Wednesday, June 21, 2023

A man in his 50s with acute chest pain who is lucky to still be alive.

 Sent by Magnus Nossen MD, written by Pendell Meyers

A man in his 50s, previously healthy, developed acute chest pain. EMS was called, and they recorded the following ECG on scene at 13:16:

What do you think?

Below is the version standardized by PM Cardio app

Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). There is a relatively normal QRS yet there is STD maximal in V2-V4, which resolves from V4 to V6. The inferior leads may have a slightly full T wave (possibly hyperacute if compared to baseline which is unavailable), but there is no clear TWI in aVL.

What does the Queen of Hearts say?

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This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

In this medical system, the EMS provider can then be routed to the ED or to a type of urgent care facility that is open 24 hrs/day and staffed by a primary care provider. 

In this case, the EMS provider was routed to the urgent care facility. The primary care physician there evaluated this patient and deemed the chest pain to be due to gastrointestinal causes. The ECG was also interpreted as normal by the primary care physician. No troponins were measured! 

The patient was sent home with the diagnosis of "acid reflux".

Two hours later, the patient returned to this same urgent care facility with worsening chest pain, and this ECG was performed:

While getting another ECG, the patient suffered cardiac arrest:

After multiple defibrillations, ROSC was achieved with ongoing "STEMI". 

The patient was given thrombolytics by EMS, then received rescue PCI after transfer to the local PCI center. The LCX was noted to be "subtotally stenosed" at the time of cath. 

Peak high sensitivity troponin T was 2,696 ng/L.  

Smith Comment: Is is common for the artery to be open at angiogram in OMI, including full STEMI.  And of course this is especially true when the patient has received thrombolytics, but is even true with only aspirin and heparin, or no treatment at all.  We can tell in retrospect whether the artery was occluded or not at the time of the ECG by the peak troponin.  Most OMI have a peak Troponin T over 1000 ng/L [reference: Baro R et al.  High-sensitivity cardiac troponin T as a predictor of acute Total occlusion in patients with non-ST-segment elevation acute coronary syndrome.  Clinical Cardiology 2019.]


The patient emerged neurologically intact. The next day echo showed an EF of 51% with inferoposterior hypokinesis.

Long term follow up is unavailable.

Learning Points:

Subtle OMI can be missed by providers without excellent ECG interpretation, and can result in dire consequences.

It is not easy to accurately distinguish GI from cardiac symptoms with history and physical alone, in adults with acute chest pain.

Adults with acute nontraumatic chest pain of unclear etiology should generally be evaluated with troponin in this day and age.

Use of our OMI AI Queen of Hearts may have caused better care for this patient and many like him.

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