We should first endeavor to better understand the working of the heart in all its details, and the cause of a large variety of abnormalities. This will enable us, in a possibly still distant future and based upon a clear insight and improved knowledge, to give relief to the suffering of our patients.
In the Preface to this atlas, I began with a self-evident observation – that the ECG plays a pivotal role in patient care. I wrote that the ECG is “where the money is” for a wide variety of chief complaints, including chest pain, dyspnea, syncope, electrolyte abnormalities, shock, cardiac arrest, arrhythmias, poisonings and other critical emergencies. And then, belaboring the point, I wrote that “more often than not, the ECG rules in or out one or more life-threatening conditions and changes management.”
Critical Cases in Electrocardiography has focused on “don’t-miss” tracings (especially those that are essential in managing patients with chest pain or dyspnea). But in fact, most of the examples in this atlas were missed – by the emergency clinicians, the consulting specialists, the computer algorithm or, often enough, all of the above. It goes without saying that I have missed many of these diagnoses too.
As famed electrocardiographer and teacher Marriott wrote, “There are two main categories of urgent electrocardiograms: Those that present you with a clear-cut, unambivalent picture that justifies definitive diagnosis, decision and action; and those that are not diagnostic but suggest a disaster that may be unforgiving if you fail to think of it” (Marriott, 1997).
Critical Cases in Electrocardiography has emphasized everyday emergencies. As I wrote in the Preface, my focus is “clinical diagnosis, late at night in the emergency department or critical care unit, in the service of seriously ill patients.”
It is time to review. This final chapter, Critical Cases at 3 A.M., is a collection of ECG tracings from patients with chest pain, shortness of breath, syncope and other cardiovascular complaints. A few have been presented in earlier chapters. Almost all of the ECGs were misinterpreted, at least at first, by the treating clinicians. I suspect that you will not miss any.
Self-Study Electrocardiograms
Case 8.1 A 75-year-old female had a syncopal episode at the airport. She had no memory of the event. There was no report of chest pain. On arrival in the emergency department, she was asymptomatic; her examination was normal except for a forehead laceration.
Case 8.2 A 69-year-old female with a history of prior aortic dissection presented to the emergency department with chest pain for 4 hours, accompanied by mild nausea. She was transported by paramedics as a “cardiac alert.” She received aspirin, nitroglycerin and an analgesic in the field, with complete resolution of her chest pain. Her blood pressure on arrival to the ED was 163/75.
Case 8.3 A 21-year-old female had substernal chest pain followed by a syncopal event while running between gates at the airport.
Case 8.5 A 64-year-old man presented with chest pain, headache and altered mental status.
Case 8.6 A 63-year-old man presented with chest pain and dyspnea. He had a white blood cell count of 18,000, and his chest x-ray suggested an acute pneumonia. His initial ED diagnosis was “pneumonia, with possible early sepsis.” His initial troponin level was 0.3. The note from the ED team read, “He appears to have pneumonia. In addition, his ECG shows a RBBB and possible anterior wall ischemia. With indeterminate troponin, we will treat him for ACS and non-STEMI.”
Case 8.7 A 79-year-old man presented with three episodes of syncope over a 2-week period. The most recent syncopal episode occurred the morning of his emergency department visit while he was sitting on his couch.
Case 8.8 A 47-year-old man presented with stuttering chest pain, with radiation to both arms and his right jaw. Aspirin was administered by the paramedics, and his chest pain resolved. Patient was a former smoker, but there was no other medical history. The initial troponin level was 0.11.
Case 8.9 A 59-year-old man presented with several hours of chest discomfort, nausea and hiccups. He had a recent diagnosis of GERD.
Case 8.10 A 40-year-old man presented with 3 hours of substernal chest pain after playing a strenuous game of basketball.
Case 8.11 The same patient – 54 minutes later.
Case 8.12 A 63-year-old man presented with 2 hours of left chest pressure. He reported intermittent “indigestion” the night before his visit. After obtaining initial laboratory studies and the ECG, he was admitted to the coronary care unit with a diagnosis of “unstable angina, possible inferior ischemia.”
Case 8.12 The same patient – the following morning.
Case 8.13 A 42-year-old man presented with severe, resting substernal chest pain (“like a ton of bricks”). He also endorsed mild dyspnea and diaphoresis.
