71 year old male: Chest Discomfort


This very interesting case comes from Bryan F, a Paramedic from Long Island.

A 71 year old male is cooking breakfast when he experiences sudden onset of 10/10 chest discomfort. He waits 20 minutes or so for it to subside, but it does not and he calls 911.

EMS arrives to find him lying in bed, stating the chest “pressure” has subsided somewhat (6/10), but he now feels some discomfort in his left shoulder. He has never experienced this before.

He denies any shortness of breath, diaphoresis, n/v, or numbness/tingling.

His Vitals:

  • HR: 74, slight sinus arrhythmia
  • BP: 178/96
  • RR: 20, regular, lungs clear,  SpO2 97% on RA
  • Skin: Pale and dry

He has taken 324 ASA prior to EMS arrival, and SL NTG and 50 mcg of Fentanyl are additionally given.

Here are two of the 12 lead ECGs:



In the time between ECG #1 and #5 shown above, approximately 30 minutes, there were no obvious changes or evolution. You are about 25 minutes from the hospital.

Would you call a STEMI alert?

Why or why not?





  • Bryon says:


    Clinical picture + Q waves and ST elevation in v1-v2 is AMI until proven otherwise

    • Jeff B says:

      The use of Sgarbosa or modified sgarbosa criteria is not indicated here since there is no LBBB or other STEMI mimic.

  • Katlego says:

    I definately would call a STEMI alert, i highly suspect anterioseptal MI. v1 and 2 def. V3 and 4 using modified sgarbossa criteria.

    Willing to be corrected.

  • Darren Earley says:

    Q waves and 1mm in v1 & 1.5 mm in v2 with history is suggestive of AMI but not cath lab activation criteria; but i doubt anyone will criticise you for activating on this ECG.

  • Rhys says:

    With the clinical picture, pain, pale. I would transport via pre-alert to the nearest ED not Cath lab. Have a bed and Dr waiting get bloods and if they want to go through ppci that’s their choice. My choice at this time given the ECG I have along with the Hx post pain relief is rapid removal to definitive care. As the ppci pathway isn’t open the only option we have is ED.

  • goran says:

    STEMI until proof otherwise

  • John McCarty says:

    Looks like Septal STEMI with Anterior involvement to me… some evidence of a BBB trying to form

  • Tron says:

    Q-S complexes v1-v2 poor lead placement?
    Anterior STEMI…

  • Greg says:

    I would offer that yes, he is having an MI. Albeit early. His HR has slowed significantly, plus his axis has shifted further to the left, indicating to me that his septal region, and possibly the anterior wall (Lead-placement specific) may have some sort of defect/infarct. The incomplete BBB may also be an early sign of Anterior hemiblock.

  • goran says:

    Abnormal QRS in V2.Any ST elevation in abnormal QRS is significant.T wave in V3 is proportionally huge comparing with QRS in V3

  • goran says:

    3-variable LAD formula = 22.057
    4-variable formula = 18.95
    (because of Q in V2 there is no need for formula)

  • goran says:

    Sadleback ST elevation -maybe Brugada tip 2

  • Jim Todd says:

    The peaked T waves and clinical presentation would be enough for me to advise ER of a possible MI although probably not a definite STEMI.

  • Laszlo Farkas says:

    BP or/and SpO2 difference between the two arms ?
    If yes > Urgent cardioecho!
    AAS (Acut Aortic Syndrome)? Dissectio?
    Laszlo Farkas
    paramedic from Hungary

  • Enrique Guadiana says:

    You have 3 options.
    1 this is a Brugada type 2, take a new ECG with V1-2 one intercostal space up. Type 2 could be a normal variant is not diagnostic of Brugada
    2 the patient has qs in V1-2 with ST elevation, lack of R progression V1-3 and T wave positive could be a LV aneurysm.
    3 Ischemic. MI days old pathologic Q waves and no T wave inversion. Is more interesting the inespecific T wave alterations in lateral leads (ischemia?)

    The Heart frecuency is to slow to be in pain, inappropriate chronotropic response?

  • Nasser says:

    well from the above ECG STMI IN V1,V2,V3,V4 which indicate anteriorseptal until proven otherwise

  • Prit says:

    I really think it is showing an early Septal MI as it well indicated in the Early V leads in the 12 leads ECG.
    Therefore ,suggest further cardiac investigation and intervention while maintaining treatment with Analgesia and GTN.

  • TJP says:

    We need 2mm of elevation for leads V1 and V2, we don’t have that. We have 1 mm elevation in V3 and V4 so this is a anterior MI. Make sure to do more 12 leads Enroute. No evidence of BBB……for BBB I use the following criteria: p waves must be present (supraventricular rhythm), QRS must be wide, and then use turn signal method in V1. We do not have wide qrs so no BBB. Scarbossas criteria cannot be used unless we have LBBB (because LBBB is a STEMI mimic). We do have left axis deviation. Bottom line I am not a cardiologist but I have signs of STEMI I would call this in as a STEMI alert. Fly, haul, to cath lab if able to.

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