Central chest pain for two hours, still present

Left bundle branch block documented three years ago during an outpatient work-up for breathlessness; no ischaemia found at the time. Hypertension on indapamide, type 2 diabetes on metformin and empagliflozin.

Stage 1 of 2

Grace Adeyemi walked into the department and was moved through from the waiting room when the triage tracing was reviewed. The pain is heavy, sits behind the sternum and has not changed in two hours. She is comfortable at rest, chest clear, no murmur. This tracing was recorded twelve minutes after she arrived.

Tracing 1 of 2 for the quiz “Central chest pain for two hours, still present”. — Twelve-lead recorded at triage, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What is on this tracing?

AAcute pericarditis with widespread ST elevation Your answer
BLeft bundle branch block with the discordance the block itself produces Your answer
CLeft ventricular hypertrophy with repolarisation change Your answer
DLeft bundle branch block with concordant ST elevation in the lateral leads Correct answer Your answer

What does that commit you to?

ACT aortogram before any antiplatelet is given Your answer
BActivate the primary PCI pathway now Correct answer Your answer
CTreat as an NSTEMI, with angiography during the admission Your answer
DAttribute the ST changes to the block and admit for observation Your answer

Stage 2 of 2

Her tracing from the outpatient clinic three years ago is retrieved from the record while the catheter laboratory is being called. She was pain free when it was taken.

Tracing 2 of 2 for the quiz “Central chest pain for two hours, still present”. — Twelve-lead from the outpatient clinic three years ago, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 82
Systolic BP (mmHg): 134
Diastolic BP (mmHg): 80

What does the old tracing add?

AThe block is old and the ST elevation is new Correct answer Your answer
BNothing, because a tracing with a block cannot be compared Your answer
CThe block is new, which is itself the indication for reperfusion Your answer
DAn unchanged block makes acute ischaemia unlikely Your answer

Central chest pain for two hours, still present

The case

On arrival

Observations

Diagnosis

Discussion