CASE: the importance of serial clinical assessments and ECGs

• A 63 year old male with a history of hypertension called 911 for chest pain. An hour ago, he started experiencing central chest discomfort and pressure, non-radiating, associated with diaphoresis.

• EMS arrived on scene at 15:35. The patient was still having 5/10 chest pain. Initial assessment showed blood pressure was 110/70 mmHg and HR 60 bpm.

• First ECG was performed at 15:41 (below)

First ECG done

• First ECG shows sinus rhythm with no evidence of ST changes.

• As EMS continued to assess the patient, the patient’s chest pain worsened to 9/10.

• A second ECG was performed at 15:49.

Second ECG done

• The second ECG showed sinus bradycardia with ST elevation in the anterior leads V1-V3 as well as lateral leads I and aVL. Reciprocal ST depression can be seen in the inferior leads (II, III, aVF).

• The ECG was transmitted directly to the Code STEMI doctor who activated the STEMI Team.

• The patient arrived at St. Boniface Hospital cath lab at 16:05.

• The patient’s coronary angiogram demonstrated 100% occlusion of the proximal left anterior descending (LAD) artery. This was treated with 1 drug eluting stent (DES) with a good final result.

Key takeaway: This case demonstrates the importance of serial clinical assessments and ECGs. Within 8 minutes, the patient’s ECG changed drastically from no ischemic changes to a clear anterolateral STEMI. As the paramedics repeated an ECG, this led to Code STEMI activation and prompt treatment for the patient.