CASE OF THE MONTH: Not All Heart Attacks Are Created Equal

Mikhail Narezkin, M.D., John M. Buergler, M.D.
December 2018


A 79-year-old man was brought by emergency medical services (EMS) to an outside hospital after experiencing severe chest pain followed by syncope. At home, he was found to be in acute respiratory distress and required intubation by EMS while en route. On arrival to the hospital, his blood pressure was 93/54 mm Hg and heart rate was 80 bpm. His oxygen saturation was 100%. Neck veins were mildly distended. Auscultation of lungs showed diffuse rales, and a holosystolic murmur was audible at the apex. Lower extremities were cool with mild edema.

An electrocardiogram (ECG) done upon arrival showed sinus rhythm anterior ST segment elevation and T-wave inversion consistent with ST-segment elevation myocardial infarction (STEMI) but also with loss of R-wave progression in the anterior leads (Figure 1). The patient was taken acutely to the catheterization laboratory where a total occlusion of the left anterior descending artery (LAD) was seen right after the origin of a first septal perforator (Videos 1, 2).

Figure 1. Electrocardiogram done in the emergency department.


Video 1. Injection of left coronary artery (LCA) in the caudal RAO view.


Video 2. Injection of LCA in the caudal RAO view.