47 year old male: Holiday Indigestion

Thanks go to a long time reader Nicholas Eisele for this holiday case! As always, details have been changed to protect patient privacy.

It is a blustery Christmas morning when you and your partner are dispatched for a 47 year old male with chest pain. Firefighters are already on scene obtaining a history and vitals when you arrive.

You check in with the officer in charge, a paramedic, and he reports that the patient has been having a "burning sensation" in the middle of his chest, going to his back. As it is Christmas morning and the patient's family is opening presents, the officer also relays the patient, "is likely going to refuse." He also relays that they witheld ASA due to the patient's "indigestion."

One of the firefighters gives your partner the patient's vitals:

  • HR: 70 bpm, regular at the radials
  • BP: 144/96
  • RR: 18, unlabored, in no apparent distress
  • SpO2: 95%
  • ECG: "normal sinus, nothing out of the ordinary" (no 12-Lead was captured)

You perform a quick patient assessment prior to making any decisions:

  • Onset: 21:00 the prior evening
  • Provocation/Palliation: pain went away over night with sleep, came back after breakfast; nothing makes it better now
  • Quality: "burning"
  • Radiation: "straight thru to my back"
  • Severity: 7 of 10
  • Timing: constant burning

A focused history reveals no prior cardiac problems and that the patient takes no medications and has no allergies.

Given the patient's symptoms and possibility of a true cardiac problem you advise the patient that a trip to the hospital is worth it just to make sure he's not experiencing something serious.

After he sits down on your stretcher your partner begins placing electrodes for a 12-Lead as you gather four baby aspirin for the patient to chew.

Frightful Weather We're Having - Initial 12-Lead

You notice the artifact and hit print again, however, you decide you can run another one in the truck. After loading the patient your partner hands you the second 12-Lead, which is a bit cleaner than the first.

Frightful Weather We're Having - 2nd 12-Lead

Not completely satisfied, you run a 3rd 12-Lead in the back of the truck.

Frightful Weather We're Having - 3rd 12-Lead

Your partner asks which facility you'd like to go to.

  • What do these 12-Lead's show?
  • What are your next steps?
  • Is indigestion a contraindication to aspirin administration?
  • Are you glad this case does not involve a narrow complex tachycardia?


  • Ben says:

    Sinus Rhythm, normal axis. Poor R wave progression in the precordials, ST depression increasing over v2-v5. 1mm ST elevation in II, III & avF. ST depression in I & avL. I would go with Inferior STEMI, do a modified V4R to rule out right ventricle involvement and and V7,8,9 to see if there is a posterior wall MI. Then treat with typical ACS bundle and transport to PCI centre.
    In the UK indigestion (GI problems etc) falls under a 'Caution' when it come to aspirin – the benefit out weighs the risk in ACS however.
    Yes I am glad this wasn't a narrow complex tachycardia!

  • Chee Yong Chuan says:

    Hi, thanks for this very interesting entry
    1) Sinus rhythm, with each QRS complexes preceded by P waves
    2) PR interval within normal limit(156ms) with a biphasic P wave best seen in lead II and lead III suggestive of left atrial enlargement(P Mitrale)
    3) Axis normal (predominant upright polarity in lead I and aVL)
    4) I believe the QRS complexes are wide, some 4 small boxes in width, I wonder why the computerized QRS interval is only 114ms. QRS complexes regular with no R-R variability beating at a rate of approximately 60 beats per minute. Terminal R wave seen in V1 and V2(rsR") with S wave seen in lead I may suggest a RBBB.
    5) Subtle but significant 1mm ST segment elevation observed in lead III with straightening of ST-T segment seen in all inferior leads(II,III,aVF). This is also accompanied by reciprocal ST segment depression in both lead I and aVL coupled with T wave inversion(lead aVL). ST segment elevation in lead III> lead II
    6) Horizontal ST segment depression are seen over the precordial leads extending from V2 to V5 with upright T waves 
    7) Poor R wave progression over the precordial leads 
    8) No Q waves seen
    Impression: Acute inferoposterior STEMI , for immediate reperfusion therapy
    Next step: 1) Peripheral IV cannulation
    2) Withold Oxygen since SpO2 is 95% with no evidence of heart failure, profound hypoxia or shortness of breath 
    3) Aspirin 300mg stat, chewed
    4) Clopidogrel 300mg stat
    5) Sublingual GTN 0.4mg can be repeated 

