Chest Pain OSCE - STEMI

Diagnosis: STEMI

Case Overview

  • Age/Sex: 55-year-old male
  • Occupation: Office administrator (sedentary)
  • Setting: Emergency Department, brought by spouse after acute chest pain
  • Chief complaint: "Chest pain"

Patient Script

Who I Am

I'm 55, I work in an office doing a lot of sitting, and I smoke about a pack a day.

What Brings Me In

"I have crushing chest pain — it started about 45 minutes ago and I feel really sweaty and sick."

My Story

I was at my desk when, about 45 minutes ago, I suddenly got a severe, crushing pain right in the middle of my chest. It felt very heavy and pressure-like, and it started getting worse over the next few minutes. The pain spreads down my left arm and up into my jaw, and I feel nauseous and have vomited once. I'm very sweaty and a bit short of breath. I tried sitting quietly and breathing slowly but it didn't get better. I took one ibuprofen tablet earlier today for my bad knee, and last night I had a spicy meal that gave me some indigestion, but this pain feels very different — it's worse and won't go away. I haven't had anything like this before.

My Medical Background

  • Past medical history: high blood pressure diagnosed 3 years ago (on tablets irregularly), occasional heartburn; no previous heart attacks
  • Medications: takes his antihypertensive pills sometimes (not every day), occasional ibuprofen for knee pain
  • Allergies: none known
  • Social: current smoker ~20 cigarettes/day; drinks 2–3 units alcohol on weekends; sedentary job, minimal exercise
  • Family history: father had a heart attack at 60

What I Think & Worry About

  • "I think this might be a heart attack — I'm scared I'm going to die."
  • "I'm worried about what will happen to my family if something happens to me."
  • "I just want the pain to stop and to know if it's serious."

If You Ask Me About Other Symptoms...

  • Chest pain: "Central, crushing, 9/10 when it started, now 8/10 — going into my left arm and jaw."
  • Shortness of breath: "A little breathless, not like asthma — it's worse with the pain."
  • Cough: "No cough, just a bit of a sore throat last week but that's gone." (red herring)
  • Recent long travel: "I drove for about two hours yesterday for work, but I felt fine." (distractor)
  • Reflux/indigestion: "I had heartburn last night after spicy food, and I sometimes get indigestion, but this pain is much worse and different." (red herring)
  • Recent heavy lifting: "I helped move a filing cabinet two days ago and my back was a bit sore — but the pain now isn't in my back, it's in my chest." (red herring)
  • Palpitations: "My heart feels like it's racing sometimes with this pain."
  • Dizziness / fainting: "A bit lightheaded now when I stood up earlier."
  • Leg swelling / pain: "No swelling or pain in my legs."

Clinical Summary

Examination

  • General: patient anxious, diaphoretic, clutching chest, pale
  • Conscious level: alert, oriented to person/place/time
  • Heart rate: 110 beats per minute, regular
  • Blood pressure: 85/55 mmHg (hypotensive)
  • Respiratory rate: 24 breaths per minute
  • Oxygen saturation: 94% on room air
  • Temperature: 36.7 °C
  • Cardiac exam: S1/S2 present, audible S3; no murmurs noted
  • Chest exam: bibasal fine crackles on auscultation (mild pulmonary oedema)
  • Peripheral: cool clammy peripheries, capillary refill 4 seconds
  • JVP: not elevated
  • Chest wall: no focal reproducible chest wall tenderness

