Way Too Overdue: Subtle STEMIs, Stubborn Platelets. Part 2/2

EMS is attending to a patient with chest discomfort. A 48 yo female presents to EMS with hypertension, right sided chest pain, and the following EKG.

12 lead EKG interpretation:

There is a baseline sinus rhythm. There is minimal, but significant, ST segment elevation in leads III and aVF. Reciprocal change in the form of ST segment depression is seen in the anterior/high lateral leads. The precordial leads do not exhibit ST segment depression which makes the diagnosis of posterior wall extension less likely. This ECG is consistent with a (subtle) inferior wall ST elevation myocardial infarction.

Case discussion:

Female patients, diabetic patients, elderly patients, and patients with a history of cocaine use are at increased risk for atypical presentations of acute coronary syndromes. Cocaine causes platelet aggregation and accelerates the development of coronary plaque. Cocaine is directly toxic to myocytes and can also induce vasospasm. Providers should remain vigilant for atypical presentations and treat accordingly.

EMS transports this patient to a STEMI center and administers NTG and ASA in accordance with established protocol. The patient does not experience any hypotension and remains hemodynamically stable. Chest pain resolves upon arrival to the ED. The patient undergoes emergent coronary angiography and has a 100% occlusion of the RCA. The lesion is ballooned. Initial troponins are positive. The patient is rapidly transitioned to a cardiac step down unit and has an uneventful recovery.

Way Too Overdue: Subtle STEMIs and Stubborn Platelets March 2016 PART 1/2

SUBJECTIVE:
EMS responds to the report of a 48 yo female with chest pain. Upon arrival, the patient is in mild distress and reports sharp, intermittent, right sided chest discomfort lasting for approximately 30 minutes. The patient reports nausea, some slight diaphoresis, and denies vomiting. The patient reports recent intake of cocaine and has a history of substance abuse. The patient has no allergies.

PMHX:
HIV
HTN

OBJECTIVE: 
The patient is awake, alert, oriented, and seated in a chair. BP: 160/100, P: 80, R: 72. Sp02: 97% on RA. Lungs are clear to auscultation bilaterally. Heart sounds are regular. The abdomen is soft and the remainder of the physical assessment is unremarkable. Peripheral pulses are strong and equal.

A 12 lead ECG is obtained:

What's your interpretation and treatment plan? 
An intravenous line is started.