The Case:

A 92 y.o female with a history of dementia and CAD presents for symptomatic bradycardia. The patient had been in her normal state of health until today when she became pale, diaphoretic, short of breath, and had chest pain while walking up stairs. EMS found the patient to be bradycardic to the 30’s but with stable vitals otherwise. 0.5mg atropine was given and bradycardia resolved. On arrival, she was completely asymptomatic and no longer bradycardic. EKG on arrival showed:

There are ST depressions diffusely throughout the EKG including II, III, aVF as well as diffusely throughout the precordial leads. I and aVL has slight ST elevation but it has retained the concave appearance. Of note, the patient is not on digoxin.

This is a scary looking EKG! However, the old EKG showed:

The ST depressions noted diffusely were seen on old EKG. They are possibly slightly worse than before with more prominent inversion especially in lead III. The concave ST elevation in I is new but aVL appears similar. aVR appears similar.

When reassessing the patient, she is having no chest pain at all. Vitals remain completely stable. No signs of heart failure. CXR negative. POC trop negative. We decided not to activate based on the patient being completely asymptomatic and having many of the changes chronically on old EKGs. It was unclear if these were ischemic changes secondary to the severe symptomatic bradycardia prior to arrival, or if the severe symptomatic bradycardia was a result of an ischemic event.

Because of the concerning initial EKG and the decision not to activate right away, we proceeded with serial EKGs. Repeat EKG showed:

The ST depressions in the inferior leads are now more prominent. Look closely at aVL, however. aVL now has a convex ST segment which is extremely concerning for active ischemia and is a dynamic change. Of note, the patient remained completely asymptomatic and chest pain free.

The decision was made to activate the cath lab, however, after a long discussion with cardiology and patient’s family based on patient’s goals of care, medical management was decided to be the plan of care rather than cath lab intervention. Patient’s troponin peaked into the 70’s.

Take home points:

  • Always compare to old EKGs if available.
  • If you are concerned, do serial EKGs, as early as every 15 minutes looking for dynamic changes
  • Watch for changes in the ST segment. Although concave ST segments can be frequently seen in early repolarization and benign EKG changes, it can also been seen in early ischemia. Watch for convex ST segment changes on serial EKGs.


Author: Beau Stokes, MD

Faculty Reviewer: Ann Hess, MD

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Beau Stokes, MD

EM4, University of Michigan and St. Joseph Mercy Residency Program

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