Palpitations and Chest Tightness: Should You Activate the Cath Lab (or Give Thrombolytics)?

This case was sent by Jessica Carmichael, and Emergency Physician  on active duty at Irwin Army Community Hospital in Fort Riley, Kansas.  She trained at Brooke Army Medical Center.

ECG and Case

I was sent this ECG with some information, but I looked only at the ECG before reading the text:

What do you think?



My response was this:

“I have not read the text of your email yet, but I would say that this is benign normal variant STE.”

(There is also atrial fibrillation without a rapid ventricular response.)

“Now I will read your text:”


Here is the text:

“The following ECG was sent to me by a former resident yesterday and seems timely given your recent post [You Diagnose Pericarditis at your Peril (at the Patient’s Peril!)]. The resident was berated by cardiology for activating the cath lab as he felt it was obviously pericarditis. I was concerned that there wasn’t a truly discernible J or S wave in V3 [note: there is both a J-wave and an S-wave in V3, so there is NOT terminal QRS distortion]. Given that there is no acceptable miss rate for MI, I felt activating the cath lab was absolutely appropriate.”

This was my response:

It is NOT pericarditis.  It is normal variant.
It is reasonable to activate. I would have instead done a contrast echo to prove no wall motion abnormality.

Comment: The very high QRS voltage, the very marked J-waves in many leads, and the short QT interval make this very unlikely to be LAD occlusion.  But it does meet STEMI “criteria” in multiple leads.

Here is the full history:

“Basics: 28 yo AA male who had a history of WPW who had sudden onset of heart palpitations and chest tightness 5/10 at rest. Had had ablation in 2016. No issues since. Presented with no other associated ROS, save for lightheadedness. Denies drug use, UDS neg. No family history.  Physically fit. Systolic BP 112. Sats normal.  Takes daily beta blocker. Denied recent illness, exertional chest pain or fever. No PE risk factors.” 

“Found to be in new afib with multiple concerning EKGs.  Rate from 50s to 80s, irregular.”

“Old EKG with early repol, but in my opinion new EKG much more drastic/changed.” 

“Called a STEMI and discussed with cards who initally advised me of early repol findings. Requested they evaluate EKG. After, they remarked it looked like pericarditis, which I argued didn’t fit the clinical picture. He admitted the EKG was abnormal but was skeptical. Went ahead with our protocol for him to get heparin, TNKase, plavix, ASA and flew to outlying hospital.” 

“Initial troponin about 1 hour after symptom onset was neg. CKMB was mildly elevated at 2.5 ish. CK 1300. After the pericarditis statement by cards, I added CRP and ESR after patient left, which came back negative.  Unfortunately, didn’t think to do a bedside echo before he left. “

“Cards texted me later and said he was fine, still in afib and that they felt his EKG was unchanged from old and consistent with early repol.  Cath lab deferred. Didn’t get report on if second troponin was done. “

Happy to get further follow up? I have about 4 EKGs from his brief stay in my ER as well as a one previous from his records. 

Found the recent blog post interesting in light of this case!
[You Diagnose Pericarditis at your Peril (at the Patient’s Peril!)]

Jessica Carmichael, MD

Further analysis:

Dr. Carmichael performed 4 serial ECGs and they were all unchanged.   The QTc was between 385 ms and 402 ms.

Here is one of them:
No significant change
Notice the computer calls it pericarditis.
On other identical ECGs in the same series, the computer calls it ***STEMI***


What if we had used the 3- or 4-variable formulas?

STE60V3 = 4 mm
RAV4 = 33 mm
QTc = 400 ms
QRSV2 = 15 mm

3-Variable: = 17.62, which is far below the cutoff of 23.4
4-Variable: = 13.93, which is far below the cutoff of 18.2


The formulas would have predicted benign normal variant STE (early repol).

Outcome

Angiogram was normal.
All trops negative.

By the way this is NOT pericarditis.
Learning Points:
1. It is never acceptable to berate another physician who is doing their best for the patient.  Obviously Dr. Carmichael was providing excellent care.
2. This ECG clearly meets STEMI “criteria” of 2.5 mm of STE in 2 consecutive right precordial leads, in addition to meeting STEMI criteria of 1 mm in lateral leads.
3.  There are features that can clue you in to benign ST Elevation: High voltage, profound J-waves, and short QT
4. Use the formulas.  They are very helpful.  (by the way, the formulas have now been externally validated in a large cohort; publication pending.  The 4-variable formula is now proven as the best!!)
5. One can avoid angiogram by performing a formal contrast echo.  Had Dr. Carmichael had access to one and been able to perform it, it would have shown no wall motion abnormality.  This would have ruled out LAD occlusion as the etiology of the STE, and she would have been able to avoid giving potentially harmful TNK-tPA.

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