Sunday, August 17, 2014

Middle Aged Male with Burning Chest Pain -- Assess the Entire Clinical Scenario

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.


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.


  1. Dear doctor there are tall t waves in vi suggesting acute ischemia.qt is short. And I would like to know if the patient is stented for marginal branch why we are getting changes in inferior leads but by marginal branch we should think of lateral mi.could you explain this

    1. Kavya,
      I would not call this a tall T-wave in V1. The OM stent was previous. This one was RCA.
      Steve Smith

  2. hello doctor

    IT's really an interesting case as it shows how amazing can be the clinical way of thinking combining all information to eventually come up with an accurate and life-saving diagnose, my question is on that T waves in V2 V3 wich appear to me symetric , am i just overlooking ?

    thank you doctor and keep "feeding" us with such great cases.

    1. I agree they are suspicious, but in this case it did not correlate with the angiogram. Good perception!!


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