    6) Posterior leads to confirm posterior involvement
    Indigestion is not an contraindication for aspirin. Only true aspirin allergies or active GI bleeding are considered contraindication. There is no reason to withold aspirin

  • Chee Yong Chuan says:

    Culprit artery likely proximal RCA

  • Stephanie says:

    12 lead shows sinus rhythm with ST elevation in II, III and aVF (inferior), and reciprical changes in I, aVL, and V2-V5. Inferior infarct and due to the fact the pain radiates to his back, I would be highly suspicious of posterior involvement, likely RCA occlusion.
    I would put the pt on O2, establish a line, administer ASA 324mg PO, NTG 0.4mg SL every 3-5 minutes to a max of 3 doses, and depending on proximity to the closest cath lab, morphine 2mg IV every 3-5 minutes. Oh, and don't forget to smack the officer/medic upside the head as you leave.
    I have doubts that the pt is truly experiencing indigestion – I suspect the "burning" is just how his chest pain is presenting.

  • Aleks B says:

    Inferior wall MI presenting in leads II, III, avF with resiprocal changes in other V leads. The "burning" in stomach is common with inferior wall MI's as well as just upset stomach or nausea. Confirm this with V4R to be done and if there is positive ST elevation in that region withold nitrates, treat with 324mg ASA because it does outweigh risk versus benefit…establish second IV and aggressively begin treating with fluid boluses to exercise "The Sterling's Law". If pain does begin to occure consider use of Fentanyl for pain managment to decrease pain induced anxiety and decrease myocardial oxygen demand through possible elevation of heart rate from pain…should be fairly safe with Fentanyl due to no preload drop of BP as there is in use of nitrates such as NTG and Morphine. Code 3 transport to nearest appropriate facility with Cath lab capability with STEMI alert. Of course treat with Zofran if needed and apply high flow O2 via NRB.

  • Zack says:

    SR; norm axis; 1st degree HB; prolonged QRS; incomplete RBBB pattern; STE in inferior leads w/ STE in III>II w/ STD in I, aVL; all indicate RCA occlusion.
    The STD in V2-V5 could indicate posterior involvemnt or anterior/lateral wall ischemia.
    If time allows would want to do 15 lead to rule posterior involvment out, but main goal is to get this pt to PCI capable facility asap. Follow local STEMI protocols except for ASA admin. 
    I  would hold off on the ASA until I at least obtained BP measurement on both arms, listened to heart/lung sounds. Beause of the P-sinistrocardiale pattern p-waves indicating LAE(could be from aortic regurg,bi-cuspid aortic valve, aortic stenosis) and the pt's description of the pain going, "straight thru to my back". These may indicate proximal aortic dissection(AD) obstructing the RCA. The pt's pain went away overnight and returned in the morn which may have to do with aortic dissections follwing a circadian rhythm and could indicate impending rupture. So I would definitely withhold the ASA until I did a more detailed physical exam. The consequences of giving it to a AD pt are worth the brief delay.
    Indigestion is not a contraindication to ASA.

  • Zack says:

    nvm the 1st degree HB, don't even remember typing that.

  • Medic Gregory says:

    My treatment plan for this pt after seeing his vitals and 12 lead would be as follows: The 12 lead shows anteriolateral ischemia with the V2-V5 leads having ST depression which could mean popsterior involvement so a 15 lead would be warranted.  Next the 12 lead shows ST elevation in leads III, aVF and depression in leads I, aVL; I would also want a look at VR4 for possible RV involvement before any nitro administration. I would also transmit these 12/15  leads to the hospital for faster treatment plans.  The pt could be having a DeBakey I Aortic dissection if VR4 shows STE.  The pts treatment would be O2 via NC at 3 LPM, ASA, and IV x2 enroute.  The pt should be transported emergency to the closest PCI facility.  Indigestion is not a contraindication for ASA, active GI bleeds and allergies to ASA or its derivatives. 

  • mancinim says:

    Poss Post Wall AMI Post leads needed. Tx ASA indigestion refered pain TX AMI.

