What’s Your Diagnosis? Evaluation and Management of ST-Segment Elevation Myocardial Infarction
December 14, 2020

Posted by Andy Jagoda MD in: What's Your Diagnosis , trackback

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Rhabdomyolysis: Evidence-Based Management in the Emergency Department right.

Case Presentation: Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency Department

A 74-year-old woman with chest pain is delivered to your ED by EMS…

  • You greet the paramedics, and they inform you that the patient called 911 from home because she was having chest pain. They have given her 324 mg of aspirin orally and 3 doses of 0.4 mg of nitroglycerin sublingually. The patient’s pain improved, but is still present.
  • Her vital signs are normal. The paramedic hands you an ECG that he obtained and states that there is anterior ST-segment depression concerning for ischemia, but no ST elevation.
  • You look at the tracing and note ST depression in leads V2 and V3. You wonder whether this could actu- ally be a STEMI, and what would be the best way to confirm your suspicion…


The 74-year-old woman with chest pain who was delivered to your ED by EMS…

The thought of anterior ischemia in this patient made you concerned for the presence of posterior STEMI. You noticed ST depression in leads V2 and V3, with a prominent R wave and upright T wave. Based on this, you obtained posterior leads, V7, V8, and V9. The posterior tracing (V7, V8, V9) showed ST elevation of 1 mm in leads V7 and V8. You promptly activated your cardiac catheterization lab and spoke with interventional cardiology.

The patient had been given aspirin in the field. You administered nitroglycerin and prepared the patient for transfer to the catheterization lab. About an hour later, the interventional cardiologist called and informed you that the patient had a 99% circumflex artery occlusion that required a stent. The patient was now in the ICU and doing very well. You successfully diagnosed an isolated posterior (inferobasilar) STEMI.

Click to review this Emergency Medicine Practice Issue

Comments »

1. Jeff - January 4, 2021

An EKG is but a “micro snap shot” in time! ACS/STEMI is a dynamic process. Repeat the EKG often. Like now, on arrival!

2. Christine - January 4, 2021

Posterior EKG

3. Steve - January 4, 2021

posterior MI. Confirm with posterior leads (V7-9)

4. Camilo Mohar - March 3, 2021

Activate the cath lab, posterior EKG is academic.

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