Symptoms And Treatment Of Chest Pain

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Chest pain is a frequent complaint in the emergency department (ED). Patients who are symptomatic with ST-elevations on ECG are at high risk for ST-elevation MI (STEMI). While this classic ECG pattern has been identified as high risk for myocardial ischemia, recent literature has reported various STEMI-equivalents which may be equally threatening.8 One STEMI-equivalent previously named the de Winter pattern describes ECG changes where there are ST-segment depression in the precordial leads in association with tall, symmetrical, hyperacute T-waves.3 These changes have been associated with proximal left anterior descending (LAD) coronary artery occlusion.9 We have identified and report a case of de Winter ECG pattern immediately following…show more content…
There is also occasionally ST-segment elevation in lead aVr.3 These ECG changes have been described as having an association with left anterior descending (LAD) coronary artery occlusion. This can subsequently cause anterior wall myocardial infarction.9 The de Winter ECG pattern has been described in various case reports. Specifically, criteria for the this ECG pattern consistently includes 1) ST depression ≥1 mm up-sloping at the J-point in leads V1-V6 continuing into tall, prominent, symmetrical T waves in the precordial leads, and 2) the absence of ST-segment elevation in the affected leads. Also, prominent J-point elevation producing ST-segment elevation up to 1.0 mm in lead aVr has also been described.10 De Winter et al illustrate this as a novel ECG pattern associated with proximal LAD occlusion in 2008.10 We recount a case in which the de Winter ECG pattern is identified immediately following ventricular fibrillation cardiac arrest. With non-specific ST changes on the initial ECG at presentation (Figure 1), and subsequently a transient complete normalization of these changes (Figure 2), the patient developed ventricular fibrillation requiring electrical defibrillation. Case: A 33-year-old man presented to the ED by ambulance with a 1-hour history of waxing and waning severe sub-sternal chest pain with shortness of breath, and diaphoresis. The chest pain radiated to his back. The pain began in the
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