50 Year Old Male: Chest Pain, Hypotension, Pulmonary Edema

Physician and cardiovascular fellow Dr. Musa A. Sharkawi shared this ECG on Twitter (@MusaSharkawi) and has graciously allowed us to reproduce it here.

A 50-year-old male presents with a chief complaint of abrupt-onset severe chest pain. He is pale, diaphoretic, and ill-appearing—in moderate respiratory distress with extensive biateral crackles and a low blood pressure. Further history is limited by the patient’s condition but listed below:

Onset – 30 min ago
Provocation/Palliation – None
Quality – Severe “crushing” pressure
Radiation – None
Severity – 10/10
Timing – Constant

Signs/Symptoms – The patient ate dinner approximately an hour ago and soon noted that he felt generally unwell. He sat on the couch to rest but then developed severe chest pressure followed by a single episode of vomiting. He currently feels like something is crushing his chest with severe shortness of breath and weakness.
Allergies – No known drug allergies
Medications – Metformin, lisinopril, aspirin, hydrochlorothiazide
Past Medical History – Type II diabetes, hypertension, chronic kidney disease (unknown stage)
Last Oral Intake – Dinner 1 hour ago
Events Preceding Presentation – See above

Temperature – 36.7 C (98.1 F)
Heart Rate – 100 bpm, irregular
Blood Pressure – 86/50 mmHg
Respiratory Rate – 30 /min, labored
SpO2 – 83% (room air)

General – Ill-appearing male in severe distress. Vomit noted on patient’s mouth and chest.
Skin – Pale, cool, and diaphoretic. No rashes seen.
Head/EENT – Unremarkable
Neck – JVD present
Respiratory – Moderate respiratory distress. Extensive bilateral rales with no wheezing or rhonchi.
Cardiovascular – S1/S2 present but difficult to hear. Radial pulse weak and irregular with occasional pulse deficit compared to apex.
Abdomen – Soft and non-tender with no distension or guarding.
Back – Not examined
Pelvis – Not examined
Extremities – Moves all four extremities. No lower extremity edema seen or felt. Calves non-tender to palpation and passive movement.
Neuro – Alert. Oriented to person, place, time, and events. Eyes open spontaneously. Answers all questions appropriately. Follows all commands. Speech clear.

The following 12-lead is performed on scene:

A simultaneous rhythm strip is also obtained:

What’s your next move?

What’s the most likely diagnosis?

Is this patient experiencing a STEMI? What is the rhythm?



  • Ciaran Maguire says:

    Trainee Technician from Belfast Ireland… ST Depression?? Old Ischemia from silent/diabetic MI? Now experiencing acute onset of Heart Failure/pulmonary odema? Treat with salbutomol, GTN & furosimide/diaretic??

  • Ashot Hovhannesyan says:

    DC cardioversion, c angio!

  • Paul says:

    Acute Anterior Lateral MI. Why cardiovert, earlier post??

  • Sara Miers says:

    Dx: Chest pain/ angina:acute: NONSTEMI with RBBB
    Differential Dx: PE/dvt, pneumonia. Pulmonary collapse

    Obtain stat labs: CBC CMP tropinion 1, d-dimer, BNP, ckMB, UA
    Apply oxygen Venti-mask non-rebreather
    Intubate if indicated
    Administer ASA 325 mg po x 1
    Administer Ntg SL x1
    Obtain stat CXR
    Obtain stat CT chest for PE protocol
    Get OR ready for stat heart cath if indicated

  • Sebastien says:

    STEMI (?Left main or proximal LAD) with cardiogenic shock and subsequent APO. Treatment is complex. Aspirin, Gentle fluid challenge with some light BIPAP and initropes as required. Fentanyl starting in low doses. Transport without delay to PCI with consideration for thrombolysis should pt deteriorate.

  • Trevor says:

    Anything that wide, we should consider hyperK.

  • Johan says:

    My guess;
    Septal MI, BBB
    Give pressor like dobutamine that supports myocardial contractility without increasing oxygen demand. CPAP if able to tolerate.

  • Javeria says:

    Rule out hyperkalemia

  • Mudasser says:

    Acute anterolateral STEMI
    URGENT angioplasty or thrombosis

  • Rachel says:

    Widespread depression? What about a posterior MI?

  • Norbert says:

    STEMI. (prox LAD or LM occlusion.) Urgent angio, consider intubation before angio. It is a junctional rhytmn.

