History:  A patient in their mid-80’s with history of kidney transplant on both cyclosporine and steroids presents to the ER at 4 am for breathing issues that woke him at 2 AM.  His wife says he is agitated and stuck in a “breathing condition” for the last 2 hours. She also relates that he has had episodes like this before and that he also recently started using a marijuana edible nightly to help him sleep.  He denies chest pain, palpitations or other complaints.

Exam:  Vital signs are normal except for mild hypertension.  Physical exam is unremarkable except for mild agitation

An ECG is done

 

What diagnosis does the ECG suggest?

  • A) Anxiety (normal ECG)
  • B) Blood clot (PE)
  • C) Cardiac (ACS)
  • D) Pericarditis
  • E) Electrolyte issue (hypoK)

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QUIZ ANSWER:

  • A) Anxiety (normal ECG) – Wrong, but this was the diagnosis on the chart
  • B) Blood clot (PE) – can cause subtle ST changes
  • C) Cardiac (ACS) – CORRECT
  • D) Pericarditis – Nope
  • E) Electrolyte issue (hypoK) – can cause ST depression

1-Minute Consult on this topic: Click HERE and scroll to proper page

Case Outcome: The subtle ST depression in leads I and V4-V6 was not appreciated on this visit.  He was given Zyprexa and albuterol and felt better and was discharged home with instructions to follow up with his PCP.  He returned a week later with recurrence of the same symptoms and requested another breathing treatment.  He tried to elope when it was not given, but was eventually convinced to stay.  Serial ECG’s are shown below.

The first ECG has more ST depression than prior.  The second one shows evolution into type A Wellens reperfusion waves

He was started on heparin and went to cath.  Troponin was 250 and peaked at 2400.  Cath showed a 95% mid LAD stenosis that was treated with two stents