphoretic, complaining of chest pain. Follow your chest pain protocol and you can’t go wrong!

  • Nick says:

    What i find so strange in this case is the change in st segments in v5/v6 in the demand paced beats versus the hearts own underlying rhythm. In the first two ekgs in v5/v6 we see the underlying afib with absolutely no st segment abnormality. However in the third ekg, demand paced beats are shown in v5/v6 with abnormally large t waves and excessively disconcordant st segments, both of which are indicators of MI in a paced rhythm/lbbb. Can someone explain how/why this occurs?

  • Arnel C says:

    Sorry for the typo in the earlier comment… typically RV pacing will have the LBBB morphology. RBBB in RV pacing hmmmm unless it is an ICD-CRT. Would also be interested if the RV lead is really in the RV (if dual chamber PM) and not somewhere else.

  • Andrew says:

    Do Lifepack monitors filter pacing spikes ?

  • Andrew,

    No, but they also don't do a great job of showing them. Modern pacemakers have really low surface potentials, and often all you have are little "nubbins" in V3-V4.

  • Rose says:

    I agree with Atrial Flutter and I also do not see ST elevation.  The top of the strip indicates a paced rhythm, but I  do not see any pacer spikes to show that there is a pacemaker.

  • Arnel C says:

    Rose as Christopher mentioned hard to see on surface ecg's. Most likely this pt had a bipolar lead which makes little "nubbins" or pacing stimuli that are difficult to see. You can see it in V3. 

    [Editors: Arnel has two great posts showing how hard it can be to see pacemaker spikes, Part 1 and Part 2]

  • Bubba says:

    The first EKG is useless, it's not even an EKG (12 lead), it's just a strip.  It is not atrial flutter.  As everyone knows AFlutter has classic sawtooth waves, and while some of the isoelectric lines aren't clear, in other leads the isoelectric line is clear.  If the patient had AFlutter the EKG would show AFlutter in every lead.
    I don't see any atrial pacer spikes.  I'm not sure what people are calling pacer spikes.
    A STEMI is a ST elevated MI, this is ST depression in some leads.  Remember you have to look at every V lead and compare it the previous EKG

  • Bubba,

    Flutter waves may not be visible in all leads or even in the leads they're normally best appreciated; axis is everything. V1 and V2 show clear F-waves at a rate of ~300 bpm. Given the ventricular response is irregular, the conduction through the AVN is irregular as well (3:1 and 4:1 is predominant in the ECGs posted). I don't believe there is much to debate around the patient's underlying rhythm in this case.

    I'll concur that the pacing impulses are not readily appreciable in the initial ECGs and 12-Leads, however, the last ECG shows irrefutably ventricular-paced complexes. I also agree that there is no atrial tracking or atrial pacing. Yet, given the ventricular rate, R-R intervals, and morphology we can deduce that in the initial ECGs we are seeing a mixture of intrinsic conduction and ventricular pacing.

    As for your final comment, traditional STEMI criteria is accurate for instances where repolarization is normal. In our narrow complex beats, repolarization is normal and there appears to be no STEMI (as you noted). However, in instances where repolarization is abnormal (LBBB, Pacing, etc) the traditional rules of STEMI identification must be augmented by Sgarbossa's Criteria (and Smith's modification). And as you state, comparison to previous ECGs is very helpful.

    Thank you for the feedback!

  • Srikanth says:

    Email me the rhythm strip. Do you have a fmlaiy history of heart conditions? Any medications or drug use? Alcohol? What’s your diet, weight and height? How long have you been having these sensations? When and how did they begin? What seems to provoke them or make them feel better? Are they accompanied by paleness, sweating, or pain? How bad is the pain on a scale from 1-10? What does the pain feel like? Where is the pain located and does it radiate anywhere?

  • Annie says:

    anstable angina, improved with NTG

  • darren says:

    Inferior-lateral MI

  • Interesting series of tracings. The rhythm is spontaneous AFib and/or AFlutter (does look like most but not all of the time that there are low amplitude flutter waves uniquely in V1 …. ) – interrupted by periodic paced complexes (with rbbb-morphology and as mentioned, tiny “nubbins” for pacer spikes). It is always a challenge to try to identify acute ST-T waves when the patient is paced … The ONLY thing I see on ECG #2 (@21:42) is in V3 what looks like more-than-expected peaking of the inverted T wave given that these beats are paced …. That’s entirely nonspecific.

    BUT – in ECG #3 (@22:05) – the ST segment in lead V5 is NOT normal. Instead – it looks to be hyperacute. What bothered me in the paced beats in ECG #2 – is not really seen in the spontaneous beats in ECG #3 – but lead V5 is NOT normal. Hard to tell about V4 in ECG #3 – as ST-T morphology changes a bit in the 3 complexes that we see in this lead.

    BUT – in ECG #4 (@22:11 – or just 6 minutes after ECG #3!) – the paced complex in lead V5 is clearly ABNORMAL – with a HYPERACUTE ST-T wave despite being paced. This is an acute STEMI until proven otherwise in my book. Await follow-up from Tom.

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