43 Year Old Female – Chest Discomfort After Eating

You respond to an office workplace for a 43-year-old female with a chief complaint of chest discomfort.

On arrival you are greeted by the patient who is pleasant and well-appearing. Her skin is warm, pink, and dry and pulse strong at the radials. Respiratory effort is normal with clear lung sounds bilaterally and she does not seem to be in any distress aside from some mild anxiety about having the ambulance pick her up at work.

She had just finished eating lunch (soup and a sandwich) when she began to experience retrosternal chest pain that she describes as “like a cramp—as if there’s something stuck in there.” She happened to mention the sensation to her boss who then called EMS, worried that there was “something lodged in her throat.”

  • HR – 85 bpm, regular
  • SpO2 – 98% on room air
  • BP – 138/82 mmHg
  • RR – 15, non-labored
  • Temp – 36.9 C (98.4 F)

She denies any shortness of breath, lightheadedness, dizziness, vomiting, or diaphoresis; though she is mildly nauseated.

  • S – As above
  • A – No known drug allergies
  • M – Levothyroxine
  • P – Hypothyroidism
  • L – Lunch 30 min ago
  • E – Just finished eating lunch when the pain started

Blood glucose is 102 mg/dL.

  • O – Fairly abruptly, less than 5 minutes after she finished her sandwich
  • P – Nothing makes it better or worse
  • Q – Like a knot behind her lower sternum
  • R – The pain seems to ache to her left shoulder blade as well
  • S – 5/10, “not too bad but not comfortable”
  • T – Constant for 30 minutes

You perform a 12-lead ECG:

1164 - ECG 01

 

It is a five minute drive to the local community hospital and thirty minutes to the region’s PCI center.

Which hospital are you going to suggest?

Is this patient experiencing a STEMI?

 

 

21 Comments

  • dr bensaleh says:

    I think this woman is experiencing a stemi ; she should be transferred to the region’s PCI center.

  • Subtle elevation V1-2 with ST depression I, aVL, v5-6.
    Cath lab and so what if we are wrong.

  • Christina Horvath says:

    Second hospital to r/o MI. Also, CT chest or other study to r/o aneurysm.

  • somnadheer says:

    I would like to treat her as acute coronary syndrome giving asprin 325 dispersible tab sublingual nitroglycerine along with plavix 300 n atorvastatin 80 mg , omeprazole and analgesic.This pt then needs cardiac enzymes & serial ECG to confirm acute Mi and further mgt as per hospital policy.

  • michelle says:

    st elevation isn’t increasing its staying suttle. possible stemi but possibly not. tp. to nearest hospital for further tests to determine.

  • Marcel says:

    The St-Elevation doesn´t evolve from a R-Spike, but from a S-, or Q-Spike. The paindescription is unusual for a pancreatitis, but isn´t it possible pancreatitis creates ST-Elevations?

  • Floyd Miracle says:

    That is a tough case. There is elevation, but there is also a short QTC, and good r wave progression. However, ST depression in many leads steers me away from ER. She may very well have something stuck in her throat. A short trip to the ER to have a formal echo obtained would be a good option, so she should atleast be transported to a PCI facility. I wouldn’t make the call to activate the CATH lab. I would transmit the EKG and contact a physician and let them make the decision. If possible contact an interventionalist and see if they want to do an immediate PCI. And of course, obtain serial EKGS and scrutinize for any changes. If the ONLY option. Was to call this a STEMI or not a STEMI, I would say not a STEMI because the QTC is very short. I’m looking forward to the follow up!

  • russell says:

    Transport to PCI. There is elevation in V1 V2 V3 with reciprical depression. With chest pain present. Women tend to have atypical presentation. Give ASA and atleast 2 rounds of NTG. If no change to pain then oh well. If its not cardiac no harm no foul. If it is and you go local. Time = muscle. Untill we can conduct further eval in the field this should be the answer. Follow your protocol.

