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5 am chest pain wake up

by on January 28, 2012

EMS received a call to respond to a local urgent care facility to transport a patient to the ER for cardiac issues.  On arrival EMS is met by the attending Dr. who has a 12 lead in his hand.  He tells the crew that he wants the patient to be taken to the ER because he has sub sternal chest pain and EKG changes.  The patient stated the chest pain woke him up this morning around 5 am, it is not 11 am, and nothing makes it better except for when he leans forward.  He denies N/V but stated he did feel mild shortness of breath.  Pain does not radiate but feels sharp with a pain of 6/10.   Family history of heart attacks. He is a non smoker but does drink.  Denies any recent trauma.  Only medical history is HTN for which he takes Lisinopril. 

BP 120/70

HR 80-90

Respiration 18

Pt has been given O2 2lpm NC, 324mg ASA and 1″ NTG paste on anterior chest prior to EMS arrival.

12 Lead EKG obtained

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9 Comments
  1. Tracing looks like a fairly classic pericarditis. The only feature suggesting against it is the ratio of the ST-segment compared to the T-wave in V6, and I don’t believe that’s a strong enough finding to sway my opinion. With zero reciprocal changes (except, as expected in pericarditis, in V1), the chances of this being a STEMI are very low.

  2. Don’t forget some PR-elevation in aVR with some ST-depression there as well. The clinical findings of relief with leaning forward is pretty suggestive as well.

  3. tina a. permalink

    diffuse st elevation pr depression and reciprocal change in v1 with presented hx >>pricarditis
    but I should not forget looking at cardiac enzymes!

  4. I agree that the history and ECG are both suggestive of pericarditis. That being said, I think caution is warranted with these cases, as it can be easy to get too comfortable with pericarditis. I like to get a couple of serial ECGs, to make sure there is no progressive changes.
    Bedside ECHO is also useful here, to look for pericarditis associated effusion,and also to look for specific regional wall motion abnormality that would make me re-think STEMI.
    Some of these pericarditis folks will have myocarditis and troponin leak, so I don’t think a troponin is truly discriminatory either (though it is probably useful).

    • @Aaoron – I definitely agree with you on taking a cautious approach. Hopefully the urgent care doc would have arranged transfer to a PCI facility, because even in such a slam-dunk case he may still end up getting a cath. One myopericarditis patient I’ve seen with a classic history and ECG had a troponin-I of over 18 ng/mL, so he still ended up going for an urgent cath to search for a vascular cause.

    • sara permalink

      agree with aaron..

  5. Anonymous permalink

    Acute pericarditis
    universal ST elevation + ups and downs in pR segment + character of pain

  6. jamil permalink

    in this case we should look for the troponin i and other cardiac enzymes there is a doubt about the ST elevation in the inferior leads ii , iii , avf then might need to take the patient to cathlab

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