tag:blogger.com,1999:blog-549949223388475481.post6707622076424601094..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: 24 yo woman with chest pain the morning after binge drinking: Is it Pericarditis? Unknownnoreply@blogger.comBlogger21125tag:blogger.com,1999:blog-549949223388475481.post-25295449418485719162018-12-29T09:16:46.646-06:002018-12-29T09:16:46.646-06:00You are correct. This was NOT an RV infarct. The ...You are correct. This was NOT an RV infarct. The ECG looks like it, but it turned out to be an LAD LV anterior MI with wraparound to inferior wall. The differential diagnosis of inferior MI with STE in V1-V3 is RCA with RV MI vs. LAD with wraparound.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43972409621634141012018-12-28T20:21:47.518-06:002018-12-28T20:21:47.518-06:00This is a big surprise to me because until now I h...This is a big surprise to me because until now I have just thought RVMI is only caused by RCA occlusion, but in this case, it is due to distal wraparound LAD... Dr. Smith, could you explain how a distal wraparound LAD occlusion can lead to RVMI? Thank you.Greenhttps://www.blogger.com/profile/07612896010522381195noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-19198554436089185672017-12-03T04:19:43.638-06:002017-12-03T04:19:43.638-06:00excellent presentation, and comments. thanks, stev...excellent presentation, and comments. thanks, stevetom fieronoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50914710931029750582013-05-29T07:32:19.214-05:002013-05-29T07:32:19.214-05:00There is a recent article on theheart.org that hit...There is a recent article on theheart.org that hits many of the points you mentioned: Girl trouble: Rising tide of STEMI in young women "clearly not acceptable" http://www.theheart.org/article/1542051.do?utm_medium=email&utm_source=20130523_heartwire&utm_campaign=newsletterAnonymoushttps://www.blogger.com/profile/04814543249032406874noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3857398960454584012013-05-27T12:36:28.664-05:002013-05-27T12:36:28.664-05:00There is a loose correlation: LAD MI is usually la...There is a loose correlation: LAD MI is usually larger than other territories, especially if proximal LAD. So, in general, troponins are higher also.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43296055742239094492013-05-27T12:17:03.873-05:002013-05-27T12:17:03.873-05:00is there any correlation between the localization ...is there any correlation between the localization of MI ( or ocluded artery) and the amount of Troponins ?<br /><br />Lotfi Djilali BensekranebornDzhttps://www.blogger.com/profile/14881573967112036335noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-52903253860771423292013-05-25T06:23:48.348-05:002013-05-25T06:23:48.348-05:00Thanks for your time. I've learnt so many thin...Thanks for your time. I've learnt so many things from your blog and I want to to use this opportunity to express my thankfulness. <br /><br />Mattia QuartaMattia Quartahttps://www.blogger.com/profile/03237777615682943044noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-67528584899884323772013-05-24T16:40:52.316-05:002013-05-24T16:40:52.316-05:00That is a very big question and depends on so many...That is a very big question and depends on so many factors: age, risk factors, quality and location of pain/discomfort etc. Sometimes an ECG is enough, sometimes serial ECGs. sometimes one troponin suffices, sometimes serial trops. Sometimes a formal echo, or stress test, or angiogram. Too complex for this forum!<br /><br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-65252563578613191382013-05-24T15:18:32.021-05:002013-05-24T15:18:32.021-05:00Agree: low pretest probability patients might even...Agree: low pretest probability patients might even be harmed by a conventional workup since stress tests have too many false positives. May I ask what would be in your opinion a reasonable test threshold for ACS?Mattia Quartahttps://www.blogger.com/profile/03237777615682943044noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-24961399421664528772013-05-24T11:36:26.132-05:002013-05-24T11:36:26.132-05:00Thanks for sharing! The initial troponin is usual...Thanks for sharing! The initial troponin is usually negative in acute STEMI.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-41559310858269248132013-05-24T11:08:35.761-05:002013-05-24T11:08:35.761-05:00I might have ordered a single troponin, or maybe n...I might have ordered a single troponin, or maybe not. I often stop at a normal ECG in low risk patients.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-76792609034254204652013-05-24T11:07:01.521-05:002013-05-24T11:07:01.521-05:00That is the reference! Thanks. If the ECG were nor...That is the reference! Thanks. If the ECG were normal, I would not have pursued it further. When patients have a low pretest probability, I generally stop with the ECG.<br /><br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-75829731293369552192013-05-24T10:56:41.001-05:002013-05-24T10:56:41.001-05:00This comment has been removed by the author.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-17970402913813802052013-05-24T08:35:13.800-05:002013-05-24T08:35:13.800-05:00We had a really similar story.
