Clinical Presentations—Case Study #1

How Much Should I Care About this EKG?

Jennifer Carlquist, PA-C, ER CAQ

Providers often wonder, “How much should I worry about this EKG?” We know how to pick up the big things like STEMI, but it is the gray area EKG findings that keep us up at night.

The way to stay safe is to recognize the “faces” of those high-risk findings that the machine will miss. Most of these patterns will be labeled by the machine software with some version of “nonspecific ST-T wave changes.” This phrase is a “catch-all” and is what the software identifies no STEMI, but not normal either. Rarely does it mean something is not wrong. The machine just doesn’t know what it is.

There are 5 patterns that are potentially lethal but will be read as nonspecific ST T wave changes by the machine are:

  • Posterior STEMI
  • Wellens Warning
  • De Winters T Waves
  • Widespread ST Depression with 1mm of Elevation in AVR
  • Hyperacute T Waves

Let’s consider this case that could happen in any Urgent Care, any day. A 36-year-old female presents with dry cough for 3 days. She has had some fatigue and was having a hard time chasing the toddlers around at the school where she worked.

She had no significant past medical history. She did not smoke.

She had no fever.  The HR was slightly elevated at 109bpm. The remaining vitals were normal.

On exam, she had a high BMI. Her lung sounds were diminished the base on the left. There was no S3 or S4. She had 1 + bilateral lower extremity edema.

At this point, what are your differentials? PE? Pneumonia? CHF? Bronchitis?

Because of her cough, a chest X-ray was performed. It was read by the provider as concern for infiltrate and she was referred to the emergency department. On arrival an EKG was performed.

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The EKG machine read this as “non-specific ST-T wave changes.”

On closer inspection, there is some minor ST depression in multiple leads and more than 1mm of ST elevation in AVR.

Her CXR was repeated in the emergency department and was read by a radiologist as pleural effusion, unilateral. No infiltrate.

Labs were normal except for a BNP of 6929 and a glucose of 310mg/dl. Troponin, CBC and CMP were otherwise normal.

A CTA was performed, and no PE was seen.

She was admitted to the hospital and had a nuclear stress test and was noted to have a low EF of 32% and occlusive disease in her RCA and LAD. CABG was recommended.

So how does a 36-year-old female come to Urgent Care with cold symptoms end up with a CABG?

She was unfortunately an undiagnosed diabetic and had familial hyperlipidemia that was undiagnosed and untreated. These two risk factors made her heart age significantly older than her chronological age.

The ACC Update Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department released in JACC November 15, 2022, now lists widespread ST depression with 1mm of ST elevation as worrisome for involvement of left main or triple vessel disease and warrants immediate angiography (Kontos, 2022).

Widespread ST depression in the setting of chest pain when the patient also has more than 1mm of ST elevation in AVR is consistent with diffuse subendocardial ischemia and usually requires immediate angiography. This widespread depression can be seen in conditions like demand ischemia if a patient is tachycardic, so this pattern is only accurate when the patient has a normal heart rate.

In Urgent Care, the history, physical, EKG and X-ray are often the only tools we have to make critical decisions. The bottom line is that as Urgent Care providers we have less tools and need to be experts in the tools we have.  Knowing these patterns could save your next patient’s life, as well as your reputation.

REFERENCES:

  • Kontos, M. C., de Lemos, J. A., Deitelzweig, S. B., Diercks, D. B., Gore, M. O., Hess, E. P., McCarthy, C. P., McCord, J. K., Musey, P. I., Villines, T. C., & Wright, L. J. (2022). 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Journal of the American College of Cardiology80(20), 1925–1960. https://doi.org/10.1016/j.jacc.2022.08.750

 

You can reach Jennifer Carlquist, PA-C, ER CAQ, at Jen@conqueringcardiology.com