ECG of The Month — January / February 2026
Case: EMS responds to a 74-year-old male with history of end-stage renal disease on dialysis (last hemodialysis yesterday), previous heart attack, and diabetes mellitus now complaining of 3 hours of shortness of breath (SOB). Denies chest pain. On arrival, patient is alert, in mild distress due to SOB. Lungs with faint crackles at lung bases, otherwise clear to auscultation.
Vital signs: BP: 102/63 HR: 86 bpm RR: 17 SpO2:88% on room air.
Given the relatively clear lung sounds in a patient with multiple cardiac risk factors, paramedics consider cardiac ischemia as a possible cause of the patient’s SOB and perform an ECG in accordance with TP 1237, Respiratory Distress. The ECG is shown below:
ECG courtesy of the Harbor-UCLA Residency Program
What is your interpretation of this ECG?
Rate & Rhythm: Sinus rhythm 77bpm
STE Segment Elevation >1mm in contiguous leads? Yes. STEs in leads V2-V4, with greater than 2mm in V3 and V4
| Learn more about this ECG pattern ST Elevations in leads V3 and V4 are considered “typical” of an anterior STEMI. While there are no ST depressions in reciprocal leads, this does not exclude the possibility of a STEMI. |
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Patient received oxygen via nasal canula and improved his SpO2 to 95% on 4L NC.
After determining the ECG concerning for STEMI or cardiac ischemia and verifying the patient had no history of allergy to aspirin, EMS administered Aspirin 325mg chewable tablets per TP 1211, Cardiac Chest Pain.
Base contact was made for concerning ECG in patient denying chest pain to discuss destination and possible preactivation. After reviewing ECG together with the Base Physician, the decision was made to transport the patient to an SRC and to activate for STEMI prior to EMS arrival. During evaluation by Cardiology after arrival in the ED the patient endorsed intermittent chest “pressure” for 3 hours prior to calling EMS. He also reported a history of a 2-vessel coronary artery bypass graft (CABG). The patient was taken to cardiac cath lab emergently where he was found to have a 90% occlusion in the saphenous vein graft to his right posterior descending artery and received PCI with stent into the grafted vein.
- Consider an ECG in patients with respiratory distress if you suspect cardiac ischemia as a possible cause of the respiratory distress.
- ST elevations often exist without ST depressions in reciprocal leads.
- This>Administer Aspirin to patients with STEMI findings and no contraindications, even if they deny chest pain.
Author: Harbor-UCLA Residency Program