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RetNavyPAC

Would you have called this a STEMI?

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Case review for the forum.  Good learning/teaching case 

 

Saw this guy Friday afternoon.  (HPI below cut-n-pasted from my Epic ASAP note)

 

51 yo M c/o of low blood pressure, slow heart rate, lightheadedness.  Two evenings ago he noted onset of chest pressure - "like someone sitting on my chest" with radiation to L shoulder.  He attributed this to "bursitis when it gets cold"

The pain/pressure lasted ~ 3 hrs and was NOT associated with any diaphoresis, SOB, lightheadedness, nausea or vomiting.  Took a couple aspirin and went to bed.

The next morning (yesterday) after he awoke and took his morning meds he noted some lightheadedness with slow heart rate ("in the 40s") and low BP (has home BP monitor and noted SBPs in 80s)

This has persisted and although he has not had any frank syncopal episodes he states "I feel like I could pass out sometimes but I lay down and put my feet up"

He currently has NO chest pain or pressure, and no shortness of breath - just occ lightheadedness

Checked BG this morning @ 190

No recent illness.  No recent drug additions or dosage changes

 

Interestingly he states that "something like this occurred a couple years ago and Dr [cardiologist] did a Holter on me for a month and then a tilt table and said he couldn't find anything. Told me maybe someday I'd need a pacemaker but not right now."

PMHx: HTN, DM - w/poor control & neuropathy, dyslipidemia, hypothyroid, obesity, OSA, gout, bilat knee DJD, Vit D deficiency

 

Exam pertinent Neg & Pos:

AOx3, WDWN. No distress (resting comfortably on gurney - good color)

Triage VS: 126/73, P56, R20, nl temp and sats 96%
Cardiovascular: RRR bradycardia (P44 on exam)  S1/S2 normal wo murmur.  2+ bilat radial/DP, no JVD  
Pulmonary/Chest: Effort & BS normal. No respiratory distress

Abdomen: soft, NTND + BS
Musculoskeletal: Normal AROM.
Skin: mild 1+ pitting edema BLE
Neurological: AOx4, CNs grossly intact, nl gait

 

Labs ordered & pending:

CBC, BMP, Troponin
 

Imaging:

CXR AP was unremarkable

 

So I'm wondering - as I'm sure you are - with this HPI, PMHx and exam findings, whether he had ACS (inferior/posterior MI?) two nights ago with involvement of the conduction system.  He is not on a β-blocker (just nifedipine for his HTN).  Obviously this guys getting admitted - and will likely get a permanent pacemaker.

In the meantime I slapped him on the monitor, put pacer pads on him and had the crash cart outside the room, and while I'm doing the evaluation the nurse does the 12-lead and you can see the two attached files

 

Something had probably gone on (2 nights previously) and something is probably going on now. Brady @ 39 and Ps marching out (CHB). Large "humpy" Ts in II, III & aVF, but with 0.5mm ST elevation (if that), and some impressive flipped Ts in I and aVL (especially in aVL)

 

Attending (18 yr EP) & I looked at it and were impressed, but unimpressed it was a STEMI (yet)

 

Called Cards and reviewed everything and he agreed to admit (labs still pending) and asked if I'd fax the EKG.  "No problemo."

 

2 min after I faxed it he called - "This gentleman is having a STEMI right now so fyou should fly him up to [Mothership Memorial] for PCI right away!"  We (attending and I) gave each other a quizzical look, while we looked at the EKG again, but - not wont to argue with the cardiologist on call

 

Got him heparinized, Lipitor'ed, Plavix'ed and aspirin'ed and had the helo launched.

 

BMP comes back with his 405 glucose and Cr of 2.34 (AKI I figure from decr renal perfusion form the decr CO), and troponin of 11.

 

Got up to the cath lab and they found - "Subacute thrombotic occlusion (late presentation) of distal RCA/PDA and PLB. S/P successful PCI with DES (Xience 4.0x32 mm) in distal RCA and DES (Xience 2.5 x23 mm) in rPDA. Unsuccessful revascularization of the rPLB. Moderate disease in mid LAD"

 

He's doing well so far, but I have to wonder - did I/we undercall the STEMI?

post-77774-0-02979000-1421023452_thumb.jpg

post-77774-0-59112100-1421023623_thumb.jpg

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These cases are all clear in retrospect.

I have had cases where I overcalled STEMI and got shot down prior to pt getting to cath lab, also had pts get cathed that turned out to have nl coronaries but had ST elevation and a good story. And then there were all the correct ones with gunked up coronaries who needed to get roto rooted fast.

I think you did the right thing. No one is perfect with EKG interpretation and I have seen multiple interpretations on the same EKG, some that drove treatment, some that created obstacles to treatment. 

