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?

Not this one Your answer AAcute pericarditis with widespread ST elevation
Not this one Your answer BLeft bundle branch block with the discordance the block itself produces
Not this one Your answer CLeft ventricular hypertrophy with repolarisation change
Correct Your answer DLeft bundle branch block with concordant ST elevation in the lateral leads

What does that commit you to?

Not this one Your answer ACT aortogram before any antiplatelet is given
Correct Your answer BActivate the primary PCI pathway now
Not this one Your answer CTreat as an NSTEMI, with angiography during the admission
Not this one Your answer DAttribute the ST changes to the block and admit for observation

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?

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

Central chest pain for two hours, still present

The case

On arrival

Observations

Diagnosis

Discussion