  • Flanmedic51 says:

    Quick and to the point. Anterolateral ischemia present. 1mm ST elevation lead III is concerning but no other evidence of AMI on 12 lead. 15-lead should be performed, chest pain workup should be done. Pt needs transport to a cardiac center…prob sooner than later, suspect AMI is on the horizon.

  • platelet says:

    Inferior STEMI, maybe posterior involvment, maybe only mirror ST-depressions. Definitely ACS, with ongoing symptoms though the patient stable, so I would go to the nearest PCI center even if the ST-elevations are not so marked. Standard STEMI treatment, though I would be cautious with nitrate (ST-elevation appers to be higher in III then II, it could be right ventricle). ASA is OK, if the patient doesn't have an active ulcer. If he doesn't even have a history of GI bleeding, there is no question that ASA is indicated.

  • BMB says:

    Sinus rhythm , RBBB. There could inferior MI occuring, but I much more concerned with the  Posterior MI that is most likely occuring. The inferior leads are right at the 1mm of ST segment elevation line, but they appear to be upwardly concave, then again there is lateral depression in 1 and AVL. Is it reciprocal to the inferior leads? probably.
    The presence of  ST depression in the anterior leads and what appears to be Concordant ST depression in V1-V2 is worrisome. Is this anterior ischemia in the presence of an inferior MI…or is it reciprocal changes seen on anterior leads from a posterior MI? 
    Without V7-V9 I cannot say for certain that the posterior MI exists, but there is a very strong case for it. V4R would be important here as well
    I mam 90% sure of a posterior MI with possible inferior involvement. 10% chance of aortic dissection. It may be worth doing blood pressures on both arms to see if there is a difference of >20mm. A more thorough physical exam would be telling as well, any murmurs present? JVD? anything Marfan like, such as arachnodactyly? The case for the aortic disection is mainly on the chief complaint of burning pain and the location.
    Tx -a trip to the cath lab, 1 if not two Iv's at TKO, 324 of ASA, as long as V4r looked ok I would administer   0.4mg of sl nitro 2-3 times BP permitting and if no response fentanyl for pain. 

  • Brian S says:

    Looks like a posterior wall MI to me, 15 lead to confirm. Some inferior involvement. Zofran, o2, and ASA. Nitro if no right side involvement. Pain management.

  • Christopher C says:

    Wellens syndrome.
    Sorry only have a second, but man this site rocks!

  • Emunamedboomer says:

    WPW, anterior depression would suggest posterior MI. Would check 15 lead

  • Doug Harwood says:

    I am a paramedic student and this is my second posting to this blog. I have followed the blog for a couple of years and really enjoy it. Please feel free to comment on my posting as it’s all about the learning…
    I see a regular sinus rhythm with a borderline wide QRS complex.  There is ST depression in the lateral leads I, AVL and precordial leads V2-V5.  ST elevation in the inferior leads II, III, and AVF.
    My working diagnosis is an inferior MI with posterior involvement. The patient has plenty of pressure to work with and there appears to be approximately 1mm of elevation in both leads II and III. I would do a V4R to determine right ventricle involvement.
    The issue I have is the burning pain that radiates to the back. It went away overnight with sleep and returned the next morning. IE change of position/effort.  This is an atypical presentation .My diff dx would include an infectious process affecting the myocardium and aortic dissection with appropriate rule outs if possible. 
    Treatment for the inferior/posterior MI would include transmission of the 12 lead for Cath lab activation, monitoring, IV N/S, 160 mg ASA, morphine, and transport.
    I would administer ASA, unless there was an active GI or other internal bleed. The benefit far outweighs the risk.
    Are you glad this case does not involve a narrow complex tachycardia?  Narrow complex tachycardia’s both scare and intrigue me. So bring it on….

  • Jessica says:

    Inferior wall MI, I would get v4R and start the O2, ASA, nitro, large bore iv regimen. Morphine if he’s in pain. I bet if a 12 lead had been obtained the night before, when symptoms started, the elevations would have been higher. It could be a normal variant, but I think I see Q waves starting to form.

    Forgive me for not knowing off the top of my head, but why should I be glad this isn’t a narrow complex tachycardia? I understand that a tachy heart is working a lot harder and using up more oxygen, but am I missing something?

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