The call comes in as “nausea and weakness.” Your patient is a 67-year-old diabetic woman who swears it is not her chest. She just feels “off.” Maybe it is something she ate. Her vitals look okay. Blood sugar is fine.
And somewhere in her LAD, a clot is quietly killing myocardium.
The Problem We Do Not Talk About Enough
We are trained to recognize the classic MI: crushing substernal chest pain, diaphoresis, arm pain, the whole Hollywood presentation. But studies consistently show that up to 30% of STEMIs present atypically—and certain populations are far more likely to fool you:
- Diabetics with autonomic neuropathy may feel nothing in their chest
- Elderly patients (especially women) often present with fatigue, weakness, or dyspnea
- Dialysis patients frequently describe “indigestion” or epigastric discomfort
- Post-surgical patients may attribute symptoms to their recent procedure
When to Get the 12-Lead Anyway
Here is the uncomfortable truth: if you are only doing 12-leads on patients with chest pain, you are missing STEMIs. Consider acquiring one for:
- Unexplained diaphoresis (especially if they look “gray”)
- New-onset weakness or fatigue in cardiac risk patients
- Nausea/vomiting without clear GI cause
- Syncope or near-syncope in older adults
- Epigastric pain that does not fit a clear pattern
- Dyspnea without obvious respiratory cause
- Any diabetic who “just does not feel right”
The ECG does not care about the chief complaint. Neither does the occluded artery.
Building Your Case
When your 12-lead shows ST elevation but your patient insists they feel fine, you need to advocate clearly:
- Document the objective findings alongside their subjective denial
- Communicate clearly with the receiving facility: “I have ST elevation in leads V2-V4. Patient denies chest pain but has risk factors including…”
- Trust the strip over the story
The Pearl
If something feels wrong about this patient—even without chest pain—get the 12-lead. The five minutes it takes could be the difference between a cath lab save and a code in the ED.
This clinical pearl is for educational discussion only. Always follow your local protocols and medical direction. Your protocols exist for good reasons—this content is meant to enhance your clinical thinking, not replace your guidelines.