A 42-year-old man with a history of hypertension, prior tobacco use (as recently as two weeks ago), prior polysubstance abuse, and currently in rehab presented to the ED with three months of intermittent central and left-sided chest pressure that was exertional and associated with shortness of breath.
The episodes lasted about five minutes and occurred after he walked a couple blocks and resolved after resting for a couple minutes. These episodes were happening over the past week with shorter distances and a little more intensity.
The triage ECG (not shown) and the troponin were normal. The hospitalist was called to admit the patient and documented: “Patient is currently in a drug and alcohol treatment center ordered by the law. He has a negative troponin and normal ECG. He is pain-free and reports symptoms consistent with reflux disease. He also seems anxious. I recommend repeating his troponin and discharging him home with a PPI if it is negative.”
This type of advice, bias, and dismissiveness sometimes occurs. A clinical presentation like this is ACS until proven otherwise. It is dangerous to assume a benign cause such as GERD or anxiety until provocative testing is completed and normal. Fortunately, the EP did not feel this was safe and did a poor-man's stress test. Shown is the repeat ECG after the patient did jumping jacks until developing pain.
The computer read the ECG as atrial flutter with RVR and minimal ST depression. Do you agree with the computer? What should you do next?
Case Lessons The computer read is incorrect. This is sinus tachycardia. The rate is close to 150 bpm, and the P waves are not that obvious, which is why the computer is calling it atrial flutter. There is also more than minimal ST depression, especially in leads V4 and V5.
The troponin I was <0.01, as was the repeat troponin. A different hospitalist was called, and the patient was admitted and had a positive stress test followed by an angiogram and a stent.
We must avoid bias caused by substance abuse, and avoid choosing an alternate explanation such as anxiety or GERD until ACS is ruled out. Chest pain that lasts five minutes is typical of ACS, so always start with this at the top of your differential for intermittent chest pain. When it is exertional, it is classic for ACS.
Normal ECGs and troponins can rule out NSTEMI, but they still cannot rule out unstable angina. The typical presentation of unstable angina is episodic chest discomfort lasting a few minutes, especially when triggered by tachycardia often caused by physical or emotional stress. Other common triggers include blood shunting after meals or any other cause of tachycardia.
Expect the ECG to be normal in ACS if the pain has resolved. Expect the troponin to be normal when episodes last fewer than 30 minutes. You are less likely to be falsely reassured by normal results if you expect these findings before you order the test.
This post was peer-reviewed by Stephen W. Smith, MD, of Dr. Smith's ECG Blog (https://bit.ly/306xAeq).
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Dr. Pregersonis an emergency physician at Tri-City Hospital and Scripps Coastal, both in Oceanside, CA. He is the author of the EMN blog Bradycardia athttp://bit.ly/EMN-Bradycardia, and of Emergency Medicine 1-Minute Consult, Tarascon Emergency Department Quick Reference Guide, A to Z Emergency Pharmacopoeia & Antibiotic Guide, Don't Try This at Home, and Think Twice: More Lessons from the ER. Follow him on Twitter@EM1MinuteGuru, and visit his website atEMresource.org.