EKG case: Recognizing acute coronary syndromes in asymptomatic patients

What's your assessment and care for two patients who had chest pain, but are now symptom free?


This EKG Club case features two scenarios with seemingly different EKG presentations, but in actuality, both predict significant risk to the patients’ myocardium.

Scenario 1: Chest pain during an office meeting

It has been a quiet morning. You had an uneventful transfer of keys from the off-going shift crew. You check your ambulance and find that supplies are fully stocked. In fact, the previous shift left you a clean truck for a change. You make a mental note to try and return the favor in the morning when your shift ends. All of your required duties are complete and you are just about to enjoy a little downtime with your favorite section of the newspaper when the tones go off. 
 
You and your partner are dispatched to a downtown business office. Upon arrival, you are guided to a fifth-floor conference room. You notice there are numerous cups of coffee on the conference room table and also several plates of doughnuts and pastries. As you approach, you overhear a man who is loudly telling a co-worker, "I told you I was fine, Why did you call them for?"
 
Your patient is a 45-year-old male who reportedly developed retro-sternal chest pain and diaphoresis during the course of the business meeting. You are told that the meeting had become rather heated and was stopped when the others noticed the man turning beet red and sweating profusely. His co-workers became concerned and called 911. Witnesses indicate that by the time you arrived – four minutes from call to arrival, the patient had told his staff he was fine and did not need an ambulance. 

Patient presentation: Several days of retro-sternal chest discomfort

Your patient seems frustrated and reluctant to talk at first, but you quickly gain his confidence and are able to proceed with your exam. He tells you that for several days he has been noticing retro-sternal chest discomfort – not pain – that seems to be brought on by exercise or stress. However, he also noticed a few episodes without those preceding factors.

He says he sweats during the discomfort but has no other associated symptoms such as nausea, vomiting or shortness of breath. He has no other known past history. He says his father died at age 52 from heart problems and he has no siblings. He takes no medications and denies any drug allergies. He insists that he feels fine now and really cannot take the time to leave work and go to the ER to “lie around for several hours.” 

Primary assessment: 

The patient is awake and alert and appears emotionally upset. His skin is pink, warm and dry. His respirations are quiet and unlabored and his lungs are clear and equal. Heart sounds are regular and without murmur. His abdomen is soft and non-tender with no pulsatile masses. Radial pulses are equal in quality and intensity.

Patient's vital signs: 

Heart Rate: 64 bpm
Respirations: 16 rpm
Blood Pressure: 148/84 mm Hg 
SpO2: 99 percent room air 
Pain: 0/10

Past medical history: 

None
 
Allergies:

No known drug allergies 

Meds:

None

Initial EKG (click for larger image):

You are able to convince him to let you do a 12-lead EKG.

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Above is the EKG that you are given. There is no computed interpretation so apply a standardized process to interpret this 12-lead EKG

Consider these questions about the patient's condition and best course of treatment. 

  • Is there anything about the patient or the EKG that concerns you?
  •  Do you allow the patient to easily sign refusal or do you spend time trying to convince him to go the ER?
  •  Do you transport to the closest facility (five minutes away, no cardiac cath) or do you go directly to a cath facility (20 minutes away)?
  •  Is there any therapy you would like to start in the field?

Patient treatment: Reluctant agreement

The patient reluctantly agrees to go to the ER with you. He allows for "one IV stick," which you perform flawlessly without a whimper from the patient. Labs are drawn and you check his blood sugar. It is 250mg/dL (13.8mmol/l).

Your patient states, "Must have been the doughnuts." 

He reluctantly agrees to chew and swallow four baby aspirin. However, he continues to deny pain or discomfort and tells you repeatedly on the way to the hospital that this is a waste of time for everyone involved.

You smile and tell him, "This is what I get paid to do, drag people kicking and screaming to the hospital so that I can lose even more friends in the ER."
 
You arrive uneventfully to the ER and report to the nurses and physician. Just as you are getting ready to sit down to start your paperwork, the tones go off again. As you are leaving, you notice the ER physician is making some excited gestures while looking at the EKG you gave him and you hear him tell the ER unit secretary to page cardiology "STAT." You wonder what he saw in the 12-lead EKG and make the second mental note of the day to do a close follow-up with this patient later. 

