tag:blogger.com,1999:blog-5499492233884754812024-03-18T18:01:43.885-05:00Dr. Smith's ECG BlogUnknownnoreply@blogger.comBlogger1662125tag:blogger.com,1999:blog-549949223388475481.post-91932513409906090902024-03-17T10:20:00.001-05:002024-03-17T10:20:43.827-05:00Why is the angiogram normal?<p><span style="font-size: medium;">Written by <a href="http://twitter.com/willyhfrick">Willy Frick</a></span></p><p><span style="font-size: medium;">A man in his 50s with a 15 pack-year smoking history presented to his primary care physician's office complaining of intermittent headache. He also complained of intermittent mild chest pain radiating into into both shoulders and his back, as well as occasional unexplained sweating. (Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually <a href="https://pubmed.ncbi.nlm.nih.gov/26547467/">modestly <i>more</i> predictive</a>). The primary care physician's note indicates low suspicion for cardiac ischemia, but "for completion, check troponin and ECG." If an ECG was obtained in the office, it was not saved. The patient had his blood drawn that morning, and troponin I was 6.496 ng/mL (ref. < 0.033). The PCP's office called the patient and advised him to present to the ER immediately. His ECG is shown.</span></p><p style="text-align: center;"><b><span style="font-size: medium;">ECG 1</span></b></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQQbwnNjFq5JQ_euRM-R2folA3leaR2KgnobLfja3MK4YpUK0DmlfIJryG25riOMSKQQq6h1fiietZmkRE6_Rz5J7ngGZmmgvsx4n0K5txgQTdx4qxDrJD2oHb52ptcwi-jFhu1j5p0aznAIHwc-bYrfouMG2iOIErq6eM6WYHla8jjXI0natNdyQzrNU/s2716/Screenshot%202024-03-09%20at%202.13.00%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="976" data-original-width="2716" height="230" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQQbwnNjFq5JQ_euRM-R2folA3leaR2KgnobLfja3MK4YpUK0DmlfIJryG25riOMSKQQq6h1fiietZmkRE6_Rz5J7ngGZmmgvsx4n0K5txgQTdx4qxDrJD2oHb52ptcwi-jFhu1j5p0aznAIHwc-bYrfouMG2iOIErq6eM6WYHla8jjXI0natNdyQzrNU/w640-h230/Screenshot%202024-03-09%20at%202.13.00%E2%80%AFPM.png" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Readers of this blog will have no trouble recognizing this as an OMI with some early reperfusion. Looking through the ECG in detail, we see:</span></div><div class="separator" style="clear: both;"><ul><li><span style="font-size: medium;">STE and HATW in II, III, aVF with terminal reperfusion TWI</span></li></ul><ul><li><span style="font-size: medium;">STD in aVL with overly upright T waves, reciprocal to inferior reperfusion</span></li></ul><ul><li><span style="font-size: medium;">ST flattening with subtle depression in V1 and probably V2, plus overly upright T waves suggestive of reperfused posterior occlusion</span></li></ul><ul><li><span style="font-size: medium;">Subtle coved STE in V6 with terminal TWI (and to a lesser extent V5) consistent with reperfused lateral occlusion</span></li></ul><div><span style="font-size: medium;">He underwent emergent angiography, which showed <i><b>normal coronary arteries</b>. </i>His troponin peaked at 10.310 ng/mL and trended down. (Smith: a typical peak troponin for an OMI is above 10 ng/mL)</span></div><div><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><b><span style="font-size: medium;">What happened?</span></b></div><div><br /></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Answer: This is <a href="https://hqmeded-ecg.blogspot.com/search/label/MINOCA">MINOCA</a> -- Myocardial Infarction with Non-Obstructive Coronary Arteries. The name is self-explanatory. But MINOCA is more of an observation than a diagnosis, <i>per se</i>. The immediate next question is why? Possible etiologies (depending on your definition) include: plaque rupture with spontaneous recanalization, coronary artery vasospasm, spontaneous coronary artery dissection, or other rarer causes. Most sources <i>exclude</i> myocarditis.