Should we send this patient home? He had a normal stress test 10 days ago…

Dive into this ER scenario with CME4LIFE Cardiology Expert, Jennifer Carlquist, PA-C.

In the face of an emergency situation it is our critical thinking skills and ability to recall information in the face of pressure that are put to the test. At times, there can also be varying factors that can pose as a distraction. Jennifer Carlquist shares this ER scenario that highlights the importance of being able to analyze details and an EKG finding that ultimately saved this patient’s life.

The Patient

• Male
• 50 years old
• Smoker
• History of Hyperlipemia, previous stent, and on Plavix and ASA

Case:

This was a 50 year old male smoker with a history of hyperlipemia, previous stent, on Plavix and ASA who presented for chest pain to the ER. This was his second visit for chest pain. He was chest pain free with one NTG SL, and his first troponin was negative. There was some discussion about sending him home if his second troponin was normal. Was this the right thing to do?

It was tempting to rely on the patient’s recent stress test that was done 10 days prior but, these tests are not always accurate. If a patient has significant risk factors such as previous stent or smoking history, they have a high index of suspicion for new disease.

Analysis:

This patient has classic “Wellens Sign” and there is a high mortality rate associated with sending a patient home with this sign. It usually means they have a high grade LAD occlusion that will require intervention (PCI). The cardiologist was called, and he came in took him to the cath lab. He required a stent in his LAD due to an 80% occlusion noted. The second troponin came back while he was in the cath lab and was 8. Wellens sign is found in V2 and V3 (can extend into V4,V5,V6 as well). You will see inverted or biphasic T waves in V2 and V3. The patient can be pain free at the time of the ECG. If stress tested or if they are not stented they have a high risk of dying within the next week. This is definitely a “Can’t Miss EKG Finding” that the EKG machine software wont always pick up.

Want to improve your knowledge of cardiology and EKGs? Try our “at-home” CME materials.

About Jennifer Carlquist, PA-C:

Jennifer works full time in cardiology and part time in an emergency room and urgent care clinic. She has lectured at conferences across the country on EKGs and cardiology related topics and her work has even been published in the Journal of the American Academy of Physician Assistants (JAAPA). Jennifer is an alumni of the University of California, Davis PA Program in Sacramento, CA.