History of Present Illness: A man in his late 60’s with a history of recent pneumonia is brought to the ED for 1.5 hours of non-radiating chest pressure, SOB and nausea.  He denies any other complaints.

Vital Signs & Physical Exam: Vital signs are normal except for bradycardia in the mid 50s.  Physical exam is otherwise normal except that the patient is holding both sides of his chest with both hands (double modified Levine sign).  Also defibrillation stickers medics have on are way too low

Initial Diagnostic Testing:

  • EKG: see below.  First ECG is from the field.  Second ECG is from the ED.  You fax both to the cardiologist who replies with “Not a STEMI”

Computer Read: sinus brady at 47, RBBB, LAFB

What is the best plan?

  • A) Get serial troponins and admit for chest pain
  • B) Call cardiologist back after troponin results
  • C) CT to rule out dissection or PE
  • D) Get serial EKG’s and call cardiologist back

SCROLL DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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My ECG interpretation:

  1. Hyperacute T waves inferiorly with T wave inversion in aVL = inferior OMI.
  2. ST depression V2-V4 = possible posterior OMI though could be from the RBBB
  3. Borderline low voltages, esp in limb leads (makes computer more likely to miss ST elevation

ANSWERS:

  • A) Get serial troponins and admit for chest pain – no, this is a clear cut OMI and troponin can stay negative for hours
  • B) Call cardiologist back after troponin results – no, this is a clear cut OMI and troponin can stay negative for hours
  • C) CT to rule out dissection or PE – no, this is a clear cut OMI and troponin can stay negative for hours
  • D) Get serial EKG’s and call cardiologist back – CORRECT, and do it within 15 minutes

 

1-Minute Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

CASE CONCLUSION: Troponin undetectable at 2h from onset.  Cardiologist not impressed with ECG and did not want to take to cath but after being pushed to see the patient relented.  Cath showed 100% RCA lesion that was stented.  Troponin at 6h after onset 2,500 and at 18h >5,000

CASE LESSONS:

  1. Don’t trust the cardiologist read.  You should be better at reading most types of ECG’s
  2. Follow Dr. Smith’s ECG blog