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Bradycardia: take a second history before a second troponin : Emergency Medicine News


ECG, cardiology, diagnosis, troponin


A man in his 60s with no significant medical history presented with chest pain and the triage report indicated that he had constant chest pain without syncope, shortness of breath, fever, cough or other symptoms for three weeks.

His vital signs were normal except for a blood pressure of 182/99 mm Hg, which was symmetrical. Physical examination was otherwise normal and an ECG was performed. The computer read it as sinus bradycardia at 59 bpm but otherwise normal.

Troponin, other blood tests and chest X-ray all returned to normal. What additional information was most critical in interpreting the ECG and troponin results? The irradiation of the pain, the aggravating factors, the duration and the moment of the pain, or the associated symptoms?

ECG analysis

My interpretation of the ECG was that it was basically normal if a normal heart rate is considered to be 50-90 bpm, which is what I generally think.

Stephen W. Smith, MD, the author of Dr. Smith’s ECG Blog, said he saw a subtle up and down T wave in lead III and a flat, long ST segment in the aVL. This is consistent with what he called inferior Wellens reperfusion syndrome after myocardial infarction by occlusion affecting the inferior wall. Such an ECG is often seen in patients who had chest pain but no longer have pain, he said, adding that such ECG findings are almost always associated with a heart attack. He said he would expect at least some troponin elevation above the 99e URL percentile (acute IM). It’s possible with such subtle results that we could see a rise and fall below this URL (unstable angina), Dr. Smith said, noting that he would expect an angiogram to show a culprit in the artery supplying the lower wall.

The radiating pain experienced by the patient was important and could be indicative of a diagnosis, especially if it radiated to the back, the right arm or both arms, but it was not really important for the interpretation of the ECG or the troponin. Aggravating factors are important in indicating a diagnosis, especially if the pain was pleuritic, positional, or exertional, but they are also not really important for the interpretation of ECG or troponin.

Associated symptoms are important because they can increase worry, particularly if the patient is sweating or vomiting, but are not really important for the interpretation of ECG or troponin. The duration and timing of the pain is the correct answer. An ECG or troponin cannot be correctly interpreted without asking if the patient is still in pain and without probing to determine the duration of the episodes. “Constant” pain for patients often means pain that keeps coming back.

Case lessons

Troponin and blood tests were normal. A better history was obtained, and the patient’s constant chest pain was actually episodes lasting five to 15 minutes with the most recent episode more than six hours before presentation. He was put on heparin, but the hospitalist pushed back because the troponin was normal, and he wanted to see the patient himself. He later recommended a second troponin with discharge home if negative. I’ll report what happened next month.

Too many patients believe ‘frequent’ is the same as ‘constant’, but asking the right questions can make the difference between the two. Classic unstable angina with episodic chest pain lasting five to 15 minutes is a common presentation, and ECG and troponin will usually be normal. You could be misled into sending a high-risk patient home if you don’t take a good history. Physical examination, ECG, and troponin, even high-sensitivity troponin, are often unnecessary in unstable angina. The HEART score can also get you in trouble here. The diagnosis of unstable angina is 100% a story, so take a good one! My axiom: Do a second story before you do a second troponin.

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Dr Pregersonis an emergency physician at Palomar and Tri-City Medical Centers in San Diego. He is the author of 1 Minute Emergency Medicine Consultation, 8 in 1 Quick Reference for Emergency Services, A to Z Emergency Pharmacopoeia and Antibiotics Guide, and Think twice: no more lessons from urgency. Follow him on Twitter@EM1MinuteGuru, and visit their sites Read his past columns on