EKG Case Study: Is There More to This Chest Pain?

This post was peer reviewed.
Click to learn more.

Author: Ashley Grigsby, DO, PGY-4
Combined Emergency Medicine/Pediatrics
Indiana University

Case
A 32-year-old previously healthy African American male presents via emergency medical services (EMS) for evaluation of chest pain. An ST elevation myocardial infarction (STEMI) code had been activated by EMS based on pre-hospital electrocardiogram (EKG) that had been interpreted as ST elevation in the anterior leads with reciprocal ST depression in the lateral leads. On arrival to the emergency department (ED), the patient appears ill and reports severe crushing chest pain radiating to the arm and down into the abdomen. He is diaphoretic and clutching his chest. His heart rate is 123 beats per minutes, respiratory rate 16 breaths per minute, and blood pressure 210/110 mmHg. He is afebrile. Initial ED EKG is shown below.

Putting the Focus Back on Diagnosis

Image Credit: Pixabay

Author: Leana S. Wen, MD MSc
AAME/RSA 2010 Resident Editor
Originally Published: Common Sense September/October 2010

Last week, Jerry got the scare of his life. Jerry is a 48-year old mechanic who is in good health. His parents are healthy, and he recently got a “clean bill of health” during his annual check-up. Over the weekend, he helped his brother move across town. Monday morning, he woke with tightness in his chest. He described it as a “spasm” and thought that he might have pulled something while he was lifting the sleeper sofa. But someone in his neighborhood had a heart attack recently, and Jerry’s wife persuaded him to go to the ED to get it checked out.

Sex-Specific Differences of Myocardial Infarction Presentation in the ED

Image Credit: Pixabay

Author: Jake Toy, MS3
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee '16-'17

This post was peer reviewed.
Click to learn more.

Heart disease is the leading cause of morbidity and mortality among women in the United States and accounts for approximately 1 in 4 deaths among women­.[1] Unfortunately, society fails to recognize this burden, often labeling heart disease as a “male problem”. In the past decade, only 54% of women recognized heart disease as a number 1 cause of mortality.[2] Exacerbating this issue further, the “classic” symptoms of myocardial infarction (MI) were historically based off studies analyzing MI in men.[3] Additionally, women often experience greater delays in care during an MI and have higher associated mortality rates when compared to men.[4, 5]

A significant body of literature exists describing sex-specific differences in MI presentation and outcomes. In the emergency department (ED), awareness of these variances in MI presentation is crucial toward providing timely and effective care to women presenting with an acute MI.

Typical vs. Atypical Chest Pain

The textbook symptoms of “typical” chest pain are well-defined – (1) precordial chest discomfort, pain, heaviness, or fullness, possibly radiating to the arm, shoulder, back, neck, jaw, or epigastrium; (2) symptoms worsened by stress or activity; (3) symptoms relieved by rest or medications, such as nitroglycerin; (4) associated symptoms that include shortness of breath, diaphoresis, weakness, nausea, vomiting, or lightheadedness.[3]

In comparison, “atypical” chest pain does not present in the aforementioned classic pattern. Signs may include: burning, sharp, pleuritic, or positional chest pain or discomfort; chest pain that is localized by one finger and reproducible; pain only in the arm, shoulder, back, neck, jaw, or epigastrium, or pain concentrated in regions of the body other than the chest, arm, shoulder, back, neck, jaw, or epigastrium.[3]

Acute Aortic Syndrome

Source: Flickr

Author: Nathan Haas, MD PGY-1
University of Michigan
Originally Published: Modern Resident February-March 2015

The acute onset of severe, ripping chest pain radiating to the back quickly brings to mind the diagnosis of aortic dissection. However, dissection is just one potential etiology of Acute Aortic Syndrome (AAS) which includes the acute presentation of aortic dissection, penetrating atherosclerotic ulcer, intramural hematoma, aneurismal leak and traumatic transection. Overlap frequently exists between these processes, and the various etiologies within AAS in some ways represent more of a spectrum of disease than distinct entities.

Aortic dissection results from an intimal tear penetrating the aortic media, with progressive dissection of the media creating a false lumen. Contrarily, a penetrating atherosclerotic ulcer occurs at the site of a preexisting atherosclerotic plaque and is the result of intimal erosion through to the media. Intramural hematoma is defined as a blood collection in the media without the presence of an intimal flap and physiologically is driven by the rupture of vasa vasorum. Aneurismal leaks are related to the acute expansion of a preexisting aortic aneurism. Traumatic transection most frequently occurs secondary to a rapid deceleration injury and classically occurs immediately distal to the left subclavian artery at the ligamentum arteriosum.

Resident Journal Review: Low Risk Chest Pain

Originally Published: Common Sense, Winter 2011

Original Authors: Susan Cheng, MD MPH; Jonathan Yeo, MD; Eli Brown, MD; Allison Regan, MD

Edited by Michael C. Bond, MD FAAEM; and Alena Lira, MD

This Resident Journal Review focuses on a common problem faced in the adult emergency department (ED) – the “low risk” chest pain patient. How do you efficiently evaluate chest pain and plan a safe disposition? What are the latest guidelines, methods of risk stratification, diagnostic aids and strategies for laboratory testing and imaging? Finally, what are the criteria for further cardiac testing?