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.