Special thanks to Dr. Ludmilla Levin for submitting these EKGs!
EKG handed to you by tech at 1am for a new patient undergoing triage:
Previous EKG you look up in the EMR for the patient on his last visit:
HPI:
- 41 y/o M
- PMHx: HTN, HLD, HFrEF (35% one year ago)
- Meds (but has not taken for 4 months): Amlodipine 5mg, Lisinopril 40mg, Toprol 50mg, Lasix 40mg, Spironolactone 25mg
- Reports feeling vaguely unwell last night so he took all his medications for the first time in 4 months around 7pm
- Around 11pm, watching TV when he developed right sided chest pressure, radiating to his neck a/w nausea and no other associated symptoms. No alleviating or exacerbating symptoms.
- After 30 minutes with no relief, decided to come to the ED at 1am
- Chart review reveals one prior hospitalization last year for similar symptoms and that was when he was diagnosed with HTN, HLD, and CHF – started on medications with outpatient cardiology followup.
- Reports he took the medications for about 2 months but felt well so he has not taken any medications for the past 4 months.
Physical Exam: notable only for BP of 198/137, HR of 77 and obese abdomen but otherwise clear breath sounds and no murmurs/rubs/gallops, or abdominal tenderness.
ED Course:
- Initial BP of 198/137 but repeat BP was 150/90s with no anti-hypertensives given
- Chest pain resolved spontaneously without any medication.
- 1st set of cardiac enzymes came back negative and a second set was sent off
- Given HEART score of 4-5, decision was made to admit to Telemetry to rule out acute coronary syndrome.
About 3 hours later, while in the ED, patient got up to use the bathroom and on the way back:
- appeared pale and diaphoretic
- complaining of chest pain with a “pressure in [his] throat”
- Repeat vitals revealed a BP of 110/70
Repeat EKG:
Given dynamic EKG changes, marked reduction in BP (with no meds) and active chest pain:
- ASA 324mg
- NS 500cc bolus
- Cardiology consulted
EKG done 5 minutes later:
2nd set of cardiac enzymes resulted as negative
Repeat EKG done 1 hour later:
EKG with ST elevations in II, III, aVF with recipricol depressions in I, aVL:
- Brillinta 180mg
- Heparin bolus and drip
- Transferred to a STEMI center for emergent cath
Cardiac Cath: Triple vessel CAD with severe LV dysfunction.
- Sub-total thrombotic occlusion at mid segment of very large RCA, TIMI 1 flow (99% stenosis).
- LAD with severe disease at mid-LAD-large Diag2 bifurcation (Medina 1,1,1) (70% stenosis).
- LCX with severe stenosis at large inferolateral branch of OM1 (80% stenosed).
Case Resolution: Patient underwent successful stenting of mid RCA with two overlapping DES stents and selective intracardiac Nicardipine was given to improve flow. Excellent final angiographic result with TIMI 3 flow.
Teaching Point:
Often times, we will obtain repeat troponins on patients being evaluated for chest pain but may not always repeat the EKG. This patient had 2 negative troponins (his 3rd troponin sent off at presentation to the STEMI center came back as elevated to 5.05) but given his persistent complaints of chest pain, repeat EKGs helped make the diagnosis. Also, a consultant may have recommended a nitro sublingual followed by a nitro drip for aggressive BP control after the second EKG.
- Do not give Nitroglycerin if you suspect an inferior wall MI.
- A consultant is just that: a consult (usually a resident in variable levels of training)- always double check the recommendations with your attending.
- Always obtain repeat EKGs for patients who present with chest pain!