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Monday, 19 November 2012

Acute Chest Pain and ST changes - Full Discussion.

#ECGclass Case 16

This 64yr old man presents to his GP, with chest pain.

His pains are sharp, transient, and very localised to a finger point area in the left chest.
The pains have been present for 2-3 months and are positional in nature. (Better when he lies on either side, or sits upright. Worse on lying down on his back).
They are not aggravated by exercise, breathing or coughing.

The pains are never exertional in nature, despite him maintaining a fairly active lifestyle.

Cardiovascular and respiratory examination are normal. He seems well.

You obtain the following ECG:
(Apologies for the poor quality - this is an old one - but don't worry, we're looking for 'patterns' here, not detailed measurements)

Clinically he seems well, and has no pain, at the time of examination. 

What do you do next?
Anything you want to know?

Please Tweet #ECGclass any thoughts you have, or further questions, you may want to know.
Do you want any further information or tests? 

Update 1

When he comes back to your room, having had his ECG with the nurse, he asks you if it looks OK?
He then discloses that although he had't been worried about his chest pain, (he thinks it is 'muscular'), he decided that he ought to get checked, as he had a coronary stent inserted several years ago, for single vessel IHD disease. He has been symptom free since then.

Does this change your interpretation of the ECG?
Is there anything you want to ask?

You note a suggestive ST elevation Pattern in the Inferior leads and in the V2-V6 lateral leads.

What are your thoughts on this?
(Remember to simply describe what you see).

Update 2
Firstly, let's study the inferior leads:   II, III and aVF 
How would you describe the ST elevation in these leads?

(You may find it useful to refer back to The July 16th blog entitled "Different patterns of ST elevation").

Update 3
Now let's study chest Leads : V2-V6 
How would you describe the ST elevation in these leads?
Does it look the same as the Inferior leads?


Leads II,III and aVF
This pattern of ST elevation looks slightly U-shaped, or saddle-back.
It's not the classic convex pattern associated with STEMI's.
If it had been more widespread, and his symptoms had been more classical of Pericarditis, then this would have been a consideration. If ever in any doubt, and you have time to investigate (i.e a well-ish patient with a non-acute presentation, like this man) then a CRP would be helpful. (A normal CRP is rare in pericarditis).
This man's symptoms, however, are long standing, and not classical of pericarditis. Coupled with his very localised saddle-back ST pattern, this makes a diagnosis of pericarditis unlikely.

Chest leads V2-6
There appears to be perhaps 1mm of 'upsloping' ST elevation. This is Typical of HIGH TAKE OFF (otherwise known as Benign Early Repolarisation).

This gentleman (quite appropriately, given his history) was referred to the local RACPC where all investigations, including Exercise ECG and ECHO were normal.

It is likely that the ECG changes seen above, are all 'normal' for him.

It was agreed that his own diagnosis, of musculoskeletal chest pain, was probably correct.

Would your accurate interpretation of this ECG have altered your management plan?

No - probably not! 

In accordance with the 2010 NICE Chest Pain Guidelines (CG95), his chest pains are, by definition,  "Non-Cardiac" in nature, and therefore 'no further investigations are indicated'. 
However, if I'd seen him in my GP role, with that ECG and past history, I'd probably still have referred him for RACPC assessment.  If he'd seemed at all unwell at the time of presentation, I may even have been tempted to admit him. Hard to say without the patient in front of you. 

What is the likelihood that a patient's chest pain, is cardiac in origin?

For people presenting with stable chest pain, suggestive of ischaemia, there is a really useful online CAD (coronary artery disease) risk calculator kindly provided by the West Hertfordshire Hospital Cardiology department:

This tool allows a calculation of the "likelihood" that the patient sitting in front of you, with chest pain, has symptoms arising from coronary arterial disease. This is the basis of the "Dukes score" table seen in the NICE 2010 chest pain guidelines. 
It is used in RACPC's all the time to determine the most appropriate next step in investigation. Equally, it could be used by any clinician wanting to confirm appropriateness for referral. 

N.B. This calculator is for people presenting with ischaemic sounding chest pain, and should not be used for people with non-cardiac chest pain (as defined by NICE). 
Neither should it be confused with the 10 yr CVD Risk Calculators, used for Primary Prevention decisions, in people without symptoms. 

Any questions?
Thank you. :)