A 75-year-old man presented with central chest pain. He lives alone and generally keeps well.
He had surgery for a duodenal ulcer 3 years ago and was found to be in atrial fibrillation (AF) as a coincidental finding in his preoperative assessment. Given his increased risk of stroke, he was commenced on a direct oral anticoagulant (DOAC) soon after his operation. He is also hypertensive and this is well controlled by medication.
One morning, he was awakened from his sleep with upper epigastric pain extending up into his central chest. He described it as cramping in nature and not dissimilar to the pain he had previously experienced from his duodenal ulcer. He felt quite short of breath and clammy. He called his daughter, who is a nurse. She lives nearby and came round to his house immediately. She was concerned that his pain was cardiac in origin and called for an emergency ambulance.
His vital signs were as follows:
- Blood pressure: 90/45 mmHg
- Pulse: 38 beats per minute and very irregular
- Respiratory rate: 16 breaths per minute
- Temperature: 36.9oC
- SpO2 on air: 91%, increasing to 96% with three litres/minute of oxygen.
The 12-lead electrocardiogram (ECG) in Figure 1 was recorded by the paramedic crew.
ECG of a 75-year-old man presenting with central chest pain
What does the ECG show?
- The heart rhythm is irregular
- The heart rate is approximately 45 beats per minute
- The heart rhythm is AF.
The most striking abnormality with this 12-lead ECG is ST elevation in the inferior leads I, III aVF, and in the lateral leads V5 and V6. There is also marked ST depression in V1, V2, V3, I and aVL.
This is consistent with inferior – lateral ST elevation myocardial infarction (STEMI) and likely posterior wall involvement.
The man was triaged for primary percutaneous intervention (PCI) and a coronary angiography revealed a completely occluded proximal circumflex coronary artery. A single stent was inserted and the patient went on to make an unremarkable recovery.
The standard antiplatelet management of patients with STEMI following PCI is aspirin and a second agent. However, this man was already on an oral anticoagulant for his AF. In this case, his antiplatelet regime was adapted and he was discharged on his usual DOAC as before, with aspirin for 4 weeks and a second antiplatelet drug for 6 months.