# Clinical Case Report

Patient 58-year-old Male
Setting Emergency Department
Specialty Emergency / Cardiology
Format SOAP

## Chief Complaint

Severe substernal chest pain for 2 hours with radiation to the left arm and jaw, associated with profuse diaphoresis and nausea.

## History of Present Illness

This is a 58-year-old male with a background history of hypertension, type 2 diabetes mellitus, and hyperlipidaemia who presents to the emergency department with a 2-hour history of severe, 9/10 intensity, pressure-like chest pain localised substernally. The pain began abruptly at rest at approximately 14:30 and radiates to the left arm and jaw.

The pain is associated with profuse diaphoresis, nausea, and one episode of non-bloody vomiting. The patient reports no dyspnoea, no palpitations, and no pre-syncopal symptoms. There is no pleuritic component, no positional variation, and no relief with antacids.

The patient has never experienced this type of pain before. He denies recent travel, prolonged immobility, or lower limb swelling. He has not taken any nitrates prior to arrival. His regular medications were taken this morning. He has a 30 pack-year smoking history (10 cigarettes/day, ongoing) and drinks alcohol occasionally. His father died of a myocardial infarction at age 62.

## Past Medical History

- Hypertension — diagnosed 8 years ago, on treatment
- Type 2 Diabetes Mellitus — diagnosed 5 years ago, on oral hypoglycaemics
- Hyperlipidaemia — diagnosed 5 years ago, on statin therapy
- No prior cardiac history. No previous myocardial infarction.
- No history of stroke, peripheral vascular disease, or renal disease

Current Medications:

- Metformin 1g PO twice daily
- Amlodipine 5mg PO once daily
- Atorvastatin 40mg PO at night

Allergies: No known drug allergies. No known food allergies.

Social History: Lives with family and has good home supports. Current smoker — 10 cigarettes/day, 30 pack-years. Alcohol: occasional, less than 14 units/week.

## Vital Signs

⚠ Critical — Activate Cath Lab ST elevation ≥3mm in leads II, III, aVF with reciprocal changes in I and aVL. Patient meets STEMI criteria. Door-to-balloon time target: <90 minutes.

Vital Signs
Parameter | Value | Reference Range | Status
--- | --- | --- | ---
Blood Pressure (Systolic/Diastolic) | 88 / 60 mmHg | 90–140 / 60–90 mmHg | ⬇ Hypotensive
Heart Rate | 112 bpm | 60–100 bpm | ⬆ Tachycardia
Respiratory Rate | 22 breaths/min | 12–20 breaths/min | ⬆ Elevated
Oxygen Saturation (SpO₂) — room air | 94% | ≥96% | ⬇ Low
Temperature | 37.1°C | 36.5–37.5°C | Normal
Glasgow Coma Scale | 15 / 15 | 15 | Normal
Capillary Refill Time | 3 seconds | <2 seconds | ⬆ Prolonged

## Physical Examination

General: Diaphoretic, pale, and in obvious discomfort. Alert and oriented to person, place, and time. Appears acutely unwell.

Cardiovascular: Jugular venous pressure elevated at approximately 4cm above the sternal angle. Heart sounds S1 + S2 present, no murmurs, no added sounds. Peripheral pulses palpable but weak bilaterally. Capillary refill 3 seconds peripherally. No peripheral oedema.

Respiratory: Respiratory rate 22/min. Air entry bilaterally. Fine bibasal crepitations present, right greater than left. No wheeze. Dull to percussion at right base. No use of accessory muscles.

Abdomen: Soft, non-distended, non-tender. No organomegaly. Bowel sounds present and normal. No renal angle tenderness.

Neurological: GCS 15/15. Pupils equal and reactive 3mm bilaterally. No focal neurological deficits. Cranial nerves grossly intact.

Skin / Peripheries: Pallor and diaphoresis. No rash, no jaundice, no cyanosis.

## Investigations

12-Lead ECG:

ECG — STEMI Criteria Met Sinus tachycardia at 112 bpm. ST elevation 3mm in leads II, III, aVF. Reciprocal ST depression in leads I and aVL. PR interval and QRS morphology otherwise normal. No left bundle branch block. Right-sided leads (V3R–V6R) ordered to exclude RV infarction.