Investigations

  • 12-lead ECG: ST-elevation 4 mm in V1–V4 with reciprocal ST depression in II, III, aVF (interpretation: acute anterior STEMI)
  • Troponin I (on arrival): 0.8 ng/mL (normal <0.04) (interpretation: elevated, acute myocardial injury)
  • Troponin I (3 hours): 12.5 ng/mL (rising)
  • CK-MB: elevated (consistent with myocardial necrosis)
  • Chest X-ray: mild pulmonary congestion, cardiothoracic ratio normal
  • ABG (on room air): pH 7.34, pO2 80 mmHg, pCO2 34 mmHg, lactate 3.0 mmol/L (mild lactic acidosis)
  • FBC: WCC 11 x10^9/L, Hb 14 g/dL, platelets 210 x10^9/L
  • U&E: Na 138 mmol/L, K 4.2 mmol/L, creatinine 120 µmol/L (eGFR mildly reduced)
  • Glucose (capillary): 8.6 mmol/L
  • Coagulation: INR 1.0

Diagnosis

  • Primary diagnosis: Acute ST-elevation myocardial infarction (anterior wall STEMI)

    • Evidence: classic severe central crushing chest pain radiating to left arm and jaw, diaphoresis and nausea, major risk factors (male, age 55, smoker, sedentary, hypertension, family history), ECG showing ST-elevation in V1–V4 with reciprocal changes, and rising troponin.

  • Important differentials (and reasoning):

    • Acute coronary syndrome—unstable angina/NSTEMI: less likely because of diagnostic ST-elevation and markedly raised troponin
    • Aortic dissection: can present with severe chest pain but usually has tearing pain radiating to back and BP discrepancy; not supported by exam/ECG
    • Pulmonary embolism: causes chest pain and shortness of breath, but ECG changes and troponin pattern support myocardial infarction; SpO2 relatively preserved and no unilateral leg signs
    • Oesophageal rupture / severe reflux: may mimic chest pain but would not give ST-elevation pattern or troponin rise
    • Musculoskeletal chest pain: pain reproducible on palpation would point to this; patient denies focal chest wall tenderness

Management

  • Immediate resuscitation and monitoring:

    • Continuous cardiac monitoring, IV access (two large-bore cannulae), cardiac arrest trolley at bedside
    • Call cardiology and activate primary PCI (percutaneous coronary intervention) pathway immediately (goal door-to-balloon <90 minutes)

  • Immediate pharmacological measures (unless contraindicated):

    • Aspirin 300 mg chew immediately
    • Give P2Y12 inhibitor loading dose (e.g., ticagrelor 180 mg) if PCI is planned and no contraindication
    • Unfractionated heparin bolus per local protocol (for PCI pathway)
    • High-intensity statin (e.g., atorvastatin 80 mg) immediately
    • Sublingual GTN for pain if systolic BP >90 mmHg and no suspicion of RV infarct (use with caution given hypotension)
    • Analgesia (e.g., IV morphine) for severe pain if needed, monitoring for hypotension
    • Oxygen only if SpO2 <90% (current SpO2 94% so oxygen not routinely given)

  • Supportive / urgent management for shock and complications:

    • Given hypotension and pulmonary oedema: prepare inotropes/vasopressors (e.g., norepinephrine) if persistent hypotension after initial measures; consider ICU/high-dependency admission
    • Monitor urine output and renal function
    • Prepare for possible arrhythmias—defibrillator available

  • If PCI cannot be performed within guideline timeframe: consider thrombolysis after discussion with cardiology and excluding contraindications

  • Secondary prevention to start once stable: dual antiplatelet therapy, ACE inhibitor, beta-blocker (when haemodynamically stable), high-intensity statin, smoking cessation referral, cardiac rehab planning

Key Learning Points

  • Obtain a 12-lead ECG within 10 minutes in any patient with chest pain; ST-elevation with compatible history mandates immediate reperfusion strategy (primary PCI preferred).

  • Initial ED management focuses on early antiplatelet therapy (chew aspirin), rapid activation of the PCI pathway, haemodynamic support, and monitoring for complications (arrhythmia, cardiogenic shock); oxygen is given only if hypoxic.

  • Beware red herrings: recent reflux, musculoskeletal strain, or anxiety do not exclude myocardial infarction — use history, ECG, and biomarkers to guide diagnosis.

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