.
FLORENCE BLACKMAN I HUMAN
CASE STUDY 66 YEARS OLD
FEMALE DIAGONISED WITH CHEST
PAIN 2 DIFFERENT VERSION FROM
EXPERT FEEDBACK LATEST
REVIEWED 2024
A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent
substernal chest pressure. A report from the patient's primary care physician's office
states that an EKG performed four days ago was completely normal. Repeat EKG in the
ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and
a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What
intervention would be indicated to provide definitive management for the findings seen
on EKG in this patient?
A. Urgent placement of a cardiac pacemaker
B. Radiofrequency ablation
C. Emergent revascularization with thrombolytics or percutaneous coronary
intervention (PCI)
D. Continuous cardiac monitoring for 24-48 hours - answer-The answer is A. "In the
face of an AMI, the risks of complete heart block are much greater when new or
preexisting bi- or trifascicular conduction blocks are present. In this setting, prophylactic
placement of a ventricular demand pacemaker is indicated."
Which coronary vessel is usually the cause of the myocardial infarction in a patient with
ST elevation in V1, V2, and V3?
A. right coronary artery (RCA)
B. left anterior descending (LAD)
C. right ventricular branch of the right coronary artery
D. left circumflex artery
E. posterior descending branch of the right coronary artery - answer-The answer is B.
This EKG pattern is consistent with that of anterior wall myocardial infarction (MI). The
LAD supplies the anterior wall of the myocardium. The left circumflex artery, the LAD, or
a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of
, the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion
of a branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF
and I, aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in
leads II, III and aVF causes an inferior MI. The right ventricle is usually supplied by the
RCA or, less commonly, a dominant left circumflex. ST elevation in leads V4 and V5 of
a right-side leads EKG suggests infarction of the right ventricle. A posterior MI (ST
depression in V1-V3) results from occlusion of the RCA, its posterior descending
branch, or a dominant left circumflex.
E. Call cardiology - answer-The answer is D. This patient is having an acute myocardial
infarction. AMI is defined when two of the following three findings are present: clinical
history of chest pain of at least 20 minutes duration, EKG changes and/or positive
myocardial enzyme testing. This patient has ST elevation with concomitant ST
depression in contiguous leads with chest pain. She needs immediate thrombolytic
therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be
achieved within 90-120 minutes of emergency department arrival, the literature supports
its selection over thrombolytic therapy as primary intervention. In preparation for either
thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery,
decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine
will increase O2 delivery to the heart. A beta blocker, which should also be administered
to AMI patients who lack contraindications, will decrease the work of the heart, and
aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered -
selections will depend on the exact treatment course chosen for the patient.
Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being
dependent on exact treatment course for patient) should be started if there are no
patient historical or chest X-ray findings suggestive of aortic dissection.
A 72-year-old male presents with five hours of substernal chest pain and pressure
despite taking three sublingual nitroglycerin. You order an EKG. What findings on the
EKG would indicate that this patient is potentially a candidate for thrombolytic therapy?
A. Ventricular tachycardia
B. ST-segment elevation of at least 1 mm in two or more contiguous leads
C. ST-segment depression of at least 2mm in any precordial lead
D. Atrial fibrillation with a rapid ventricular response - answer-The answer is B.
"Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time
to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm ST-
segment elevation in two or more contiguous leads."
A 58-year-old male previously in good health presents with chest pain for two hours.
Vital signs are BP 126/78, HR 80 (sinus rhythm), RR 14, oxygen saturation 99%, T
36.8. His EKG shows ST segment elevation in leads II, III, aVF and V1. ST-segment
FLORENCE BLACKMAN I HUMAN
CASE STUDY 66 YEARS OLD
FEMALE DIAGONISED WITH CHEST
PAIN 2 DIFFERENT VERSION FROM
EXPERT FEEDBACK LATEST
REVIEWED 2024
A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent
substernal chest pressure. A report from the patient's primary care physician's office
states that an EKG performed four days ago was completely normal. Repeat EKG in the
ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and
a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What
intervention would be indicated to provide definitive management for the findings seen
on EKG in this patient?
A. Urgent placement of a cardiac pacemaker
B. Radiofrequency ablation
C. Emergent revascularization with thrombolytics or percutaneous coronary
intervention (PCI)
D. Continuous cardiac monitoring for 24-48 hours - answer-The answer is A. "In the
face of an AMI, the risks of complete heart block are much greater when new or
preexisting bi- or trifascicular conduction blocks are present. In this setting, prophylactic
placement of a ventricular demand pacemaker is indicated."
Which coronary vessel is usually the cause of the myocardial infarction in a patient with
ST elevation in V1, V2, and V3?
A. right coronary artery (RCA)
B. left anterior descending (LAD)
C. right ventricular branch of the right coronary artery
D. left circumflex artery
E. posterior descending branch of the right coronary artery - answer-The answer is B.
This EKG pattern is consistent with that of anterior wall myocardial infarction (MI). The
LAD supplies the anterior wall of the myocardium. The left circumflex artery, the LAD, or
a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of
, the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion
of a branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF
and I, aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in
leads II, III and aVF causes an inferior MI. The right ventricle is usually supplied by the
RCA or, less commonly, a dominant left circumflex. ST elevation in leads V4 and V5 of
a right-side leads EKG suggests infarction of the right ventricle. A posterior MI (ST
depression in V1-V3) results from occlusion of the RCA, its posterior descending
branch, or a dominant left circumflex.
E. Call cardiology - answer-The answer is D. This patient is having an acute myocardial
infarction. AMI is defined when two of the following three findings are present: clinical
history of chest pain of at least 20 minutes duration, EKG changes and/or positive
myocardial enzyme testing. This patient has ST elevation with concomitant ST
depression in contiguous leads with chest pain. She needs immediate thrombolytic
therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be
achieved within 90-120 minutes of emergency department arrival, the literature supports
its selection over thrombolytic therapy as primary intervention. In preparation for either
thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery,
decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine
will increase O2 delivery to the heart. A beta blocker, which should also be administered
to AMI patients who lack contraindications, will decrease the work of the heart, and
aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered -
selections will depend on the exact treatment course chosen for the patient.
Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being
dependent on exact treatment course for patient) should be started if there are no
patient historical or chest X-ray findings suggestive of aortic dissection.
A 72-year-old male presents with five hours of substernal chest pain and pressure
despite taking three sublingual nitroglycerin. You order an EKG. What findings on the
EKG would indicate that this patient is potentially a candidate for thrombolytic therapy?
A. Ventricular tachycardia
B. ST-segment elevation of at least 1 mm in two or more contiguous leads
C. ST-segment depression of at least 2mm in any precordial lead
D. Atrial fibrillation with a rapid ventricular response - answer-The answer is B.
"Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time
to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm ST-
segment elevation in two or more contiguous leads."
A 58-year-old male previously in good health presents with chest pain for two hours.
Vital signs are BP 126/78, HR 80 (sinus rhythm), RR 14, oxygen saturation 99%, T
36.8. His EKG shows ST segment elevation in leads II, III, aVF and V1. ST-segment
