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Chest Pain after a Nap

“BRADY” DOWN FOR THE REST

History: A 90-ish–year-old female with a history of pacer for heart block but no CAD presents to the ED for 45 minutes of non-radiating, non-pleuritic chest pain that woke her from an afternoon nap.  She denies syncope, palpitations, SOB, fever, cough or other complaints.  Nitro by medics helped slightly if at all.

Exam: Vital signs are normal.   Exam is otherwise normal.

Initial differential diagnosis: GERD, Acute Coronary Syndrome, gallstones

Initial EKG:

COMPUTER EKG READ:

  1. Electronic AV pacemaker
  2. Abnormal rhythm ECG

Do you agree with the computer?  What should you do next?

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS: 

1) EKG analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): The computer read is incomplete.  This patient is having a STEMI by all of the Smith-modified Sgarbossa criteria.  There is concordant ST elevation >1mm in multiple leads: I, aVL, V2.  There is also concordant ST depression >1mm in leads III and aVF and perhaps lead II.  Finally, there is discordant ST elevation >25% of the QRS height in leads V5 and V6 and perhaps also V4.

2) Case Conclusion:  The cardiologist declined to take the patient to the cath lab based on age and could not come to the ED to see the patient.  He did call a second cardiologist to see the patient.  He did a bedside echo and recommended heparin but no TPA.   Tropoinin-i was <0.01 about 1 hour after pain onset (99% URL <0.030: troponin-i immunoassay, Abbott laboratories).  The 2nd troponin drawn 2 hours after onset was 0.07 and 5 hours after onset it was 2.1.  The peak troponin was >77.0.

3) 1-Minute Consult (from the Emergency Medicine 1-Minute Consult Pocketbookon the topic for this case:

4) Case Lessons: 

  1. Know the criteria identifying STEMI in LBBB and in RBBB.  For most pacers there will be a LBBB like pattern.  This one has more of a RBBB pattern however.
  2. Either the traditional Sgarbossa or the Smith-modified Sgarbossa may be used.  The Smith modification is rather than using 5mm of appropriate discordance as a cut-off for criteria 3, >25 % height of the QRS is instead used.
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