EXTRA COPY — ECG Blog #543: A 24-Hour Holter was Done- EXTRA COPY

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Figure-1: The initial ECG in today's case.

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Acknowledgment: My appreciation to ANONYMOUS? OR Passang Jinpa (from Guayaquil, Ecuador) — for allowing me to use this case and this tracing.

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Passang Jinpa — Guayaquil, Ecuador (Cardiologist at a free clinic! ) – 7/31/2026

THE CASE — Passang Jinpa

An 80-year-old woman presented with mild dizziness and fatigue, denying chest pain or dyspnea. Resting12-lead ECG showed marked sinus bradycardia with biphasic T-wave changes in anterior precordial leads, suggestive of a Wellens pattern. Ambulatory heart rate response was preserved. Echocardiography revealed regional wall motion abnormalities in the basal and mid-anteroseptal segments with sinus bradycardia throughout. A 24-hour Holter monitor was ordered.

 

Clinical Timeline: Day 1: Resting 12-lead ECG. Day 2: 24-hour Holter monitoring initiated. Day 3: Patient found deceased while wearing the Holter monitor. Retrospective review of the Holter recording captured the entire electrocardiographic evolution of the acute myocardial infarction, from initial ischemic changes through ST-segment elevation to the terminal arrhythmia.

 

What should I've done at first? Cath lab activation?

On Day-2 when she came to clinic no chest pain, absolutely fine.

 

MY REPLY:

Be sure to carefully review my ECG Blog #350 (https://ecg-interpretation.blogspot.com/2022/12/ecg-blog-350-severe-cp-not-much-on-ecg.html ) that reviews what Wellens' Syndrome truly is. Be sure to also review material in the Addendum (including the 8 minute Audio Pearl). So your patient did not have a true "Wellens' Syndrome" — because there was no history of chest pain that then went away. But it's important to remember the pathophysiology of Wellens' Syndrome (which I review in Blog #350) — as well as the fact that an IDENTICAL ECG may be seen AFTER an infarction. And in older patients — a "silent" MI (ie, an MI but without any chest pain) is the probable explanation for the T wave inversions that we see in your patient's ECG. So my main questions would relate as to WHEN the patient had those symptoms of mild dizziness and fatigue. It is a very fine line as to which older patient who you strongly suspect has had a "silent MI" needs to be hospitalized until you can be comfortable that their condition has stabilized. So — IF this patient's symptoms were in the last day or two — and especially since the heart rate on this ECG is SLOW (about 50/minute) — a period of monitoring in the hospital would seem warranted. Were Troponins done? If so — and if still elevated, that's another clue that this patient's MI was recent — and if this is a fully functioning 80-year old — cardiac cath should probably have been done before sending the patient home. P.S. Again, the history here is very subtle — but serial Troponins and serial ECGs may have provided insight as to WHEN the MI occurred (and the need for cath). Finally — Before I'd want to send this patient home — I would want to see if she is able to walk at a level comparable to doing her everyday activities. Ideally she is monitored when you do that. The point is that many patients don't want to stay in the hospital — but if this 80 yo woman normally is able to walk everywhere — and now she gets fatigued on much less activity — that's one more sign that she has had a recent MI that may not yet have "completed" (such that cath may be indicated before she goes home). TOUGH case. I hope the above is 

helpful ...

 

 

PASSANG Reply:

