32 yo M with substernal chest pressure

Original case from Brandon Fainstad, MD. Edits by Yilin Zhang, MD.


CASE

32 year old man developed substernal chest pressure and SOB while playing tennis at 1830. The symptoms did not resolve with rest. He took aspirin 182mg and asked his friend to take him to the the ED. About 15min after arriving in the ED his symptoms self resolved. His PMH is notable for hypertension but does not take any medications. He smokes 1 ppd but denies any other substanace use.

On exam, he is afebrile, HR 86, BP 165/82, RR 20, SpO2 96% RA. He is breathing comfortably, CTAB, RRR, no murmurs, skin is warm with good distal pulses, non-elevated JVD.

ECG – 2100
Click for ECG Interpretation


What is the best way to determine if these are benign early re-polarization (J point elevation)?

What is the criteria for STEMI?

When do you want to get another ECG?

Do you want to call cardiology or code STEMI yet?


CASE CONTINUED

ECG – 2120 (20 min after initial ECG)
Click for ECG interpretation


Does this make you more or less worried?  What are your next steps in management? 


CASE CONTINUED

No interventions were done. More than an hour goes by before the subsequent ECG.

ECG – 2245
Click for ECG interpretation

CASE CONTINUED

Finally, a code STEMI was called, received the above listed medications and went to the cath lab with the following angiography.

Based on the ECG what vessel is likely involved and at what level is the occlusion?

Pre-PCI 23:35

Post PCI 23:43


OUTCOME

A 90% occluding lesion was seen in the mid LAD (culprit). Post-PCI with drug-eluting stent, there was 0% residual stenosis across this lesion.  He tolerated the procedure well, remained chest pain free and was discharged the next day on aspirin, atorvastatin, clopidogrel, lisinopril and metoprolol.  At 4 week follow-up he was playing 2hr of tennis without CP or SOB and had quit smoking.