Case Files 10 - My aching stomach - SOLVED

A 53 years old Malay gentleman with no known medical illness came to ED complaining of worsening epigastric pain for the past 3 days.He had earlier seek treatment from a GP 2 days ago and was treated as gastritis. He was discharged with syrup MMT and oral ranitidine. He claimed that the symptoms improved after taking the medication, albeit not completely.

However, today, the pain worsened and became rather severe, hence the reason he made a trip down to the ED. He was given syrup MMT and ranitidine and a baseline ECG was done. Routine blood investigations was done and it was noted that cardiac enzymes were normal as well.

2 hours later, the patient was noted to be sweating. He looked lethargic and pale. He still complained of epigastric pain. A repeat ECG was done in view of the patient's discomfort.
Normal 12-lead ECG
Posterior lead ECG
Inferior ECG

What would be your intepretation? Is there any bedside test to confirm your diagnosis? Any further blood investigations that can be taken?


The 12-lead ECG showed significant ST - elevation over the inferior leads II, III, aVF whilst the lead V1-V3 showed ST depression. In a case of inferior MI, it is prudent to do a right sided ECG and posterior lead ECG The reason being is that inferior segment of the heart is supplied by the right coronary artery, which also supplies the right and posterior aspect of the heart. An occlusion at the right coronary artery that affects the inferior aspect may affect the other 2 as well. Of coursem other signs may include bradycardia and subsequent hypotension, as a result of sinuatrial node involvement, which is also supplied by the right coronary artery.

The right sided ECG showed no ischemic changes over the right aspect of the heart, but a quick look at the posterior leads showed significant ST-elevation as well.

Hence, this is an acute inferoposterior myocardial infarct. A bedside ECHO can be done and for this patient, there is hypokinesia over the inferoposterior region, correlating with the ECG findings. Cardiac triple test (bedside rapid test) was done for this patient. Myoglobin and CKMB was positive whilst TnI was negative, suggestive of recent onset basis. (Kindly refer to Malaysian CPG for acute coronary syndrome to have a quick review of the peak and through of the cardiac enzymes).

The patient was started on streptokinase fibrinolytic therapy in view of no PCI in the center. 1.5mU Streptokinase was given in 100cc normal saline over 1 hour (there are 2 other recommended regime). The streptokinase was witheld once midway as patient developed hypotension (side effects of streptokinase therapy) and restarted slowly once BP picked up after 1 pint of NS was given. Repeated ECG showed good resolution of the ST elevation and the patient was sent to CCU for close monitoring and management.

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