Middle Aged Male with Burning Chest Pain -- Assess the Entire Clinical Scenario
Posted Aug 17 2014 2:49pm
A middle-aged male presented with “burning” mid chest pain, with radiation to bilateral shoulders ( pain radiating to both shoulder is very specific for ischemia ). It started about 5 hours prior to arrival. He obtained little relief from nitro x 3 by EMS. There was a history of previous MI, with a stent in the 1st Obtuse Marginal. He had taken his Plavix for 6 months, then discontinued and also stopped taking his antihypertensives and statin. He continued to smoke about 1.5 pks per day.
Here is his ECG:
Junctional Bradycardia (this is sinus arrest with junctional escape, and is highly suggestive of ischemia). There is a pathologic Q-wave in lead III (old? new?). There is slight ST depression in leads I, II, and V3-V6 (fairly specific for ischemia). Down-Up T-wave in aVL: very specific for ischemia! There are slightly hyperacute T-waves in inferior leads (probable ischemia).
These are subtle findings. No single finding is diagnostic of ischemia but he has a very specific combination of factors: 1. typical pain 2. h/o coronary disease 3. pain radiating to both shoulders 4. junctional bradycardia 5. Q-waves 6. ST depression 7. Down-Up T-wave in aVL 7. Possible hyperacute T-waves All of these together, but none of them by themselves, diagnose acute MI.
One of my former residents diagnosed this as inferior MI and activated the cath lab. I love it when my residents become better than I at reading ECGs!
There was a 100% acute occlusion of the RCA, with ischemia of the SA node causing sinus arrest.
Lesson 1. When highly suggestive ECG signs of ischemia combine with a high pretest probability and refractory ischemic pain, activate the cath lab even if the ECG does not meet STEMI criteria.