Case 8.14 A 68-year-old man was on an antiretroviral regimen for HIV/AIDS. He presented with substernal chest pain at rest, reporting two similar episodes with mild exertion over the past 2 weeks. He was asymptomatic in the emergency department.
Case 8.15 A 64-year-old female with a history of COPD but no history of coronary artery disease presented with 5 days of stuttering chest pain that radiated to both arms. In the emergency department, she had bilateral rales on lung examination. She received heparin and nitroglycerin for a presumed diagnosis of “unstable angina, possible non-STEMI.” The computer reading is shown.
Case 8.16 A 59-year-old man presented in cardiac arrest. He had a history of coronary artery disease. His wife reported he had complained of left arm numbness and shortness of breath and then collapsed. Paramedics found him in ventricular fibrillation. In the ED, despite receiving more than an hour of chest compressions and multiple rounds of cardiac medications, he could not be resuscitated. This rhythm strip was obtained after a third defibrillation shock.
Case 8.16 Same patient, 12-lead ECG taken during the resuscitation.
Case 8.17 A 72-year-old man with no history of coronary artery disease had severe chest pain while running at the airport. He reported a history of pulmonary fibrosis, and he used home oxygen. His initial troponin was 0.01.
Case 8.19 A 57-year-old female presented with leg stiffness and shortness of breath. On examination, she was well appearing. However, her oxygen saturation was only 90 percent on 5 liters of nasal oxygen, and she had signs of deep venous thrombophlebitis of the left leg.
Case 8.20 A 36-year-old man presented with hallucinations and fatigue.
Case 8.23 A 35-year-old female noted shortness of breath and anxiety while visiting her newborn in the neonatal intensive care unit.
Case 8.24 A 54-year-old man without any significant medical history presented with new-onset shortness of breath. He reported progressive fatigue and weakness over the past month, and on the day of his visit, he noted marked exertional dyspnea while shopping. In the ED, he was tachypneic (RR = 30), and he was in respiratory distress. His lung examination revealed decreased breath sounds and dullness to percussion at the left base. Rales were noted in the middle left lung field. He was felt to have an acute coronary syndrome; his first troponin was elevated at 8.0.
Case 8.25 A 53-year-old female with diabetes and chronic renal insufficiency presented with shortness of breath, chest pain, pulmonary edema, hypoxia and hypotension.
Case 8.26 A 52-year-old man presented with shortness of breath and generalized weakness. His initial blood pressure was 118/84. His respirations were 18 and unlabored. He was not in any respiratory distress. He had a history of lung carcinoma, chronic hoarseness and a prior episode of deep venous thrombosis (DVT), and he was taking warfarin.
Case 8.27 A 41-year-old man presented with intermittent chest pain over 1 day, worsening in the previous 30 minutes. The pain radiated down both arms but was reproduced by changes in body position and direct chest wall palpation. He was pain-free in the emergency department. His initial diagnosis was chest pain, likely musculoskeletal muscle strain.
Case 8.27 Same patient, 40 minutes after the first ECG.
Case 8.28 A 73-year-old female with a history of hypertension presented with epigastric pain starting at 1 A.M. Her pain was relieved by sublingual nitroglycerin. Her initial troponin level was 0.04.
Case 8.28 Same patient – baseline ECG.
Case 8.29 A 72-year-old female presented with chest and epigastric pain. The initial troponin levels in the emergency department were 0.01 (negative) and 0.10 (indeterminate). She had recurring episodes of pain; heparin was administered.
Case 8.30 A 22-year-old female presented to an urgent care clinic with a complaint of shortness of breath and pleuritic chest pain. The ECG was obtained while she was in the waiting room. After a prolonged wait, she left the clinic.
Case 8.31 A 47-year-old man with a history of hypertension presented after a prolonged episode of chest pain. He experienced temporary relief with sublingual nitroglycerin.
Case 8.33 A 58-year-old female with a history of diabetes and hypertension presented with shortness of breath, weakness and confusion along with subjective fevers. In the emergency department, she was noted to be “ill-appearing and lethargic, with anasarca.”
Case 8.34 A 59-year-old man with a history of diabetes presented with chest and epigastric pain for 2–3 days. He endorsed shortness of breath, dizziness and bilateral ankle swelling.
Case 8.35 A 66-year-old female returning from Mexico complained of nausea, vomiting, weakness and vision changes (halos and spots).
Case 8.36 An older man presented with altered mentation, possibly after a fall. No other clinical information was available.
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