Interesting Cases No. 2 (July 2010)
Rural Viginia: The patient is a Hispanic male in his mid-50's who was awakened by at 4am by sharp stabbing chest pain. This continued without relief so he called EMS. Upon EMS arrival he was pain free but did agree to transport to the hospital. Pre-hospital ECG was reportedly normal. On arrival at the ED, the patient complained of epigastric burning; a repeat ECG was completed.
*Click any of the images on this page to enlarge.
ED Arrival @ 6AM
Prior ECG: May 16, 2010
The patient was given a 325 milligram ASA, supplemental oxygen and pain control. An old ECG was available for comparison on site as the patient had been seen previously for chest pain and "heartburn" several times.
ECG Just Prior to Hospital Admission
Symptoms improved with GI cocktail and observation; initial troponins x2 were negative. Patient seen by the Cardiology service and it was decided to admit the patient for additional testing based on his recurrent symptoms. At 1400 the patient was being transferred from his ED bed to his hospital bed when he began to experience severe "heartburn.' He told the patient transport tech who promptly summoned the ED physician and repeated the ECG.
Coronary Tree
Minutes later the patient became diaphoretic and hypotensive. By this time a STEMI ALERT had been called; the patient was prepped for the cath lab and given appropriate medications, including heparin. Cardiac catheterization revealed the following lesions and a stent was placed.
ECG 10 Hours Post-Cath
Post procedure the patient did well with an improving ECG and no additional pain.
The patient was discharged the next day with instructions to stop smoking and to lose weight. Follow-up one month later revealed that his episodes of sharp chest pain and frequent heartburn had largely resolved.
Lesson(s) Learned
"Atypical" chest pain can still be cardiac in origin…and never underestimate the value of a repeat ECG!
Referred from Central Virginia.