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">When coronary artery vasospasm is suspected, it can be assessed in the cath lab with intracoronary acetylcholine. Comprehensive coronary evaluation (with testing for vasospasm and microvascular dysfunction) was shown in the randomized trial <a href="https://pubmed.ncbi.nlm.nih.gov/30266608/">CorMicA</a> to significantly improve angina, quality of life, and diagnostic accuracy. Unfortunately, this is not performed in most cath labs, and was not done in this case. The patient underwent cardiac MRI which demonstrated transmural infarction of the inferolateral wall as expected.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">He was managed medically with aspirin, clopidogrel, and atorvastatin. In addition, his cardiologist suspected vasospastic angina and therefore started amlodipine. He had no further chest pain. Repeat ECG at follow up in clinic a few weeks later is shown. Clear inferior and posterior reperfusion.</span></div><div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: medium;">ECG 2</span></b></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBLLmfdPnH3qbAA4xSw2lQDEn7bda-JPs95xND7nyn2ac4263Cb7eeOFk3pHdvtuI9tjpEB9PI-9m4t3jiqhKmJgezO6n3VLN-NtyNK9PzzRXmY5yxR5PLdntu6fArHDZ3rvpuQ8rQ8ts2OTqrD0f11kl1aH6CUREUkWFx3gU1uTCPBOj0k6DhAt599rE/s2716/Screenshot%202024-03-09%20at%202.56.53%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="932" data-original-width="2716" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBLLmfdPnH3qbAA4xSw2lQDEn7bda-JPs95xND7nyn2ac4263Cb7eeOFk3pHdvtuI9tjpEB9PI-9m4t3jiqhKmJgezO6n3VLN-NtyNK9PzzRXmY5yxR5PLdntu6fArHDZ3rvpuQ8rQ8ts2OTqrD0f11kl1aH6CUREUkWFx3gU1uTCPBOj0k6DhAt599rE/w640-h220/Screenshot%202024-03-09%20at%202.56.53%E2%80%AFPM.png" width="640" /></span></a></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><b>Six years later:</b> He presented to the ER with recurrence of his prior symptoms. He described mild substernal chest pain, again radiating into both shoulders with occasional sweating. He said the pain would come and go, sometimes lasting only a few seconds. In the ER, his symptoms had remitted. He stopped taking all his medications about a year prior. ECG is shown.</span></div><div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: medium;">ECG 3</span></b></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9mccuJnpYmtFZ9sVBAKE7v-E9Fr-5NWg0gEyY302Ugn44h7fj9EemvnNW9Rk_Ouq8YogziAQRVyX3LTEMzP5AsQMgSQXNIK3SfQK5x6dNyYJR_BTB5H3n8Xu_EjpQbyHjX_kpNfUS2DhU3a_tCitnIHjrZTmnhJH5utSDmsMasPOWIu-HRpU6LrfpEvc/s2716/Screenshot%202024-03-09%20at%203.25.05%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="932" data-original-width="2716" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9mccuJnpYmtFZ9sVBAKE7v-E9Fr-5NWg0gEyY302Ugn44h7fj9EemvnNW9Rk_Ouq8YogziAQRVyX3LTEMzP5AsQMgSQXNIK3SfQK5x6dNyYJR_BTB5H3n8Xu_EjpQbyHjX_kpNfUS2DhU3a_tCitnIHjrZTmnhJH5utSDmsMasPOWIu-HRpU6LrfpEvc/w640-h220/Screenshot%202024-03-09%20at%203.25.05%E2%80%AFPM.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div><span style="font-size: medium;">In isolation, this ECG is suggestive of possible reperfused inferoposterolateral OMI (inferior and lateral precordial TWI with ST flattening and overly upright T waves in V1-3 reciprocal to posterior leads). However, knowing that this patient had a prior infarct in this territory, it is unclear what these findings represent. (That is to say, this <i>could </i>be his baseline ECG.) Initial troponin I was 0.013 ng/mL (ref. < 0.033), repeat 2 hours later 0.016. At this point, the ER consulted cardiology who requested repeat ECG. The patient told the cardiologist that his symptoms had <i>not</i> returned since arriving at the hospital.