HR 150? STEMI or PE? I was wrong!!
TLDR
STEMI is rare to have significant tachycardia. ST changes as rate increases- in particular left main pattern (STE aVR w/ STD diffuse) is frequently false +.
Keep differential with atypical STEMI clinically i.e.— hypoxic 70s and HR 130-150. Consider PE or cardiogenic shock. In shock HR is often compensating for diminished SV (CO=HRxSV).
Bedside ultrasound should be able to easily distinguish.
TLDR
STEMI is rare to have significant tachycardia. ST changes as rate increases- in particular left main pattern (STE aVR w/ STD diffuse) is frequently false +.
Keep differential with atypical STEMI clinically i.e.— hypoxic 70s and HR 130-150. Consider PE or cardiogenic shock. In shock HR is often compensating for diminished SV (CO=HRxSV).
Bedside ultrasound should be able to easily distinguish.
When is the last time I saw a STEMI with HR 150?
I asked myself as I listened to the story on an incoming transfer. I hear the the patient is tachycardic. I mean really tachycardic… upper 140-150 and on top of that spO2 70s on arrival.
It’s a fact that I rarely see very tachycardic true STEMIs; but, I very often see fake out STEMIs at a rate like that. Especially the left main pattern (avr ste w/ diffuse st depressions) comes up an awful lot.
The hypoxia also gave me pause. The patient’s chief complaint was shortness of breath x 1 hour. No hx of CAD or COPD. Certainly the top differential I had was not STEMI but something like a pulmonary embolism. Had to be. The transferring facility hadn’t uploaded ecg to EMR and I couldn’t get a photo of it as they were en route.
ECG on arrival. Click on to enlarge.
I went ahead and explained my teaching point to my residents: That in my experience, STEMI likelihood and HR were inversely proportional.
There’s always the exception to prove the rule and I must say on the way to cath lab we took about all of 30 seconds to confirm wall motion abnormalities in conjunction with the ECG that this was a stemi. There was not even a whiff of a pulmonary emboli. What we did find was cardiogenic shock from a massive MI. The sono showed obvious wall motion abnormalities particularly anterior along with a severely depressed EF and B-lines/pulmonary edema. To put it plainly: cardiogenic shock.
Post cath ecg. Click to enlarge.
Cath-aclysm
An impella device was used during cath and suffered intra procedure cardiac arrest w/ ROSC later required ecmo and ultimately expired in ICU.
Cath findings:
Main Proximal LAD: 100% occluded , PCI w/ DES successful
LCX: 95% occluded, POBA/Balloon
Comments
HR 150? STEMI or PE? I was wrong!!
TLDR
STEMI is rare to have significant tachycardia. ST changes as rate increases- in particular left main pattern (STE aVR w/ STD diffuse) is frequently false +.
Keep differential with atypical STEMI clinically i.e.— hypoxic 70s and HR 130-150. Consider PE or cardiogenic shock. In shock HR is often compensating for diminished SV (CO=HRxSV).
Bedside ultrasound should be able to easily distinguish.
When is the last time I saw a STEMI with HR 150?
I asked myself as I listened to the story on an incoming transfer. I hear the the patient is tachycardic. I mean really tachycardic… upper 140-150 and on top of that spO2 70s on arrival.
It’s a fact that I rarely see very tachycardic true STEMIs; but, I very often see fake out STEMIs at a rate like that. Especially the left main pattern (avr ste w/ diffuse st depressions) comes up an awful lot.
The hypoxia also gave me pause. The patient’s chief complaint was shortness of breath x 1 hour. No hx of CAD or COPD. Certainly the top differential I had was not STEMI but something like a pulmonary embolism. Had to be. The transferring facility hadn’t uploaded ecg to EMR and I couldn’t get a photo of it as they were en route.
ECG on arrival. Click on to enlarge.
I went ahead and explained my teaching point to my residents: That in my experience, STEMI likelihood and HR were inversely proportional.
There’s always the exception to prove the rule and I must say on the way to cath lab we took about all of 30 seconds to confirm wall motion abnormalities in conjunction with the ECG that this was a stemi. There was not even a whiff of a pulmonary emboli. What we did find was cardiogenic shock from a massive MI. The sono showed obvious wall motion abnormalities particularly anterior along with a severely depressed EF and B-lines/pulmonary edema. To put it plainly: cardiogenic shock.
Post cath ecg. Click to enlarge.
Cath-aclysm
An impella device was used during cath and suffered intra procedure cardiac arrest w/ ROSC later required ecmo and ultimately expired in ICU.
Cath findings:
Main Proximal LAD: 100% occluded , PCI w/ DES successful
LCX: 95% occluded, POBA/Balloon
Comments