70 Year Old Male: Short of Breath

Good morning sports fans!

You are dispatched to the residence of a 70 year old male, complaining of “shortness of breath”.

You pull up to a well kept home, and are met at the front door by the patient’s wife. She tells you that her husband came home from the hospital yesterday after cosmetic eye surgery.

You are led into the kitchen, and find your patient sitting in a chair at the kitchen table. There is an eye patch over his right eye. He appears to be in moderate respiratory distress. His color is ok, but you note he can only speak in short sentences.

He tells you that he was fine until this morning when he suffered a sudden onset of shortness of breath. His wife describes it as “wheezing”. You ask about any Asthma/COPD history, and he says he has none. He also denies any cardiac history. He tells you he also had bouts of “coughing up phlegm”, and felt “very weak”. As the day went on, his breathing worsened, so EMS was called.

You listen to his lungs and note basilar crackles. His history is significant for hypertension, repaired AAA, and skin cancer.

His vitals:

  • Pulse: 116 and weak
  • BP: 102/70 (patient states his systolic is normally in the 120-130 range)
  • RR: 24 and labored
  • SpO2: 92% on room air, and 97% on O2
  • Skin: unremarkable

Here is his rhythm strip:


and 12 Lead ECG:


ECG interpretation?

What could be wrong with your patient?

How do you want to treat him, and where do you want to take him?

The nearest hospital is the local hospital 20 minutes away, and the nearest cardiac center is 50 minutes away.

Let’s hear it!


  • K.Linder says:

    Possible hyperkalemia , Peaked T waves with LBBB look at lead V6, lead 1.

  • Floyd says:

    LBBB. Inappropriate discordance in the inferior leads. I would treat with 324 asa and withhold nitro due to the blood pressure being lower than normal and the possibility of right ventricular involvement. Transport the the PCI capable facility. Watch for elevation to start coming up in avL with serial EKG’s. Unfortunately my service and local facilities consider new LBBB stemi equivalent. Fortunately in this patient the LBBB could be new and I would activate the Cath lab.

  • Ezio says:

    He is experiencing an acute left ventricular failure with left bundle branch block at the ECG; if this finding is new should be treated like STEMI

  • sohail ali says:

    Patient having angina equivalent and left ventricular failure secondary to acute MI. He has LBBB with ST Changes equivalent to STEMI. NEEDS PRIMARY PCI.

  • Floyd says:

    Edit to last post. The depression is in the inferior leads. Looks like may have subtle elevation in the high lateral leads. Subtle but would do serial ECG’s and look for changes.

  • Ricky says:

    Pt has a physiologic left axis, a LBBB, and what appears to be a septal infarct age undetermined. There is no documentation of heart sounds and evaluation of lower extremity edema, although there is “limited note of basilar crackles”. Since we don’t know if this is a new or old LBBB, you have to assume this is a cardiac event until proven otherwise. Patient should be treated as such.

  • Jason says:

    I may be way off…I definitely see the LBBB and agree there…but could this also be a PE maybe? Wide spread depression with slight elevation in AVR and V1. History of eye surgery. Would get moving fast…O2/ASA/Line/Monitor either way.

    • Joe says:

      Looking at De Winters as well, but should we be looking at the J point (depression) as well as the sweeping and symmetrical T waves? De winters is a newer LAD lesion indicator primarily seen in younger men with a hx of hyperlipidemia (yes understand the idea of not all pts follow rules of inclusion vs exclusion.) regardless of de winters or not, tx is not effected in any way. Jason if you’d like i recently had de winters pt. if youd like I can email you the EKG

  • jason says:

    Interesting case…
    So the rhythm is a sinus tach. There is a LBBB present as others have mentioned. With the patient denying a cardiac history we are going to go ahead and presume that is a new LBBB. I do not see anywhere in this 12-lead where this patient meets any of the 3 Scarbossa criteria. As such this patient does not meet the threshold for emergent cath.
    The shortness of breath, the lung sounds suggesting cardiac insufficiency, the presumed new LBBB and the relative hypotension leads me to believe this problem is cardiac in nature.
    A previous comment mention hyper K+. The t-waves here are not symmetrical. They are large and pointed. I’m think De Winter’s T-waves are more likely than hyper K+.
    The recent surgery leads me to consider a PE. Dr Amal Mattu’s blog talked about EKG findings in PE this week. It is well worth checking out. This EKG does not show a PE. I believe though the PE needs to be very large to cause EKG changes.
    As far as treatment goes for this patient. O2 to hopefully relieve SOB ant target an SpO2 between 94-99%. I’m going to consider aspirin but I’m going to need to evaluate what, if any, anti-platelet medications he is already on given the recent surgery. I suspect I will not give NTG. He is already relatively hypotensive and, to the best of my knowledge, NTG has not been shown to affect M&M. Further he is pain free.
    As mentioned above his EKG is non-diagnostic and so if the receiving facility believes this to be cardiac in nature he ought to be managed medically as opposed to cath’d. Local ED here we come.