  • Eric says:

    Elevation in V1 and V2. The elevation in V3 is borderline 1mm and in my opinion not enough by itself to call elevation, but is significant due to the elevation in the septal leads. Due to the atypical presentation females often have I would describe her symptoms as chest tightness or pressure and work down my chest pain protocol. I would also call this a STEMI, activate and transport to the Cath Lab.

  • Shane says:

    How about a right sided EKG?

  • Hazmat Medic says:

    One might be inclined to correlate this to a hiatal hernia and/or GERD exacerbation or lower esophageal spasm. However, I would advise TXP to an interventional PCTA facility with notification for a possible STEMI and appropriate prehospital STEMI treatment per protocol for the following reasons (let them rule out STEMI): 1) 12 Lead Indicators: Mild ST elevations in V1-V2 seem consistent with early repolarization; however, the ST depression in Lead I, ST segment abnormality in V6, and T wave abnormality in aVL in their presence could arguably be reciprocal changes (think septal against lateral locations). 2) location of retrosternal symptoms that radiate to the left shoulder, described as a 5 Borg level cramp/knot AND nausea. Symptoms unchanged x 25 minutes (nothing provokes/palliates them). 3) the B/P could be mildly elevated for her normal B/P. 4) Symptoms developed after eating, not during. 5) Age/gender places patient in the “atypical presentation” category.

  • Fritz Fuchs says:

    Go time, (reciprocity)

  • Chad says:

    Treat as STEMI

  • Ken says:

    We do not have enough info as if we were there. I want to know the food that she ate.
    I am betting toward the 4F’s Female+. Forty+, Fertile+\-, Fat?.
    2 1/2 for 1 1/2 possible with better questions.
    I would like to enter gall bladder into the possibilities.

  • Ripson says:

    Ranitidin,metoklopramid and metamizol-natrium I.V. wait 10 min and if the pain is gone then it is not cardiac,if it’s still present,then M.O.N.A. th and treat as STEMI 🙂

  • CHRIS says:

    Sliding Hiatus Hernia could cause all these. She obviously stable, so transport to a PCI hospital would be the logical decision. The history, timeline, presentation all looks GI related with the ache to the left shoulder, sliding hiatus hernia fits.

  • Peggy says:

    Esophageal spasm, non cardiac

  • Stan says:

    MI, cath lab bound.

  • Chris says:

    Esophageal spasm may be possible, but having experienced this phenomenon myself, I would say the pain from them isn’t constant, as is described here, due to peristalsis waves every few seconds. Gall bladder may also be a potential, but I would want some more abdominal assessment details (Murphy’s sign) and history of occurrence with her soup/sandwich combo. I agree with the previous assessments of 1mm STE in V1/V2 and the depression in the superior and inferior lateral leads, so it sounds like reciprocal changes to me. Also, are those J Waves/ slurs in the downslopes of the R wave in II/III/aVF? Where I work, she would meet criteria for field activation of the Cath lab. I would transmit this initial ECG to the PCI capable hospital, acquire serial 12-Leads en route to the receiving hospital (PCI capable) to monitor for progression, administer an IV, ASA, NTG (no evidence of an IWMI) and MSO4 titrated to comfort with respect to V/S with a blood draw. She’s got a good SpO2 on room air so no need for supplemental right now. I would consider doing V7/8/9.

  • Ken Graurer says:

    Agree with those stating transport to the PCI center while contacting ED staff and the Cardiologist On Call. Changes are subtle, but there clearly is more ST elevation (coved in shape) in lead V1 than should be seen — which in association with some ST elevation in V2,V3 + slight ST elevation in aVR + slight-but-real ST flattening/depression in leads I,aVL,V5,V6 — make this in my mind suspicious of acute LAD occlusion in progress until we can demonstrate otherwise … A follow-up ECG/stat Echo should tell the tale. Whether this ends up getting done in the ED on arrival vs in the cath lab is a judgment call (based on personnel, local procedure, etc.). P.S. Is this 43yo woman a smoker? (unless I missed it — I didn’t see this noted in the history given …) — in which case her relatively “young age” offers no “protection” … Await follow-up from Vince — 🙂

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