Using 12 Lead to Rule Out MI: A bad move?

[BEorP]

I was recently speaking with a friend (Primary Care Paramedic) who had a patient with a history of more than five MIs and a heart transplant who was suffering from chest pain like his past MIs. After a variety of assessments, my friend decided that the pain was most likely non-cardiac and did not treat it with ASA or nitro.

Given all assessments performed, he may have been right to call the pain non-cardiac, but my concern is the weight that was put on the 12 lead being normal. As much as having a 12 lead showing STEMI could possibly improve care by decreasing the time in the ED, couldn't it be a risky thing if it makes medics think non-cardiac without considering the possibility of a non-STEMI? It seems to me like 12 leads should be used more to call a unique presentation as cardiac rather than what seems like a typical presentation non-cardiac (since I think that I have heard that about half of MIs are non-STEMI).

Thoughts?

[DwayneEMTP]

Yeah, I posted a thread similar to this in the past and was shocked by the answers.

I think many said that...and I'm trying to remember, not quoting...that 30-40% of AMI will not present on a 12 lead?!

I believe this is truly a case of "treat the patient, not the monitor."

Someone smarter than I will likely post a link to the thread...but this is a great question.

Dwayne

[Doczilla]

Ruling out an acute MI with a normal 12 lead is a terrible idea. Only 30%-50% of acute MI's show acute EKG changes.

I'm not sure what "assessments" your friend used, but unless they included serial cardiac enzymes over several hours and a stress test/echo, he was incorrect.

'zilla

[FUBAR]

All I have to say is WOW! Now from what i have been thought and follow is treat the pt not the machine. He is having c/p simular to previous M.I's, and has an extensive cardiac hx, for the love of god treat it. As for the absence of elevation in the 12 lead, I would agree with possibility of non-stemi mi. The only reliable way to rule out an MI is through labs.

[chbare]

Hard to say without all of the information. The medic's decision was based entirely on his assessment of the 12 lead? I wonder if there were other factors to consider?

In addition, a s/p cardiac transplant patient experiencing typical chest pain from an AMI would be a little unusual. Remember, the heart is not directly linked to the nervous system. In many cases, transplant patients will not know they even had an MI. Signs and symptoms of CHF (dyspnea, activity intolerance, etc) would be of concern however.

Not to discredit your concern, just additional information for consideration.

Take care,

chbare.

[BEorP]

Yeah, I posted a thread similar to this in the past and was shocked by the answers.

I think many said that...and I'm trying to remember, not quoting...that 30-40% of AMI will not present on a 12 lead?!

I believe this is truly a case of "treat the patient, not the monitor."

Someone smarter than I will likely post a link to the thread...but this is a great question.

Dwayne

:oops: I did not see that thread in my search. If anyone has it I would love to look at it.

[BEorP]

Hard to say without all of the information. The medic's decision was based entirely on his assessment of the 12 lead? I wonder if there were other factors to consider?

In addition, a s/p cardiac transplant patient experiencing typical chest pain from an AMI would be a little unusual. Remember, the heart is not directly linked to the nervous system. In many cases, transplant patients will not know they even had an MI. Signs and symptoms of CHF (dyspnea, activity intolerance, etc) would be of concern however.

Not to discredit your concern, just additional information for consideration.

Take care,

chbare.

His decision was not based entirely on the 12 lead, but he seemed to weight it very strongly. I kept the information vague because I was looking for more general answers, rather than a critique of this specific call since I wasn't there and don't have all the info. Apparently, the patient had had at least one MI with the new heart, and this is what if felt like. In this specific case, the pain did also change to some degree after their arrival and may have began to feel more like indigestion to the patient (I only spoke a bit about this call with my friend so I do not have all the information.)

Thanks to everyone for the input!

[spenac]

I have had patients with all the signs/symptoms of an MI but have normal sinus rhythm. Get to hospital they are positive for MI. The only thing an EKG does is give you another tool to help confirm your diagnosis, but not rule it out. As already mentioned, treat the patient not the machine.

[northernmedic]

Given the Hx you have provided I would say the benefit of treating the pt with ASA far outweighs the risk (provided there are no contraindications). I agree with what Doczilla said. With a history that extensive this guy should pretty much get the full deal until he has a complete cardiac workup. 12 leads are useful but it seems like they are becoming they new EMS lunchbox toy. The only difference it makes to my treatment plan at the end of the day is whether I am going to transport to a STEMI receiving hospital or not.

[ccmedoc]

Using 12 Lead to Rule Out MI: A bad move?

Yes..very bad move :roll: