tag:blogger.com,1999:blog-549949223388475481.post27400134970041051..comments2024-03-26T22:42:04.176-05:00Comments on Dr. Smith's ECG Blog: A man in his 50s with fever and shortness of breathUnknownnoreply@blogger.comBlogger12125tag:blogger.com,1999:blog-549949223388475481.post-33107120384061071432020-05-13T18:57:29.330-05:002020-05-13T18:57:29.330-05:00Thanks for your comment Mario! As you can see from...Thanks for your comment Mario! As you can see from Pendell’s discussion and his answer to the concern voiced by Maarten Van Hemelen (above) — He agrees on the need for strong consideration of cardiac cath for this patient (Sounds like it wasn’t his decision to make … ). As to the possibility of RVH (You said “LVH” in your comment — but I know you meant “RVH”) — you’ll note in my Pearl #2 above that RVH is one of the 3 common causes I list for an indeterminate axis. Persistence of lateral chest lead S waves is supportive of this — but really not “enough” (in my opinion) to make a definitive ECG diagnosis of RVH. I usually would write down something like, “Findings consistent with pulmonary disease; Suggest clinical correlation”. As you know — a definitive ECG diagnosis of RVH is often extremely difficut to make in adults — because the LV typically is 3X as thick, and has up to 10X the mass of a normal RV — so in order for RV forces to predominate in adults — the degree of RVH must usually be marked before you see a clear ECG picture of true RVH. This is different for infants and children, in whom there is not so much discrepancy between LV and RV mass — so the ECG diagnosis of RVH in young children is much easier to make. THANKS as always for your comments! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-63288103464981884122020-05-13T11:24:06.195-05:002020-05-13T11:24:06.195-05:00Very challenging initial management.
Personally I ...Very challenging initial management.<br />Personally I (if I would have been consulted as Cardiologist) would have activated cath lab despite the absence of chest pain and the clincal scenario highly suggestive for an infectious disease based on the following reasons: as mentiond above, despite a very likely infectious disease (essentially acute myocarditis here), acute myocarditis is a diagnosis of exclusion and therefore define coronary anatomy is of paramount importance. Another important feature suggestive of an acute coronary event is the textbook localization of the ST-T wave abnormalities, confined to a restricted coronary territory (=posterolateral); moreover there are reiprocal changes (STD in III-aVF).<br />Finally, Ken, don't you think that there are some ECG findings favoring LVH, such as the indeterminate axis and persistence of S in chest leads (the transition is in V6!)? It would have been very useful to have data on RV function and morphology on echo results.<br />Very interesting and timely (with regard to COVID-19) case!<br /><br />Mario Parrinello<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-16515448704769763602020-05-12T13:01:25.574-05:002020-05-12T13:01:25.574-05:00Tom — I suspect MANY providers these days are havi...Tom — I suspect MANY providers these days are having the "same thought" — as we continue to learn more about this "novel" virus (that initially was thought to primarily affect the lungs ...). As has become apparent — it affects MANY more systems in many patients ...ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-12219679320418060682020-05-12T10:37:52.701-05:002020-05-12T10:37:52.701-05:00it's funny... Maarten had the same thought, bu...it's funny... Maarten had the same thought, but his comment had not yet posted when i wrote mine thirty minutes later..<br />tfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-62465321216635615552020-05-12T06:16:06.538-05:002020-05-12T06:16:06.538-05:00I think his d-dimer was between 1-2000, I remember...I think his d-dimer was between 1-2000, I remember it being elevated but not the exact number.<br /><br />Really nothing can be excluded for sure in this case. I do not think that PE would account for the ECG findings, but PE was not excluded in this patient.<br /><br />Nor was OMI. <br /><br />I do think that myocarditis can be focal and not involve pericarditis, but that is just my hunch thinking back on several posts in the blog. No solid evidence that I have there.<br /><br />Very annoying that the same process can cause both myocarditis and acute thrombotic events.Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-64165434171178041312020-05-12T06:11:50.513-05:002020-05-12T06:11:50.513-05:00I completely agree.I completely agree.Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-28063991676441837132020-05-12T05:24:08.519-05:002020-05-12T05:24:08.519-05:00THANKS so much Jerry. YOUR Comments are always a m...THANKS so much Jerry. YOUR Comments are always a most welcome addition to this ECG Blog! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-1122259468838790992020-05-12T04:17:14.913-05:002020-05-12T04:17:14.913-05:00interesting.
