tag:blogger.com,1999:blog-549949223388475481.post2229854535067934038..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: What, besides large anterior STEMI, is so ominous about this ECG?Unknownnoreply@blogger.comBlogger8125tag:blogger.com,1999:blog-549949223388475481.post-22004529432894547992016-03-22T16:59:34.573-05:002016-03-22T16:59:34.573-05:00Hi Prof Smith, Lambda STE and Reverse Lambda (Reci...Hi Prof Smith, Lambda STE and Reverse Lambda (Reciprocal), if I am not mistaken was described in Brugada and it was a foreshadow of VF. A very graphic ECG with Lambda STE and Reverse Lambda in a patient is to be found Brugada Syndrome Variant Or Atypical Brugada Syndrome<br />http://www.fac.org.ar/qcvc/llave/c053i/perezriera.php<br />I have seen lambda in one patient with Tombstone STEMI and he had a very bad time but survived, 2 other cases (With Lambda and reverse Lambda)I am acquainted with died, one of VF...Plus Ultrahttps://www.blogger.com/profile/01735827112800682222noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-22729306139556827422016-03-22T16:33:48.177-05:002016-03-22T16:33:48.177-05:00Thanks for your insights Steve after researching t...Thanks for your insights Steve after researching the lambda wave finding. I think we both view assessment of this finding similarly.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-16468532058553501442016-03-22T14:05:35.691-05:002016-03-22T14:05:35.691-05:00Mario,
Good observations.
By Birnbaum's defini...Mario,<br />Good observations.<br />By Birnbaum's definition, there is TQRSD: J-point more than 50% of the height of the ST segment. But there is an S-wave; it is followed by the large R wave of RBBB.<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-61200631378843675472016-03-22T11:10:24.611-05:002016-03-22T11:10:24.611-05:00My first thought was the patient was very unlucky ...My first thought was the patient was very unlucky since despite all efforts. <br />Let me add also two more electrocardiographic signs of poor prognosis. The first one is atrial fibrillation which seems to imply a poor prognosis in the context of STEMI.<br />The other one is terminal QRS distortion: I have some difficulties in interpreting the anterior leads because of the presence of RBBB but I see terminal QRS distorsion in aVL and perhaps in I. Isn’it?<br />MarioMario Parrinellohttps://www.blogger.com/profile/07136945770330333718noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-14286093747472877332016-03-22T06:35:31.114-05:002016-03-22T06:35:31.114-05:00See my response to Dr. Grauer.
Steve SmithSee my response to Dr. Grauer.<br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-42326521029419872492016-03-22T06:34:40.059-05:002016-03-22T06:34:40.059-05:00Ken,
All great comments as usual. I hadn't he...Ken,<br />All great comments as usual. I hadn't heard of lambda STE, but just read the paper and it is very interesting:<br />(Aizawa, Yoshifusa et al. Characteristics of electrocardiographic repolarization in acute myocardial infarction complicated by ventricular fibrillation Journal of electrocardiology , 2012, Vol.45(3), p.252-259)<br />1. The lambda STE apparently was not described with bundle branch block, but in normal conduction, and it is not clear if it applies to BBB. In this case, the lambda is only present in V2 and V3, which have large R' waves. aVL has a "type II" which has some upward slope from the J-point<br />2. The STE in aVL is not lambda-type<br />3. Lambda predicted ventricular fibrillation, not cardiogenic shock. However, it is well known that the more myocardium at risk, the higher the risk of BOTH VF and shock.<br />4. In the study, the mean ST elevation was 7mm in patients who had VF vs. 3.5 mm in those who did not. So I don't think that lambda adds as much additional prognostic information as the authors claim, though clearly there is something to it. <br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50404527796269389762016-03-22T05:18:48.918-05:002016-03-22T05:18:48.918-05:00I am taking a bird's eye view of the first ECG...I am taking a bird's eye view of the first ECG and the morphology of the STE in V2,3 aVL I are strikingly reminiscent of Lambda STE, a harbinger of Electrical storms. In addition there is the reverse Lambda in II, III, aVF. Recently, a Cardiologist sent me 2 ECGs, the first look very much like a D1 Occlusion but it metamorphosed into Lambda STE and Reverse Lambda...angiogram showed LMS occlusion, he went into VF and died. I sent the ECGs to Prof Ken Grauer and he thinks that the Lambda STE and reverse Lambda were present. Subsequently, another Cardiologist sent me an ECG with Lambda and reverse Lambda...I wonder if you agree this might be the case here?Plus Ultrahttps://www.blogger.com/profile/01735827112800682222noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-80364887519530668272016-03-21T18:34:54.121-05:002016-03-21T18:34:54.121-05:00Insightful case by Dr. Stephen Smith. Although the...Insightful case by Dr. Stephen Smith. Although the diagnosis is obvious (large anterior acute STEMI from proximal LAD occlusion) — the teaching points center around picking out ECG indicators of severity. As emphasized by Dr. Smith, these include new AFib as the rhythm (with loss of “atrial kick” and the fairly rapid rate contributing to reduced cardiac output and the patient’s cardiogenic shock) — new bifascicular block (RBBB/LAHB) — plus profound ST elevation in anterior and high lateral leads — with equally profound reciprocal ST depression in inferior and lateral chest leads. I’ll simply add 2 additional features conveying “ominous outcome” unless (albeit even if) prompt revascularization is undertaken: i) that large Q waves have already formed (in V1,V2,V3) with loss of R wave amplitude in lateral chest leads in this patient is obvious extensive ongoing stemi; and ii) the “Tombstone” ST segment appearance with “lambda” wave-like downsloping in leads aVL, V2,V3 — which some investigators feel portends imminent VFib in many of these patients. That said, rather than this “lambda-like” ST-T wave shape being predictive of imminent VFib — I’ve always felt the combination of OTHER findings specified above are more than enough to predict likely VFib secondary to cardiogenic shock in many of these gravely ill patients even when prompt treatment is undertaken. THANKS to Dr. Smith for posting this wonderfully illustrative tracing of these high-risk ECG findings. ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.com