What truly postponed this pts treatment was their own delay in seeking treatment from onset of significant symptoms. Making his EKG intepretation a group effort is helpful. You were doing all the correct things cause you also had a potentially unstable pt there with that bradycardia. 

Within the last year I had a similar pt brought in by family, actually lived closer to the medical center than our little place. Bradycardic, hypotensive, inferior ST elevations similar to what you have here just more pronounced and therefore more obvious. Dumped a bunch of saline in her, ASA, plavix, heparin, started dopamine on her at the recommendation of the interventional cardiologist. Told her family it didnt look good, thought she may die enroute, offered them TNK but they wanted to go to the medical ctr and get cathed. She lived. So didnt this guy. Chalk up one in the win column.

G Brothers PA-C

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EKG looks suspicious for inferior stemi besides the bradycardia.

confounding factor is renal issue which may artifically raise troponin.

agree with George. you did the right stuff and he ended up in the right place.

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I agree EKG looks suspicous for inferior STEMI with reciprocal changes in the lateral leads. Trop of 11 even with a calculated GFR is pretty high to be artificially bumped by a Cr 2.34 in a 270 lb male. I would also recommend that when assessing the isoelectric line you do it from the start of the J pt or ST segment moving towards the next complex. Had you done that, you can see the elevation. Going from the PR can get you in trouble for a multitude of reasons. RCA correlates with the EKG. These cases keep us sober, great job. 

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"I would also recommend that when assessing the isoelectric line you do it from the start of the J pt or ST segment moving towards the next complex."

 

^this, and look at AVF... And trop of 11 in AKI (acute being the word here) is the real deal, not 2/2 reduced clearance or structural disease. Great case, good save!

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Agree with above- everything looks better in retrospect, but ultimately you saved the patient.

 

I had a kinda similar case yesterday- 76 y/o male brought by EMS for "low blood pressure from church"- EMS reported he was having dyspnea and lightheadedness but was talking when they picked him up- BP 80/40's, which after 500 cc NS still was at 80/40.  When he arrived to us, EMS reported that within 10 minutes he was starting to be nonverbal and just "gagging".  No EKG done by EMS.  Tachy to 120's but appeared sinus on the monitor, BP for us stable at 139/70's  He wasn't responding to my commands but his eyes were clearly open and he clearly was in distress- thought maybe he was initially having an acute CVA.  Attending comes in, and feels he is having a GI bleed as the guy is more awake and talking now- does a rectal which he thought had some blood, but turns out to be guaiac neg.  During this, nurse notices what appeared to be ST elevation on the monitor- I go get EKG machine since it hadn't been retrieved yet, put stickers on and out comes read of "inferior STEMI"- has some reciprocal change in lateral leads, but doesn't look that much more impressive than the EKG in the original post.  Attending activates cath lab, and pt was again doing those "gagging" episodes - his pulse would drop to 70's with multiple PVCs during those episodes, and when he would become more awake rate would increase > 100.  Then he had a run of V-tach for about 6 beats- we start amio.  Interventionalist arrives, then BP starts to drop.  Decision made to intubate- I intubate him, heparin/ASA started and he was bagged on the way up to the cath lab.  I didn't get cath report, but nurses told me he actually ended up on ECMO in the ICU.  Oh, and he had a 100% LAD lesion that was stented just 4 months prior.  He was clearly circling the drain in front of us, but his confusing presentation tripped us up at the beginning of the evaluation, which also didn't help with EMS not even having done an EKG in pre-hospital setting but was able to start an IV and give enough fluid to check for therapeutic response.

 

Point of all this is, for inferior STEMI's or at least non-anterior/septal wall STEMIs, they really do have atypical presentations which may or may  not have chest pain- but low BP, dyspnea, weakness and/or altered mental status can be taken as "anginal equivalents" for a reason.

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Dr. Amal Mattu has a great lecture on a finding called the "check mark sign" found in early STEMI. Your EKG looks like it has this sign. May be worth checking out. The lecture is about differentiating STEMI from pericarditis, but nevertheless has some good info about detecting early STEMI. Hope this helps

 

http://ekgumem.tumblr.com/search/Stemi+

Episode 162 on October 6, 2014

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Greeting from the outlying hospital formerly associated with [Mothership Memorial].

 

Good story for ACS. One of the things that would have made me sweat a little more is the TWI in avL. Iffy ST elevation inferiorly by itself probably would not have made me call a STEMI, although that is a pretty flat ST segment, but the avL reciprocal changes likely would have sealed the deal.

 

http://ekgumem.tumblr.com/post/17948735839/killer-t-wave-inversions-in-avl-episode

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Concur - inferior wall MI with reciprical changes in lateral leads.  Would have treated as STEMI upon presentation.

 

Hindsight is 20/2o though...

 

G

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