Chest pain and other affairs of the heart (Professional)

If you looked at any textbook in your GP rotation at medical school, or in some previous dalliance with general practice then you may also recall one of the few gems that stuck by me from the Murtagh.

“More things are missed by not looking than not knowing”

I take this advice in a couple of ways- firstly- it does not mean that should look for everything- just because you thought of it, but it means that if you don’t look for it- you may not find it.

It also means that if you do not wish to know, then you should not go looking:-

This is where patients need to be involved in informed decision making- eg. If you find a tumour in a 95 year old patient who feels that they have had a good life- you may just be needlessly burdening them with information by going looking.

Also- if you don’t know what you are looking for then how will you know if you find it? Blind searching is for the visually impaired person yet to acquire a Labrador.

Below are some things that you should look for in the patient presenting with chest pain, and or syncope. You also need to know enough about them when you see them to know what to do- or where to go looking.

If you familiarise yourself with the new(ish) chest pain pathway- depending on when you are reading this- you will note at the bottom there are ECG STEMI Mimics and ECG STEMI Equivalents

There are few ECG changes that were only described since I was a baby doctor, as an example:- If a patient had chest pain and an old LBBB then no further analysis was attempted of the ECG.

Enter:

Sgarbossa Criteria

https://litfl.com/sgarbossa-criteria-ecg-library/

Modified Sgarbossa Criteria:

· ≥ 1 lead with ≥1 mm of concordant ST elevation

· ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression

· ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave.

10-15% of MI’s are posterior or include significant posterior territories.

Posterior infarct

Posterior MI is suggested by the following changes in V1-3:

· Horizontal ST depression

· Tall, broad R waves (>30ms)

· Upright T waves

· Dominant R wave (R/S ratio > 1) in V2

In patients presenting with ischaemic symptoms, horizontal ST depression in the anteroseptal leads (V1-3) should raise the suspicion of posterior MI.

This should not be confused with persistant juvenile Twave pattern- and should prompt a posterior ECG, troponin, senior review and consideration of emergent revascularisation.

(Persistant Juvenile Twaves is less common in males, and extremely uncommon in males over 30- if changes are dynamic or assosciated with a history suggestive of a possible cardiac cause- then err on the side of caution.)

De Winter T-waves

This should prompt urgent/emergency revascularisation (lysis/PCI) in the context of chest pain.

I have personally seen the below type ECG morph back and forth from STEMI pattern both with and without GTN administration.

Diagnostic Criteria

· Tall, prominent, symmetric T waves in the precordial leads

· Upsloping ST segment depression >1mm at the J-point in the precordial leads

· Absence of ST elevation in the precordial leads

· ST segment elevation (0.5mm-1mm) in aVR

· “Normal” STEMI morphology may precede or follow the deWinter pattern

https://litfl.com/de-winter-t-wave-ecg-library/

For more detail please review the below articles.

https://litfl.com/posterior-myocardial-infarction-ecg-library/

https://wikem.org/wiki/STEMI_equivalents

Wellens syndrome- This is a tricky one: and should prompt early cardiology referral, and in the case of a patient with active chest pain, should also prompt consideration of emergency revascularisation.

https://litfl.com/wellens-syndrome-ecg-library/

https://www.wikem.org/wiki/STEMI_mimics

Brugada syndrome-

Brugada Syndrome is an ECG abnormality with a high incidence of sudden death in patients with structurally normal hearts.

Diagnostic criteria

· Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.

· This is the only ECG abnormality that is potentially diagnostic.

· It is often referred to as Brugada sign.

https://litfl.com/brugada-syndrome-ecg-library/

Hypertrophic cardiomyopathy:-

https://litfl.com/hypertrophic-cardiomyopathy-hcm-ecg-library/

Clinical features

· Exertional syncope or pre-syncope — this is the most worrying symptom, suggesting dynamic LVOT obstruction ± ventricular dysrhythmia, with the potential for sudden cardiac death.

· Symptoms of pulmonary congestion (e.g. exertional dyspnoea, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea) due to left ventricular dysfunction.

· Chest pain — may be typical anginal pain due to increased demand (thicker myocardial walls) and reduced supply (aberrant coronary arteries).

· Palpitations due to supraventricular or ventricular arrhythmias.

ARVD

As a junior doctor I almost definitely sent a patient home with this. It is the most common cause of fatal arrhythmias in young people in Europe. I recall seeing a patient with this odd ECG and an episode of syncope and discussing the patient with the consultant- who reviewed the ECG- we agreed that it was weird- but both were unaware of the significance. I hope that by seeing this ECG- your patient will not be left to fend on their own without a proper review and plan from a cardiologist.

The key feature is the Epsilon wave:-

Check out the below ECG and article for more detail to prevent a sad family and an appearance in coroners court.

https://litfl.com/epsilon-wave-ecg-library/

There are a number of other STEMI mimics which it would be worth refreshing your knowledge on:-

Here is a link to an article with many hyperlinks you can peruse at your leisure. https://www.wikem.org/wiki/STEMI_mimics