  • Niko g says:

    Sinus arrest with accelerated idioventricular rhytm (and a nodal escape beat seen in rhythm strip) with possible anterolateral stemi. Treat pulmonary oedema with cpap and DOBUTAMINe, treat like stemi and run for cath (fast echo if possible to rule out pulmonary embolism)

  • Hovhannes says:

    Rhitm is AF with RBBB Diagnosis is STEMI duo to ACT VAL V2 V3 ST elevation mayby duo to LM or Prix LAD occlusion There is cardiogenic shoke so Morhpi Dopamine intubate and cito to cathlab

  • Tomasz Numrych says:

    Irregular WCT, no obvious P-waves. Some things working against AIVR/VT: too wide, too slow, too irregular, taller right rabbit ear, RS complexes present. On the other hand, statistically it’s more likely that this WCT is VT, plus we have a fusion beat, possible Josephson’s and Brugada signs. My guess is there is an underlying afib with aberrancy. With a CKD history and the ST/T segment morphology , hyperK is high on my list. However, more urgent is the hypoxemia and hypotension. ASA 325 mg PO for the CP, CPAP for the hypoxemia, 2xIV/IO, consider an inotrope if you have it for the hypotension. Per ACLS he is “unstable” but I would start Ca/bicarb empirically for the suspected HyperK, but at least place the pads on and prep for DC cardioversion. While on the way to the ER repeat ECGs looking for QRS narrowing, and treat as patient condition changes.

  • Dane says:

    Left main or proximal LAD. Patient is in very bad shape. I saw a few people had suggested a pressor like dobutamine. While dobutamine is not a bad idea it is not a pressor. It causes pulmonary vasodilation and in most cases that I have used it initially drops the blood pressure and the patient is hypotensive already. It is a positive inotropic agent. Rarely some minimal vasoconstriction may be seen. Dobutamine does not cause the release of norepinephrine. Dobutamine alone should be used cautiously in the patient. Also, CPAP may not be a good idea at the moment because the patient is already hypotensive. Also he has been vomiting already and the use of dobutamine causes nausea in a lot of patients. The patient should probably have a small fluid challenge and maybe consider the use of levophed if hemodynamics continue to decline. Focus should be on PCI. Everything is patient dependent. Dobutamine and CPAP may work for this patient but should be used with caution. True vasopressors and intubation should be considered and on immediate standby.

  • Daniela Baltesiu says:


  • Alexander says:

    The patient in circulatory shock from ACS IMA STEMY probably trivasculary o common trunk desease. Steps of treatment : CPAP with mask during the transportaion FiO2 50 % PEEP 6 cm H2O, morfin 0,1 mg per kg ev; heparin 0,9 mg per kg ev; aspirin 300 mg ev, furosemide 20 mg ev, pantoprazol 20 mg ev Dopamine 5 mcg/kg/min, alert catlab and on calling cardiologist about arriving patient in cardiogenic shock. in CatLab insert the IABP and stenting in follow up.

  • Alexander says:

    The use of NTG is containdicated during cardiogenic shock because can compromise arterial pressure valour and in follow up reduce coronary circulation. Oral intubation must be considered only in cardiac arrest. The application of adhesive plaque for monitoring and possible defibrillation is imperative.

  • kevin says:

    Treatment should focus on correcting wide QRS.

  • Jason askelin says:

    STEMI. Direct to cath

  • Khalid Wikerson says:

    Patient is in Atrial Fibrillation widespread ST segment depressions means the whole heart has ischemia along with JVD and has thrown a clot.
    Rales with no wheezing or rhonchi means fluid is not in lungs but pooling trying to supply lungs.

    Dx = NonSTEMI RBBB and early stages of congestive heart failure with possible pulmonary embolism (pedal and sacral edema has not occurred yet or hard to tell patient seems to be overweight because of diabetes type II and relatively young with cardiac Hx).

    Tx = ASA, standby for transcutaneous cardioversion, prep OR, CPAP (no NTG BP too low and will drop at least another 10mmHG)

  • Atrial fib. RBBB. LAFB. STE anterior and high lateral. Proximal LAD occlusion. This ECG is almost always associated with cardiogenic shock and/or v fib arrest. Critical!!

    • Nick says:

      Completely agree with your diagnosis.
      Oxygen, pressor, cath lab alert, & diesel . . . reassess and adapt as necessary to changing pt condition en route.

