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Cardiac Case Review

black and red heart illustration

A 52 Year old male presents to the emergency department with 6/10 substernal chest pain that started two hours ago. Patient has already taken NTG X 3 and 324 mg ASA. Patient states he was sitting in his chair when the pain started.


BP 90/40

HR 54 Sinus Rhythm

Sp02 97%

RR 16

12 Lead EKG



This is a sinus bradycardia with normal axis and early R wave progression. There is obviously some concave S-T elevation in leads V4-V6 along with hyper-acute T waves. V3 appears to have upsloping S-T elevation with a hyper-acute T wave as well. Does this patient have a coronary occlusion?

Let’s go down our check list and see if this EKG meets criteria for a STEMI.

  1. We see obvious STE clearly in v3-v6. However we do not see any reciprocal changes. Now we know that we can have an anterior-lateral wall MI with no reciprocal changes. However this should pique our attention to progress down the differential of ER (Early Repolarization).
  2. The S-T elevation has the concave “smiley” face appearance with a notching of the J point. This is very common in ER.
  3. The next thing that should pique out interest is the amplitude of the R wave in V4-V5. When the heart becomes ischemic usually the R wave amplitude starts to diminish. This is why diagnosing an MI in the presence of LVH can be difficult, because usually when the muscle becomes ischemic the R wave amplitude shrinks down. This was mentioned by Dr.Smith in the Emcrit podcast “When to Activate the Cath Lab
  4. Lastly, if we plug in the formula validated by Dr Smith Et al. and published in the Annals of Emergency Medicine in July of 2012, we get a reading as illustrated below.


This formula takes into consideration the STE at 60ms after the J point in V3, the QTc, and the R wave amplitude in V4. This EKG gives us a formula value of 21.1 which is below the 23.4 value that is quite sensitive for an LAD occlusion.

The crew called a STEMI alert which was cancelled by the attending physician upon arrival. Our follow up shows this patient was admitted for observation and did receive an exploratory cath with no acute findings. This EKG was diagnosed as Early Repolarization.

So what does this mean for me?

Do we expect you to commit this formula to memory? Absolutely not! The point is to maybe pick out a few points to help you differentiate between the possibility of ER and an LAD occlusion in the field. Remember we should always err on the side of caution when considering activating the Cath lab from the field.

Any patient with chest pain refractory to NTG or ASA should be transported to a cath lab ready facility regardless of EKG findings. Whether the attending physician or cardiologist activate the cath lab is out of our control. Our goal is to get them to a tertiary facility capable of coronary artery reperfusion.

Now it’s your turn…

Do you think the S-T Changes on the EKG below are due to an MI?





Electrocardiographic Differentiation of Early Repolarization From

Subtle Anterior ST-Segment Elevation Myocardial Infarction

Stephen W. Smith, MD, Ayesha Khalil, MD, Timothy D. Henry, MD, Melissa Rosas, MD, Richard J. Chang, MD,

Kimberly Heller, MD, Erik Scharrer, MD, Mina Ghorashi, MBBS, Lesly A. Pearce, MS

Novel use of REBOA- A Patient Report
EMS Vision 20/20

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