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Central chest heaviness with nausea for ninety minutes

The case

47-year-old man. Central chest heaviness with nausea for ninety minutes

Smokes twenty a day. No regular medication and no rate-limiting drugs. Brought in by ambulance; the pain started while he was carrying boxes and has not eased.

On arrival

HR
51
SpO₂ (%)
97
Respiratory rate
16
Temperature (°C)
36.6
Systolic BP (mmHg)
118
Diastolic BP (mmHg)
72

Stage 1 of 1

Gareth Whitlock is grey and sweating but talking in full sentences. The chest is clear, the heart sounds are normal and the abdomen is soft. He has vomited once in the ambulance. This twelve-lead was recorded three minutes after he arrived, with the heaviness still there.

The tracing for the quiz “Central chest heaviness with nausea for ninety minutes”.
Twelve-lead recorded on arrival, 25 mm/s, 10 mm/mV. Open this tracing in the studio
What do these twelve leads show?

The anterior leads V1 to V3 show ST depression with tall, upright T waves. In a patient with acute chest pain, this pattern is the reciprocal view of ST elevation on the posterior wall and should be read as a posterior STEMI rather than as primary anterior subendocardial ischaemia. Pericarditis would produce widespread concave-up ST elevation with PR depression, neither of which is present here.

The ventricular rate is 51. What does the tracing show about the mechanism?

Each QRS complex is preceded by a P wave at a constant PR interval of about 173 ms, confirming one-to-one conduction and therefore sinus bradycardia. The regular PP and RR intervals with no progressive PR lengthening exclude Mobitz I, and the absence of extra P waves between complexes rules out 2:1 block and complete heart block. Sinus bradycardia is common in inferior and posterior infarction owing to heightened vagal tone.

What could be a bedside diagnostic to strengthen the diagnosis?

Posterior leads V7, V8 and V9 placed across the left posterior chest wall will show direct ST elevation when the posterior wall is injured. This confirms what the anterior ST depression implies and is the standard adjunct when posterior STEMI is suspected. A Lewis lead looks for atrial activity in AV conduction disorders and is not relevant here. Moving V1 and V2 up two spaces is used to unmask a Brugada pattern, not to diagnose ischaemia.

Diagnosis

Acute inferior ST-elevation myocardial infarction with sinus bradycardia

Always consider the possibility of a posterior STEMI when there is ST segment depressions in anterior leads. You should be prompted to scrutinize especially inferior leads for subtle ST elevation. Posterior leads could be an adjunct but is not necessary in typical posterior MI ECG:s.

References

  1. Matetzky S, Freimark D, Chouraqui P, et al. Significance of ST segment elevations in posterior chest leads (V7 to V9) in patients with acute inferior myocardial infarction: application for thrombolytic therapy. J Am Coll Cardiol. 1998;31(3):506-511.
  2. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-177.
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This tracing was generated, not recorded. It opens in the studio with every dial live.

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Discussion

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