  • Ismail Muhammad says:

    AF Accelerated idiovetricular rythm.
    Previou anterior mi.
    Serum k level .Serum digoxin level
    Urea creatinin.
    Echo .
    Further management supportive .
    Oxygen nitrates diuretics .

  • Carolina says:

    My next step would be put 2 gr calcium gluconate, with that 12 lead looks like hiperK and Pt is almost running on cardiac arrest. You need to act quickly without wait for the results. Monitoring and take other EKG.

  • Matt S. says:

    I have seen an ECG very similar to this before. A-Fib with a RBBB. But everyone is ignoring the he on the pt. Pt has renal disease, pt is probably in extreme Hyperkalemia and is in desparate need of dialysis and sodium bicarbonate. Treat as you would any stemi but also push fluid and bicard, of course alert the ED and Cath lab just in case.

  • Paul says:

    When will the official diagnosis be listed??

  • Dana says:


  • Mark Dzwonkiewicz FP-C, LI says:

    Outstanding education!

  • Rita says:

    STE = High lateral wall MI (consider Left main with aVR morphology and > 6 leads of ST depression), Hyperkalemia, A-fib with RBBB (BiFasicular block). ASA 324 mg PO if patient can tolerate. C-PAP if respiratory distress continues and BP stabilizes. Drug assisted intubation if BP does not stabilize. IV x 2. Consider Levophed for inotrope (and vasopressor) with less myocardial demand increase (dobutamine hold for hypotension). Heparin bolus 60 u/kg, heparin drip, Cath Lab preferred, thrombolytic capable facility second choice (need to have dialysis available as well).

  • Mike says:

    My initial thought process was hyper K based on the ECG. My first priority would be to jump on the PE and hypotension via dopamine and high flow O2, once the pressure is within limits I would utilize CPAP and begin down the Bicarb, calcium and albuterol route. I believe this to be more renal in nature causing cardiac involvement. We have the capability here to transmit the ECG to the recieving facility so if they feel the need they can activate the cath lab.

  • Chris says:

    This is a very interesting case. The patient is presenting with signs and symptoms of either a pulmonary embolism or renal failure and hyperkalemia. My treatment would include IV with saline bolus up to 20 ml/kg. High flow O2, CO2 monitoring, CPAP is contraindicated due to hypotension below 90 systolic. I would try calcium gluconate, and sodium bicarb due to the widening QRS almost looking like patient may go into ventricular tachycardia. If I was going to give a pressor levophed at 5 mcg/min to start with and titrate to effect. If patient does not stabilize I would consider RSI with ketamine and rocuronium due to patient being hypotensive and the succynalcholine can cause a potassium shift which is contracindicated in patient with renal failure. Our service also carries heparin with a 5000 unit bolus and 1000 unit an hour for infusion to treat AMI or pulmonary embolism.

  • Herbert Gray says:

    Give 02 4L via NC tirate to 15L via NRB obtain SPO2 level above 94%. DO NOT ATTEMPT C-PAP!! B/P IS TOO LOW!! Give 325 mg of ASA po. WITHHOLD NITRO B/P IS TOO LOW. WITHHOLD DIURETICS B/P IS TOO LOW. Consider using a vasopressing agent if fluid challenge poses a problem. Use a narcotic pain reliever under Dr.s orders CAREFULLY, as not to exacerbate difficulty in breathing and further drop in B/P. Continue to monitor HR for changes. Transport to the nearest cardiac care center immediately!!

  • Jessica G. says:

    A-fib with underlying RBBB & LAFB. High lateral STEMI [I & avL] + anterior [v2] with reciprocal STD in inferior leads. Pretty wide for RBBB + PMH kidney disease moves hyper K up the list, though I wouldn’t expect such sudden onset or pain, or pulmonary edema. History of present illness definitely better fits ACS STEMI with acute heart failure.
    I would admin ASA, High flow oxygen via NRBM – I would NOT do CPAP due to the vomiting, and also relatively contraindicated due to hypotension. If pt fatigues to the point of respiratory failure I would nasally intubate and start positive pressure ventilation [realizing that the positive pressure would decrease BP, likely more so than CPAP – though the vomiting would not be an issue]. I would be very uncomfortable “RSI-ing” this unstable hypoxic and hypotensive pt. I would consider Calcium to rule out a potassium issue, but my main treatment plan is to admin a small [250-500 ml max] fluid bolus of NacL in conjunction with a Dopamine drip. Increase as needed. Emergent transport for Cath.

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