Dear Guru KEN, Thank you very much for your thoughtful comments and for taking the time to review my case. I really appreciate your insights. This was actually the patient's first medical evaluation. She had never previously seen a physician. I work in a charitable foundation that provides free outpatient cardiology consultations. Although it functions as a private clinic, patients are responsible for any additional investigations or hospital care, and many have significant financial limitations. Clinically, she looked remarkably well. She was an active 80-year-old woman who came with a friend in her 90s. They were both independent, regularly went shopping together, and she denied chest pain or dyspnea. She only mentioned mild fatigue. Because she appeared so functional and stable, I did not initially suspect an acute coronary syndrome. On the first day, I obtained a 12-lead ECG and observed an abnormal T-wave pattern. I ordered routine laboratory tests, but unfortunately I did not obtain troponin levels. Immediate coronary angiography was also not a realistic option because of the patient's financial situation. What makes this case particularly fascinating is what happened afterward. A 24-hour Holter monitor had been placed, and sadly, the patient was found deceased the following day before returning to have it removed. During my retrospective analysis of the Holter recording, I was able to observe the complete electrical evolution—from the initial ischemic T-wave abnormalities, through progressive ST-segment elevation, and ultimately to the terminal rhythm. The transition began at approximately 11:00 PM. To my knowledge, it is uncommon to have continuous Holter documentation of the entire evolution of an untreated myocardial infarction ending in sudden death. I believe this provides a unique opportunity to correlate the initial 12-lead ECG with the continuous ischemic progression. Do you think this case would be suitable for publication as a case report? If so, I would greatly appreciate any suggestions regarding the best way to present it or which aspects should be emphasized.

 

MY REPLY:

Hi. I can totally relate to ALL that you describe. Knowing more of the details — I may have done what you did.

My training is in family medicine. I was faculty in a Family Medicine Residency for 30 years — so we would see ambulatory patients and on occasion we'd get a history similar to what you describe, in which you suspect that an MI occurred days earlier. So the question then arises as to HOW MUCH to do for a "completed MI?" in an older patient who doesn't want to come into the hospital.

I am also familiar with free clinics as you describe (but for which funding is lacking if additional investigations are needed. You deserve CREDIT for providing care to people who otherwise have NO care .... but situations like this one are clearly frustrating!

In retrospect — the only thing I could say is that subtle change in symptoms (ie, development of some new "fatigue" in recent days in an older person with the initial ECG that you show is suggestive that a recent MI may have occurred, and that we are now seeing reperfusion T waves. What to do with this IF the patient otherwise "seems well" is a difficult question and "Ya gotta be there!" because there is NO certain answer.

In my capacity as hospital Attending for 3-4 months each year — I would read all of our service ECGs and I'd see the Holter Monitors. I will NEVER forget reading ECGs one day — and seeing a Holter monitor of a hospitalized patient, when I suddenly saw on the Holter that the rhythm was getting slower and slower — and then stopped. So I ran up to the floor where this patient was — only to find everyone at the bedside treating her cardiac arrest. It was an EERIE feeling seeing that Holter, and then seeing the patient (just like the eerie feeling that I'm sure you have when you saw these tracings!).

The above said — YES, this is rare to catch this — but I'm not sure you have best exposure by writing an article. Instead — I propose that you let me write an ECG Blog Case that I will publish within a couple weeks. I will show the 12 lead ECG that you sent me and ask the reader how they will interpret this?

I will write up the case giving enough basic info to "set the scene" — but I will not give specific details that may identify the patient. And then I will show the sequential tracings you sent me (that I put into a PDF here).

When I was on faculty — I would "collect" code tracings and later went thru them for insight while I was writing my books on ACLS. So these sequential tracings that you sent me show a similar sequence of events as this unfortunate woman evolved her huge extensive LAD occlusion.

These are TOUGH cases. Given age, vague symptoms (!!!) and lack of resources — there is no right or wrong answer — but the fact that you are soul searching events is sign that YOU are truly a good, caring physician doing the best you can given limited resources for the best you can do for your patients. Many clinicians would not give this case a second thought ....

Is it OK with you that I write this case up as an ECG Blog? I would be happy to acknowledge you if you like? — or the case can be anonymous — JUST LET ME KNOW. It will be published as a Blog post on-line, so it can be referenced by a link to my Blog.

Let me know what you prefer. THANK YOU for sharing this very difficult case with me. I believe it IS worthwhile to soul search events and think IF there is anything for you to learn from this OR if in fact you considered everything and from the information you had simply thought this was a completed MI with not much to gain by hospital admission in an older, minimally symptomatic patient. Putting older patients in a hospital is NOT benign, as "things happen" in the hospital ...

Should I acknowledge you as Passang Jinpa from Guayaquil, Ecuador — Dejame saber lo que quieres que hago por este caso — Ken