Laboratory Results:

Laboratory Results
Investigation | Result | Reference Range
--- | --- | ---
Troponin I (high-sensitivity) | 2400 ng/L ⬆ | <40 ng/L
CK-MB | 48 U/L ⬆ | <25 U/L
BNP (B-type Natriuretic Peptide) | 520 pg/mL ⬆ | <100 pg/mL
Haemoglobin | 13.8 g/dL | 13.5–17.5 g/dL
White Blood Cells | 11.2 × 10⁹/L | 4.0–11.0 × 10⁹/L
Platelets | 224 × 10⁹/L | 150–400 × 10⁹/L
Sodium | 138 mmol/L | 135–145 mmol/L
Potassium | 4.1 mmol/L | 3.5–5.0 mmol/L
Creatinine | 98 µmol/L | 62–106 µmol/L
eGFR | 72 mL/min/1.73m² | ≥60 mL/min/1.73m²
Glucose (random) | 9.4 mmol/L ⬆ | 4.0–7.8 mmol/L
HbA1c | 7.8% ⬆ | <7.0% (diabetic target)
Total Cholesterol | 5.9 mmol/L ⬆ | <5.2 mmol/L
LDL Cholesterol | 3.8 mmol/L ⬆ | <2.0 mmol/L (high-risk target)
INR | 1.1 | 0.8–1.2
Lactate | 2.8 mmol/L ⬆ | <2.0 mmol/L
Arterial pH | 7.31 ⬇ | 7.35–7.45

Chest X-Ray (Portable AP): Mild cardiomegaly. Pulmonary vascular congestion with upper lobe diversion. Small right pleural effusion. No pneumothorax. No mediastinal widening.

Bedside Echocardiogram (Emergency): Inferior and inferolateral wall hypokinesia. Estimated ejection fraction 40%. No pericardial effusion. No obvious valvular pathology on this limited study. Right ventricle appears mildly dilated — formal right-sided assessment pending.

## Assessment

Primary Diagnosis: Inferior ST-Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock. Most likely culprit vessel: Right Coronary Artery (RCA) based on inferior lead involvement.

Killip Class: IV — Cardiogenic shock (hypotension + end-organ hypoperfusion). | Shock Index: 1.27 (HR/SBP — normal <0.7)

Differential Diagnosis:

1. Inferior STEMI — RCA Territory Most Likely

ST elevation in leads II, III, aVF with reciprocal depression in I and aVL is the hallmark ECG pattern of inferior STEMI. Elevated troponin I (60× upper limit of normal) and inferior wall hypokinesia on bedside echo confirm ongoing myocardial injury. Cardiogenic shock (SBP 88, elevated lactate 2.8, BNP 520) indicates significant haemodynamic compromise. Right ventricular involvement must be excluded with right-sided leads before initiating fluid therapy.

2. Type A Aortic Dissection Considered, Less Likely

Severe chest pain with radiation to the jaw raises dissection in the differential. However, the pain character is pressure-like rather than tearing, there is no pulse deficit, no limb ischaemia, and no mediastinal widening on CXR. The ECG and troponin pattern is more consistent with primary ACS. Dissection is lower probability but cannot be fully excluded without CT aortogram if clinical doubt persists after ECG correlation.

3. Massive Pulmonary Embolism Unlikely

Haemodynamic instability and low SpO₂ are consistent with massive PE. However, the patient has no PE risk factors (no recent travel, immobility, or DVT history), the ECG shows inferior ST elevation rather than right heart strain or S1Q3T3 pattern, and the troponin rise matches ACS kinetics. Bedside echo shows inferior wall hypokinesia rather than RV dilation as the dominant finding. PE is considered unlikely.

4. NSTEMI / Unstable Angina Excluded

The presence of ≥1mm ST elevation in two contiguous inferior leads, combined with the degree of troponin elevation, meets full STEMI criteria. NSTEMI is excluded by the ECG findings.

## Management Plan

1. Immediate — Revascularisation (Priority)

- Activate cardiac catheterisation laboratory — target door-to-balloon time <90 minutes
- Primary Percutaneous Coronary Intervention (PCI) of culprit lesion (RCA) — preferred strategy over thrombolysis
- Urgent cardiology consult — notify interventional cardiologist immediately
- Obtain right-sided leads (V3R–V6R) before any fluid administration to exclude RV MI

⚠ Medication Safety Checks — confirm before prescribing

- Known (from this case): No documented drug allergies; eGFR 72 mL/min/1.73m² (renal function currently preserved — monitor closely around contrast and acute illness); no current anticoagulants documented; patient is male, age 58
- Weight not provided — weight-based dosing (e.g. heparin bolus) should follow local formulary/protocol once weight is confirmed
- Bleeding risk not assessed — confirm no active bleeding, recent surgery, or prior intracranial haemorrhage before dual antiplatelet therapy
- Hepatic function not documented — review prior to high-dose statin and ACE inhibitor initiation
- Pregnancy status not applicable (patient is male, age 58)
- All doses below are educational/simulated. Verify against your local formulary, current guidelines, and full patient context before administering.

2. Antiplatelet and Anticoagulation

- Aspirin 300mg PO loading dose — stat, then 75mg PO once daily
- Ticagrelor 180mg PO loading dose — stat, then 90mg PO twice daily (preferred over clopidogrel for STEMI per ESC guidelines)
- Unfractionated heparin — IV bolus per cath lab protocol prior to PCI
- Do not administer GPIIb/IIIa inhibitor pre-PCI; consider intra-procedure per operator discretion

3. Cardiogenic Shock

- Hold IV fluids until right-sided leads reviewed — if RV infarct present, cautious fluid challenge 250mL normal saline
- If MAP <65mmHg despite fluids: commence norepinephrine infusion per local vasoactive-infusion protocol once weight and concentration are confirmed; titrate to MAP ≥65mmHg
- ICU/CCU bed request — post-PCI high-dependency monitoring
- Consider intra-aortic balloon pump or Impella device if shock refractory post-PCI — per cardiology discretion

4. Respiratory / Oxygenation

- Supplemental O₂ only if hypoxaemic (SpO₂ <94%) or in respiratory distress — use the lowest-flow device (nasal cannula or simple face mask) needed to maintain SpO₂ 94–98%; do not give routine high-flow oxygen in normoxic STEMI (may worsen ischaemia)
- If pulmonary oedema worsens and haemodynamics permit: Furosemide 40mg IV once
- Escalate to non-rebreather mask, CPAP, or intubation per local protocol if SpO₂ falls below 90% or respiratory distress worsens despite initial measures

5. Monitoring

- Continuous 12-lead ECG monitoring and pulse oximetry
- Arterial line for continuous BP monitoring given haemodynamic instability
- Repeat troponin at 3 hours and 6 hours post-admission
- Repeat ECG immediately post-PCI and at 1 hour
- Hourly urine output via urinary catheter — target ≥0.5mL/kg/hr
- Strict fluid balance chart
- Blood glucose monitoring q2h — target 6–10 mmol/L

6. Secondary Prevention (commence post-stabilisation)

- Beta-blocker: Bisoprolol — defer until fully stabilised: shock resolved, off vasopressors/inotropes, euvolaemic, no bradycardia or heart block, SBP >100mmHg and HR <110bpm; early beta-blockade in cardiogenic shock/Killip IV can worsen haemodynamics. Initiate at 1.25mg PO once daily per cardiology review post-stabilisation.
- ACE inhibitor: Ramipril 1.25mg PO once daily — commence within 24 hours if tolerated; uptitrate over weeks
- Statin: Atorvastatin 80mg PO at night — high-intensity statin regardless of baseline cholesterol
- Diabetes: Hold Metformin — renal function and contrast exposure risk. Resume 48 hours post-procedure if creatinine stable
- Dual antiplatelet therapy: Aspirin 75mg + Ticagrelor 90mg BD for minimum 12 months post-PCI
- Cardiac rehabilitation referral before discharge
- Smoking cessation counselling and pharmacotherapy referral
- Repeat echocardiogram at 6–8 weeks to reassess ejection fraction

7. Disposition

- Admit to Coronary Care Unit (CCU) post-PCI
- Expected length of stay: 3–5 days if uncomplicated post-PCI course
- Notify next of kin — serious illness discussion