The same occlusion has declared itself as ST elevation

The artery has reperfused and the segments are recovering

The earlier pattern was a false alarm and this is the real event

A second, new occlusion has occurred in a different artery

Central chest pain for forty minutes, still present

2026-09-02

The case

41-year-old man. Central chest pain for forty minutes, still present

Smokes fifteen a day, no other history and no medication. Father died of a heart attack at 46. The paramedic tracing was transmitted and reported as no ST elevation, so he was brought to the emergency department rather than straight to the catheter laboratory.

On arrival

HR: 94
SpO₂ (%): 97
Respiratory rate: 20
Temperature (°C): 36.5
Systolic BP (mmHg): 128
Diastolic BP (mmHg): 78

Stage 1 of 2

Kwabena Mensah is sweating and restless on the trolley, describing a heavy band across his chest that has not eased since it began. Pulses are equal, chest clear, no murmur. The first troponin is pending. This tracing was recorded four minutes after he arrived.

Tracing 1 of 2 for the quiz “Central chest pain for forty minutes, still present”. — Twelve-lead on arrival, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What is on this tracing?

ADeep symmetric T-wave inversion in V2 to V4 Your answer
BConcave ST elevation with J-point notching Your answer
CUpsloping ST depression with tall symmetric T waves across the praecordial leads Correct answer Your answer
DPeaked T waves on a narrow base with a broadening QRS Your answer

What does that commit you to?

AThrombolyse in the department Your answer
BActivate the primary PCI pathway now Correct answer Your answer
CWait for the three-hour troponin before deciding Your answer
DTreat as an NSTEMI, with angiography within 72 hours Your answer

Stage 2 of 2

Twenty-five minutes later he is still in the department and the pain is worse. The tracing is repeated. His first troponin has come back at 34 ng/L.

Tracing 2 of 2 for the quiz “Central chest pain for forty minutes, still present”. — Twelve-lead repeated twenty-five minutes later, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 98
SpO₂ (%): 96
Respiratory rate: 22
Temperature (°C): 36.5
Systolic BP (mmHg): 118
Diastolic BP (mmHg): 72

Bloods

Troponin T (ng/L): 34

What has changed?

AThe same occlusion has declared itself as ST elevation Correct answer Your answer
BThe artery has reperfused and the segments are recovering Your answer
CThe earlier pattern was a false alarm and this is the real event Your answer
DA second, new occlusion has occurred in a different artery Your answer

Diagnosis

Acute proximal LAD occlusion with a de Winter pattern

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<iframe src="https://www.squiggler.io/blog/central-chest-pain-for-forty-minutes-still-present/embed" title="Central chest pain for forty minutes, still present — ECG case from Squiggler" width="100%" height="900" style="border:0" loading="lazy"></iframe>

This tracing was generated, not recorded. It opens in the studio with every dial live.

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Discussion

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