A 42-year-old man is brought to the emergency department due to 4 hours of chest tightness and shortness of breath. He has not had similar symptoms before. He returned to the United States from a business trip to Paris a week ago. He thinks that his symptoms are due to an upper respiratory infection, which he suspects he contracted from recirculated air on the plane. The patient takes no medications and does not use alcohol or illicit drugs. He has a 20-pack-year smoking history. Blood pressure is 152/99 mm Hg and pulse is 92/min. BMI is 32 kg/m2. ECG is shown in the exhibit. Which of the following is the most appropriate next step in management of this patient?
Show Explanatory Sources
The following ECG findings are diagnostic of ST-elevation myocardial infarction (STEMI):
This patient's ECG shows >2 mm ST elevation in V2 and V3, and >1 mm ST elevation in aVL, V1, and V4 (each box is 5 mm in height), consistent with anterolateral STEMI. Reciprocal ST depression in the inferior ECG leads (II, III, and aVF) is also present. STEMI requires urgent revascularization that is best accomplished with percutaneous coronary intervention (PCI), ideally within 90 minutes of first medical contact (even if symptom onset was earlier, as in this patient with 4 hours of chest pain) or within 120 minutes for patients who require transfer to a PCI-capable facility. Patients who are not able to undergo PCI in a timely fashion should be considered for fibrinolytic therapy.
(Choice A) Cardiac enzymes and serial ECGs are appropriate for patients with suspected but undiagnosed ACS. This patient's initial ECG is diagnostic of ACS due to STEMI, and further diagnostic testing is not necessary.
(Choice B) CT angiography of the chest is appropriate for patients with suspected acute pulmonary embolism, which often presents with chest discomfort and shortness of breath; however, this patient's ECG is diagnostic of STEMI.
(Choice C) Exercise ECG stress testing should be performed in patients with recurrent chest pain that raises suspicion for stable coronary artery disease. It is contraindicated in patients with acute, active chest pain.
(Choice D) Nonsteroidal anti-inflammatory agents (eg, aspirin, ibuprofen) and colchicine are indicated in patients with acute viral or idiopathic pericarditis. ECG typically demonstrates diffuse ST elevation and PR depression rather than ST elevation confined to several contiguous leads. Reciprocal ST depression is not consistent with pericarditis.
Educational objective:
In men age >40, ST-elevation myocardial infarction (STEMI) is diagnosed by ECG showing >1 mm (0.1 mV) ST elevation (>2 mm in leads V2 and V3) in ≥2 anatomically contiguous leads. Primary percutaneous coronary intervention is recommended within 90 minutes of the first medical contact in patients with STEMI.