She was 22. She ha...We had a really similar story. <br />She was 22. She had a similar ECG changes. <br />Our first theory was pericarditis, but we saw apical wall motion abnormality on the echo, but no efflusion. Than we thought, it could be Takatsubo (she had broken up with her boyfriend, and had lost her job on the previouse day). We performed the angio and we found an LAD occlusion. <br />It was a real shock for me!<br /> <br />Moreover her first Troponin was negative, and she had higher WBC, CRP results. Unknownhttps://www.blogger.com/profile/07978086283870479286noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-14596580191133405622013-05-24T02:29:02.969-05:002013-05-24T02:29:02.969-05:00This might be the reference you were looking for h...This might be the reference you were looking for http://www.ncbi.nlm.nih.gov/m/pubmed/22748404/. <br />Great case. Would have you performed a full workup if the ECG was normal?Mattia Quartahttps://www.blogger.com/profile/03237777615682943044noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-47471324938602774582013-05-24T00:50:05.933-05:002013-05-24T00:50:05.933-05:00I completely concur on that: any ST depression any...I completely concur on that: any ST depression anywhere (except for aVR!!), and it is NOT pericarditis. aVR is reciprocal to the other leads and is always an exception.<br /><br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-59297670121529057402013-05-24T00:00:53.272-05:002013-05-24T00:00:53.272-05:00Dr. Smith,
Dr. Amal Mattu has a number of EKG of ...Dr. Smith,<br /><br />Dr. Amal Mattu has a number of EKG of the Week videos on pericarditis, and he constantly stresses that if there is any ST depression, it is a STEMI. In this case there was clear depression in aVL from the first EKG. What are your thoughts on this?Moshehttps://www.blogger.com/profile/09015783041237520805noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-8269502041664531502013-05-23T19:14:18.563-05:002013-05-23T19:14:18.563-05:00Dane, I'm glad you're advocating for your ...Dane, I'm glad you're advocating for your patients!<br /><br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-45222808750086239292013-05-23T18:54:41.772-05:002013-05-23T18:54:41.772-05:00First of all I would like to thank you Dr. Smith f...First of all I would like to thank you Dr. Smith for all of you excellent posts and teachings. I am an RN and I work in Huntington, WV. It is very bothersome to me that most people immediately say pericarditis d/t age. I have personally seen a 24,26,30 year olds with true stemi's unrelated to stimulants. Sadly most of the physicians in our ER would jump straight to pericarditis even after seeing young people with AMI. There have been a few instances one very recent where I begged a physician to activate the cath lab for an EKG that was transmitted to us from the volunteer fire department I am a part of. This was an obvious anterior/lateral mi with depression in inferior leads and this pt was 55 years old! So,you can imagine when a young person presents with CP and ekg changes. So,again thank you for your posts and teachings on up to date electrocardiography findings. I wish more of our physicians were like you. It makes ER work a lot easier when you aren't arguing with a physician over an ekg. Anonymoushttps://www.blogger.com/profile/08310055855499420030noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-41448645478896860332013-05-23T16:14:44.934-05:002013-05-23T16:14:44.934-05:00This is an old rule which has not panned out and i...This is an old rule which has not panned out and is not well supported by our data or others. For II can be greater than III if the QRS axis is between 60 and 90 degrees. Many MI have an axis between 60 and 90, and these all have ST depression in aVL. That is why ST depression in aVL is far more accurate. Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-84275587934864964712013-05-23T16:08:02.060-05:002013-05-23T16:08:02.060-05:00The other thing going for MI over pericarditis is ...The other thing going for MI over pericarditis is that the ST elevation in III is> than in II, whereas in pericarditis the ST elevation in II is usually greater than in III. Not a hard and fast rule but it all adds to the weight of evidenceDavid Lhttps://www.blogger.com/profile/01212376414388118979noreply@blogger.com