pendell, i wonder. we know that COV...interesting.<br />pendell, i wonder. we know that COVID is a hyper-coagulable state. yes, COVID is associated with a number of associated entities, including cardiomyopathy, myocarditis, much more. But these patients clot, in their lung, brain, <br /> ? kidney micro-vasculature, and i suspect their coronaries.<br />here we had a patient with dyspnea. an ECG with a ST elevation with reciprocal changes, in the ? high LAD or circumflex(?) territory. <br />you already asked the question: why not take the patient to cath?<br />what was the d dimer? just curious. can this be, Pendell, a pulmonary embolism, with positive trop? (no CT-A i suspect).<br />also, isn't there usually some pericarditis with myocarditis, but there was no ecg or echo sign of pericarditis. just a thought...am i off-base?<br /><br />interesting case. thank you so much for sharing<br /><br />tomtfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-71713249351344005332020-05-12T03:47:43.739-05:002020-05-12T03:47:43.739-05:00In addition to myocarditis, I'd be worried abo...In addition to myocarditis, I'd be worried about COVID-related thrombotic events. While probably the patient did indeed have myocarditis, I'd be hesitant to forgo cath in the absence of MRI or high quality echo?Maarten Van Hemelennoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-38847989621489939882020-05-11T21:24:44.940-05:002020-05-11T21:24:44.940-05:00"the calculation of axis is not so easy for t..."the calculation of axis is not so easy for the tracings here …"<br /><br />AMEN!!<br /><br />Actually, Ken, I don't disagree with anything in your comment. The ECG looks "almost" like an indeterminate axis (though it really isn't) and the axis is definitely in the right upper quadrant. Also, it is a rare occasion when we have to be any more specific than noting the quadrant in which the axis is located.<br /><br />I enjoy our discussions because I certainly learn from you. It's proof that two physicians can argue two different viewpoints and still be respectful and cordial to each other. I see too many posts where someone tries to be aggressive and demeaning in their attitude toward anyone who disagrees with them.<br /><br />And thanks for the links to the other myocarditis cases.Jerry W. Jones, MD FACEP FAAEMhttps://www.medicusofhouston.comnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-26116495103008149672020-05-11T20:07:52.209-05:002020-05-11T20:07:52.209-05:00Hi Jerry. It’s ALWAYS a Learning Experience for me...Hi Jerry. It’s ALWAYS a Learning Experience for me when you comment! I believe you and I use some different terminology and different conceptualizations with regard to axis description and determination (I noted that a number of years ago on one of your comments on the ECG Guru that approached the subject quite differently than I have). So while I completely agree that an “easy” diagnosis of “indeterminate” axis is when all limb leads are biphasic and equiphasic — the calculation of axis is not so easy for the tracings here … I’d put the axis for ECGs #1 and #2 in the upper right quadrant — which is not “indeterminate” in the sense of being unable to come up with some number of degrees — but it IS “indeterminate” in the sense of not being able to determine with confidence if there is marked RAD or marked LAD. In my experience, determining a precise number of degrees for the axis when you are located in the right upper quadrant is highly challenging, as well as clinically irrelevant — since clinical implications for an axis anywhere between +181 to +270 degrees are for practical purposes quite similar. And from a teaching point of view — it should take even the novice interpreter no more than seconds to determine that the axis is (by my definition) “indeterminate” (ie, predominantly negative in both leads I and aVF). And for those occasional circumstances like this tracing (looking at my ECG #1) — since I’m hard pressed to calculate a specific number of degrees from looking at the 6 limb leads (and using “area-under-the-curve” rather than just number of positive and negative little boxes) — we know (by my Pearl #1) that the axis is in that right upper quadrant. Jerry — I realize and fully accept that you may disagree with my above explanation. I’m happy to agree-to-disagree with you on this one. And as always — it’s GREAT to debate these concepts with you! — :)<br /><br />As to cases on Myocarditis — Steve always publishes these as they come up. Here are a few links on cases I’ve participated in over the past 2 years.<br /><br />http://hqmeded-ecg.blogspot.com/2019/07/what-does-this-ecg-with-significant-st.html<br /><br />http://hqmeded-ecg.blogspot.com/2019/12/teenager-with-chest-pain-and-slightly.html<br /><br />https://hqmeded-ecg.blogspot.com/2020/01/a-40-something-with-sharp-chest-pain.htmlECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-55085718276202255642020-05-11T18:17:38.190-05:002020-05-11T18:17:38.190-05:00An ECG that is very a propos in these times!
Ken....An ECG that is very a propos in these times!<br /><br />Ken... You have me confused. You describe the mean QRS axis in the frontal plane as "indeterminate" and yet you immediately place the axis in the right upper quadrant. In fact, the axis is not indeterminate. For it to be indeterminate all the limb leads would have to be both biphasic and equiphasic. Had there been no STE in Leads I and aVL, I would quickly agree that those two leads were equiphasic with zero net voltage. But with Leads II, aVR (mustn't forget about aVR!) and aVF not being equiphasic, there should be no problem determining the mean QRS axis. Granted, it probably won't be so simple for introductory level readers.<br /><br />Otherwise, a great discussion on a very complicated and seldom-discussed topic (myocarditis). There are very few articles that discuss myocarditis without the discussion being mostly about pericarditis. Perhaps you guys could do a few more.Jerry W. Jones, MD FACEP FAAEMhttps://www.medicusofhouston.comnoreply@blogger.com