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Cardiology

Migrating Localized ST-Segment Elevation With Ongoing Chest Pain

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JAMA Internal Medicine

Published Online: July 3, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Yunling Xiao, MD¹;

Ruihai Zhou, MSc, MD²

Author Affiliations

¹Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, PR China
²Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

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A patient in their 60s with no previously known cardiac disease presented with a 6-hour history of sudden-onset worsening chest pain associated with shortness of breath and diaphoresis via emergency medical services (EMS). On arrival at the emergency department (ED) the patient had ongoing chest pain, rated at 8 out of 10 in intensity. The patient was afebrile. The patient’s blood pressure was 127/79 mm Hg, heart rate was 106 beats per minute, and respiration rate was 22 breaths per minute. The cardiopulmonary examination was overall unremarkable. The electrocardiograms (ECGs) obtained by EMS showed ST-segment elevation (STE), up to 2 to 3 mm in amplitude, in leads II, III, and aVF, and less in amplitude in precordial leads (Figure, A). However, the repeated ECG on arrival at the ED showed that the inferior STE resolved with development of T-wave inversion (TWI) in leads III and aVF, the STE became more prominent in leads V₂ and V₃, and new STE occurred in leads I and aVL (Figure, B). Due to ongoing chest pain and abnormal ECGs, ST-segment elevation myocardial infarction (STEMI) code was activated. The patient underwent emergency cardiac catheterization and coronary angiography.

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A patient in their 60s with no previously known cardiac disease presented with a 6-hour history of sudden-onset worsening chest pain associated with shortness of breath and diaphoresis via emergency medical services (EMS). On arrival at the emergency department (ED) the patient had ongoing chest pain, rated at 8 out of 10 in intensity. The patient was afebrile. The patient’s blood pressure was 127/79 mm Hg, heart rate was 106 beats per minute, and respiration rate was 22 breaths per minute. The cardiopulmonary examination was overall unremarkable. The electrocardiograms (ECGs) obtained by EMS showed ST-segment elevation (STE), up to 2 to 3 mm in amplitude, in leads II, III, and aVF, and less in amplitude in precordial leads (Figure, A). However, the repeated ECG on arrival at the ED showed that the inferior STE resolved with development of T-wave inversion (TWI) in leads III and aVF, the STE became more prominent in leads V₂ and V₃, and new STE occurred in leads I and aVL (Figure, B). Due to ongoing chest pain and abnormal ECGs, ST-segment elevation myocardial infarction (STEMI) code was activated. The patient underwent emergency cardiac catheterization and coronary angiography.

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Article Information

Corresponding Author: Ruihai Zhou, MSc, MD, RPVI, Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, 160 Dental Circle, Campus Box 7075, Chapel Hill, NC 27599-7075 (ruihai_zhou@med.unc.edu).

Published Online: July 3, 2023. doi:10.1001/jamainternmed.2023.1723

Conflict of Interest Disclosures: None reported.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.