Triage: MID CHEST PAIN WITH RT ARM PAIN

History of Present Illness: 63-year-old male with a history of coronary angiogram 4 months prior showing a 50% lesion that was treated medically comes in for 3 days of episodic chest pain with a total of 3 episodes. The first 2 were exertional lasting about 5 minutes each relieved by rest.  The third episode was more severe and lasted about 10 minutes and was not exertional. Currently he is pain-free. The pain is associate with mild shortness of breath and radiates to the right arm but not the back.  He has no other complaints.

Vital Signs: T: 36.6 °C (Tympanic) HR: 72 (Monitored) HR: 72 (Peripheral) RR: 15 BP: 120/83 SpO2: 98%

Physical Exam: Lungs clear, heart regularly irregular, distal pulses symmetric x 4

An ECG is done

Computer Read: SINUS RHYTHM WITH FREQUENT VENTRICULAR PREMATURE COMPLEXES
MARKED T-WAVE ABNORMALITY, CONSIDER ANTERO-LATERAL ISCHEMIA

What is the most likely cause of the ECG findings in this patient?

  • A) Gastritis
  • B) GERD
  • C) Cardiac: ACS
  • D) Gallstones
  • E) Electrolyte abnormality

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My ECG Analysis: Wellen’s Type A up-down biphasic T-waves c/w reperfused OMI

QUIZ ANSWER: What is the most likely cause of the ECG findings in this patient?

  • A) Gastritis
  • B) GERD
  • C) Cardiac: ACS – CORRECT, ECG shows Wellens warning
  • D) Gallstones
  • E) Electrolyte abnormality

1-Minute Consult on this topic: Click HERE and scroll to proper page

 

Case Outcome: Cardiology consulted after history and EKG obtained. Patient also ordered to have IV heparin. Chest x-ray came back normal as is CBC and metabolic panel but initial troponin elevated at 1,700 and eventually >5,000. Case discussed with hospitalist and patient was admitted for NSTEMI with Wellens warning.  Had cath next day showing 90% LAD stenosis and 90% second diagonal stenosis, both of which were stented.

Lessons:

  1. Radiation to the Right Arm: this is more specific for cardiac pain that is radiation to the left arm.  To both arms is the most specific.
  2. Wellens Warning: this EKG finding of anterior biphasic T-waves once pain free is often due to tight proximal LAD stenosis and is at high risk of re-occlusion.  These patients should go straight to cath not to stress test first