Scenario 2: Chest pain while gardening

You are dispatched for a woman complaining of chest pain. “It is going to be another chest pain day,” you think. Fortunately the prior crew left you a fully stocked truck to work with, so you already know you have plenty of IV kits, angios and EKG patches to care for a nursing home full of chest pain complaints if you had to. 

On your arrival to the scene, you find a pleasant but frightened-looking 55-year-old female sitting on the front steps of her suburban residence. She is attended by her husband. 

The patient is awake and alert and is able to tell you her history. She states that she was doing some gardening and was helping her husband lift some heavy bags of mulch due to his heart problems that prevent him being over exerted. She states that she began feeling some chest pain and broke out into a sweat, despite it being 65 degrees that morning, after lifting just the third 50 pounds bag.

She says these symptoms were completely new for her. She tells you that she sat down on the steps and told her husband about the pain and he promptly called 911 and also gave her one of his NTG tabs sublingually. The patient also took a 325 mg aspirin prior to your arrival.

Patient presentation: Pain free now, but scared

She promptly had resolution of her chest pain and remains pain free. In fact, she tells you she feels almost normal, but that she is frightened. 

Primary assessment:

The patient is awake and alert and slightly anxious and tearful. Her skin is tanned, cool and barely moist. There is no chest wall tenderness or respiratory distress. Her breath sounds clear and equal. Heart sounds are regular without murmur. Her abdomen is soft and completely non-tender. There is no guarding or pulsatile mass on the abdominal exam. There is also no lower extremity edema or pain. Radial pulses are equal in quality and intensity.

Patient's vital signs: 

Heart Rate: 72 bpm
Respirations: 18 rpm 
Blood Pressure: 132/60 mm Hg 
SpO2: 96 percent room air
Pain: 0/10

Past medical history:

Hypertension 
Diabetes Mellitus Type 2 
Dyslipidemia 
Hysterectomy 

Allergies: 

No known allergies 

Meds:

Hydrochlorothiazide 
Capoten (captopril) 
Avandia (rosigltizazone) 
Aspirin 

Initial EKG (click for a larger image):

#########


Above is the EKG that you are given. There is no computed interpretation so apply a standardized interpretation process.

Consider these questions about the patient's condition and best course of treatment. 

  • Is there anything about the patient or the EKG that concerns you? 
  •  Do you transport to the closest facility (five minutes away, no cardiac cath) or do you go directly to a cath facility (20 minutes away)?
  •  Is there any therapy you would like to start in the field? 

Patient treatment: Eager acceptance

The patient eagerly agrees to be transported to the hospital. An IV saline lock is established and blood is drawn. Blood sugar is 180mg/dL. 

From your history assessment, you had determined that she has already taken an aspirin; you warily double check to make sure it was not ibuprofen or acetaminophen. It was indeed a full strength aspirin. 

You continue to monitor her vital signs throughout your transport and she remains pain free, with warm and dry skin, and shows no respiratory distress. No arrhythmias are noted and a repeat EKG is similar to the first. 

Again, you arrive uneventfully to the same hospital where you had delivered your last patient, who had also experienced temporary chest pain, but soon felt better. You transfer care and report to the same staff and ER physician. You look over to room five, where your last patient was placed, and notice that the bed is empty and the room is being cleaned by housekeeping personnel. You ask the staff where the last patient went and you are told that he was taken straight up to the cath lab, but they have not been given an update yet. You track down the ER physician to pick his brain. 

Are these cases similar?

The EKG Club experts created this case for these learning objectives: 

  • Basic: To recognize signs and symptoms of acute coronary syndrome(ACS), even in the asymptomatic patient, and to encourage delivery of all ACS patients to a cath lab facility.
  • Intermediate: To recognize and appropriately treat suspicious clinical presentations.
  • Advanced: To recognize the ECG patterns associated with Wellens' syndrome and to understand the close association with a proximal left anterior descending coronary artery lesion/stenosis and need for urgent coronary angiography.

Review the case findings as you answer these questions:

  • What seems similar about these two cases?
  • Are there any clues from the EKGs that suggest significant myocardium at risk?
  •  What is the likely "culprit vessel" if indeed there is one?

Patient follow-up: How to recognize Wellens' Syndrome

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