Central chest tightness during a five-a-side football match, settled after twenty minutes

38-year-old man. Central chest tightness during a five-a-side football match, settled after twenty minutes

Kwabena Mensah, warehouse team leader, plays football twice a week. No cardiac history, no diabetes, no family history of sudden death. Takes no regular medication. The paramedics recorded a 12-lead in the changing room, called a STEMI activation and brought him in with the cardiology registrar meeting the ambulance. He is now pain free.

Stage 1 of 2

He is sitting up on the trolley, comfortable and talking in full sentences. The chest tightness came on in the second half, eased once he stopped running and has not returned. There is no radiation, no sweating and no breathlessness. The department repeats the 12-lead on arrival while the cath lab team wait in the corridor.

Tracing 1 of 2 for the quiz “Central chest tightness during a five-a-side football match, settled after twenty minutes”. — 12-lead recorded on arrival in the resuscitation room Open this tracing in the studio

Observations

HR: 52
SpO₂ (%): 98
Respiratory rate: 14
Temperature (°C): 36.7
Systolic BP (mmHg): 128
Diastolic BP (mmHg): 74

How do you read this tracing?

ASinus bradycardia with a type 2 Brugada pattern in the right precordial leads Your answer
BSinus bradycardia with acute inferolateral ST-elevation myocardial infarction Your answer
CSinus bradycardia with acute pericarditis affecting the inferolateral leads Your answer
DSinus bradycardia with high QRS voltage and benign early repolarisation in the inferolateral leads Correct answer Your answer

Which feature of this tracing argues hardest against an acute coronary occlusion?

AThe ventricular rate is 52/min rather than tachycardic Your answer
BThe elevated segments are concave with notching at the J point, and no lead shows reciprocal depression Correct answer Your answer
CThe T waves are tall and upright in the leads carrying the elevation Your answer
DThe QRS complexes are of high amplitude in the left-sided leads Your answer

Stage 2 of 2

Three hours later he remains pain free and has walked to the toilet without symptoms. Records show he attended the same department in 2022 after a work injury, and that visit's 12-lead has been retrieved. Two high-sensitivity troponins are back.

Tracing 2 of 2 for the quiz “Central chest tightness during a five-a-side football match, settled after twenty minutes”. — 12-lead from his attendance in 2022 Open this tracing in the studio

Bloods

Potassium (mmol/L): 4.2
Hs-Troponin T at 0 h (ng/L): 4
Hs-Troponin T at 3 h (ng/L): 5

With both tracings and both troponins in front of you, what do you do?

ATreat as pericarditis with high-dose ibuprofen and colchicine for three months Your answer
BLoad with aspirin and ticagrelor and admit for inpatient angiography within 24 hours Your answer
CStand the STEMI activation down and manage him on the low-risk chest pain pathway Correct answer Your answer
DGive thrombolysis in the department, since the elevation has persisted for over three hours Your answer
ETake him to the cath lab now for primary percutaneous coronary intervention Your answer

Central chest tightness during a five-a-side football match, settled after twenty minutes

The case

On arrival

Observations

Bloods

Diagnosis

Discussion