This is the EKG (ECG) for Deepak Patel from scenario SIE003US
Clinical Picture
64-year old man presenting with chest discomfort and shortness of breath after exertion, 4 hours ago. Discomfort lasted 5 minutes and resolved with rest. Pain free at present
Extensive past medical history including ischemic heart disease
Findings
Rate: 75 bpm
Rhythm: Regular
Axis: Normal
Waves and intervals: Normal
ST-Segment: Slight ST-depression in V4, V5 & V6 (lateral leads). This is present in his old ECG.
Normal 4 hour troponin
Summary
The EKG demonstrates sinus rhythm with old, minor ST-depression in lateral leads.
Differential diagnosis
In a patient with a history of ischemic heart disease, presenting with transient chest discomfort and shortness of breath after a period of exertion, which resolved with rest combined with no acute features on the EKG and a normal troponin is likely to indicate stable angina.
Acute coronary syndrome (STEMI/NSTEMI/Unstable angina) is likely to show more significant EKG changes. This may be ST elevation or depression or T-wave inversion, which are new and not present on old EKGs. Repeat EKGs might reveal dynamic changes and their troponin will be raised. The patient may also have ongoing symptoms of pain, breathlessness and sweating. Some patients with unstable angina may have a normal EKG and this is why is it important to measure a troponin (which can be raised) and take a thorough history (looking for escalating symptoms) to differentiate from stable angina.
Costochondritis often presents as central pain which is worse on movement (rather than exertion). It is often associated with a recent viral illness and the patient’s EKG should be normal. It often responds well to anti-inflammatories.
Pneumonia may give a patient chest pain, but you would also expect to see other signs of infection, such as a productive cough or fever, as well as associated breathlessness.
Reflux is often described as burning pain and is usually associated with eating. It is generally not associated with breathlessness or exertion and can last minutes to hours.
Management
Deepaks history, EKG and lab work all point to stable angina. Should he have the symptoms again, the most appropriate initial treatment would be nitroglycerin. This is usually given sublingually as a spray or tablet. Even in patients with acute coronary syndrome, nitroglycerin is commonly used at the onset of pain.
High dose aspirin would only be appropriate if you suspect acute coronary syndrome (STEMI, NSTEMI or unstable angina), rather than stable angina.
Oxygen should only be used if saturations are below target range. For Deepak this would be less than 94%, which means in this scenario, oxygen is not indicated at any point. This is important to remember when dealing with patients with suspected cardiac chest pain as, when treating acute coronary syndrome, the use of unnecessary oxygen can actually worsen outcomes.
Antibiotics are not indicated as Deepak does not have any symptoms to suggest infection. Deepak symptoms do not fit with indigestion, therefore antacids are unlikely to help.
Simple analgesia might help Deepak’s pain, but it is not the most appropriate choice when treating Angina.
Wagner, P., Strodthoff, N., Bousseljot, R., Samek, W., & Schaeffter, T. (2020). PTB-XL, a large publicly available electrocardiography dataset (version 1.0.1). PhysioNet
Wagner, P., Strodthoff, N., Bousseljot, R.-D., Kreiseler, D., Lunze, F.I., Samek, W., Schaeffter, T. (2020), PTB-XL: A Large Publicly Available ECG Dataset. Scientific Data
Goldberger, A. et al. (2000). PhysioBank, PhysioToolkit, and PhysioNet: Components of a new research resource for complex physiologic signals. Circulation [Online]. 101 (23), pp. e215–e220.