  • Floyd says:

    The 2013 AHA Stemi guidelines no longer recommend treating even a new LBBB as a stemi equivalent.

  • Spencer Oliver says:

    Our gentleman has a sinus rhythm with a LBBB. Not only that, but he has an Acute STEMI! There is concordant depression in V3 so Sgarbossa criteria is met. So we should take him to a PCI facility.

  • Fritz Fuchs says:

    New onset LBB, treat for MI and try to rendezvous with a helicopter for the cardiac center. Critical pt

  • Alex says:

    Sinus tachy, LBBB. There is some depression in V3, which hits Sgarbossa’s criteria for STEMI in the presence of LBBB.


    There’s no report of chest pain and I’m not clear what ST depression in V3 might indicate… A posterior STEMI?

  • Chris says:

    One explanation could be that as the patient has got home the day before from surgery he may be a bit dry and could be hypovolemic, which could account for him being tachy with a weak pulse and also his drop in blood pressure. However the ECG leads me to believe that a more accurate diagnosis is that he could be suffering an non STEMI possibly due to a severe left main stenoisis and or triple vessel disease, so the ST axis looks to be towards aVR so this is why ive said non STEMI as the STE in aVR is most likely a reciprocal change to the lateral ST depression caused by diffuse subendocardial ischemia, which is maximal in V4-6… so id take the cardiac centre..

  • Chris says:

    And also a new onset of LBBB furthers the emergence if this situation..

  • jason says:

    So in reconsidering v3 I took the ekg and put it in PC paint. There I was able to enlarge it and draw some lines. I find the J-point easiest to pick out in V1 for leads v1-v3. So I find the j-point and drop a line straight down for the 1st 4 complexes of v1. from there a perpendicular line show STD in v3 complexes 3 and 4 but not 1 and 2. So Scarbossa?
    Tom- you got an answer coming soon? Did they shot dye? What did it show?

  • Peter Hammarlund says:

    Sinus tach and LBBB with positive Sgarbossa criteria (concordant ST segment depression in V3), i.e. STEMI equivalent complicated by congestive heart failure and cardiogenic pre-chock. In addition there is concordant ST depression in V4 which isn’t technically a Sgarbossa criteria, but something you wouldn’t expect in a normal LBBB

  • DT medic FF says:

    I see Sinus Tach with LBBB. Sounds like new onset of LBBB if the patient has no Hx of it. The T waves appear to be appropriately discordant for LBBB. There is some diffuse ST segment depression in the inferior leads and V4-V6. The J point in V3 appears to me to be level with the isoelectric line of the PR interval which I would consider abnormal for LBBB as there should be proportionate ST segment elevation in this lead as there is in V1 and V2. I found it was easiest to find the J point in V1 and chose a complex where a vertical line from the EKG paper intersected with the J point and followed that line down through the other leads below to measure the ST segments. There is also ST segment elevation in aVR. I would consider this 3 vessel disease or left main disease and the patient needs to have a CABG performed. This to me makes the better destination decision to be the cardiac center. During transport I would give O2 via NRB, establish an IV, and continue monitoring the patient. If the patient improves with the NRB I would keep him on that. If he deteriorates I could consider CPAP but want to be careful with the patients BP.

  • Larkin says:

    Always focusing on cardiac. A few things I would think about immediately would be some type of infection, said something about him coughing up phlegm. Was he intubated during cosmetic eyes surgery? I would guess not. Was he previously on anticoagulant meds and taken off pre-surgery, hx. of hypertension and AAA, probably not. I wouldn’t think eye surgery increases risk of PE that much but something to think about. I would guess either ARDS with pneumonia after surgery or acute heart failure/cardiogenic shock. I’m not going to call a STEMI on LBBB (unless elevation to inferior leads), would treat with CPAP and possible RSI if pt. deteriorates. Transport to PCI capable facility. My 2 cents.

  • Patrick says:

    Sinus tach, physiologic left axis, with left bundle branch block. To me the concordant ST depression in V3 meets Sgarbossa’s criteria. Also, there is concordant ST depression in V4 which is not normal in LBBB.

    I would bet that this patient is having an MI and is starting down the road to cardiogenic shock from left ventricular insufficiency. I would start toward the PCI center, give ASA and get serial ECG’s for comparison. If his pressure drops any further I might consider 250 mL IV fluid, and dopamine if and only if I can’t keep his pressure above 90 systolic.

    Other things on my ddx list: pulmonary embolism (although I think it’s unlikely) or a new AAA or dissection. People with previous aneurysm/dissection repairs are at risk for additional aortic syndromes.

    Just my two cents. I’m interested to see what the outcome is.

  • ade says:

    left axis, sinus tachicardy, M shape on P lead II: sign of enlargement in left atrial, Ischemia inferior wall, lateral wall, injury at right anterior wall. And left bundle branch block

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