</span></div><div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: medium;">ECG 4</span></b></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3BV2gLGhv4cfnkEHUMX9LSizOtq0qj-NecUPJfW4eAbDKjco0GQho92KMYhIr3qCyVh29y6VW2nX_LXvDdeUcq06rysVs6t-IK0ukAwg_0rAiLQQb9gBy8pI36gwlEbouUf73IQef_e0LPeHWy0FyaLvYvHcDUpkyq-5Phjk4Y3YC3DOim3_ipOcEjjU/s2716/Screenshot%202024-03-09%20at%203.34.20%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="932" data-original-width="2716" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3BV2gLGhv4cfnkEHUMX9LSizOtq0qj-NecUPJfW4eAbDKjco0GQho92KMYhIr3qCyVh29y6VW2nX_LXvDdeUcq06rysVs6t-IK0ukAwg_0rAiLQQb9gBy8pI36gwlEbouUf73IQef_e0LPeHWy0FyaLvYvHcDUpkyq-5Phjk4Y3YC3DOim3_ipOcEjjU/w640-h220/Screenshot%202024-03-09%20at%203.34.20%E2%80%AFPM.png" width="640" /></span></a></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">In the context of resolved chest pain, this was interpreted as confirmation of inferolateral reperfusion, and the patient was loaded with aspirin and clopidogrel and started on continuous heparin infusion with plan for catheterization. Serial cTnI values were 0.019 ng/mL and 0.027 ng/mL, rising but still within the reference range (< 0.033). The patient reported transient return of his pain, and repeat ECG was obtained.</span></div><div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: medium;">ECG 5</span></b></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigvQHfXwRrvbdAIokdW8taYyXKOq3sRhYKEc3qs_qZsjsCoBGQk3XaibG1ignFvLnzJTywXPGJmyWKtnFo0JlJ7bMeiYXjb2WhkHaghgnAAPkYcLOdlv4wqMeveueRxCfPkbkIz3dLqMW5i6hN30UyPh9zPSh78bJMVYrTTsqw55Ycvn9prhEaQyLGGYs/s2716/Screenshot%202024-03-09%20at%203.43.05%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="952" data-original-width="2716" height="224" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigvQHfXwRrvbdAIokdW8taYyXKOq3sRhYKEc3qs_qZsjsCoBGQk3XaibG1ignFvLnzJTywXPGJmyWKtnFo0JlJ7bMeiYXjb2WhkHaghgnAAPkYcLOdlv4wqMeveueRxCfPkbkIz3dLqMW5i6hN30UyPh9zPSh78bJMVYrTTsqw55Ycvn9prhEaQyLGGYs/w640-h224/Screenshot%202024-03-09%20at%203.43.05%E2%80%AFPM.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div><span style="font-size: medium;">Like ECG 3, this ECG could be mistaken for being non-specific. However, in this clinical context and especially following ECG 4, the current ECG actually represents re-occlusion! It is a snapshot of the T waves during their transition <u>from</u> deeply inverted reperfusion T waves <u>to</u> upright, hyperacute T waves. If the ECG had been recorded a few minutes later when the T waves were slightly <i>more</i> upright, it would have appeared <a href="http://hqmeded-ecg.blogspot.com/2022/06/when-normal-is-only-pseudo-normal-it.html">pseudonormal</a>. At this point, the patient went for angiography. The RCA is shown below.</span></div><div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='577' height='480' src='https://www.blogger.com/video.g?token=AD6v5dxd6GkGQZ0t0i74F7w6dGKH0pML-Qy2sHoKojWfBViWa6L63wify0l0xoiohGorQlOjmAwKt9cCkfSvqjaylw' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;">Below is a still frame with a red arrow pointing to an area of focal vasospasm in the proximal RCA</span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiup1-pJMSXX0sbGg_4iWVlegFZ1eKqmtli7ay7lHV-xcbw9Gjbpu6tHc3hkntLRg6X3qvQcHLP_7wag2UmyuFyvHr9VxE3BxX6zOjT67bHcxiY5S9kSN9FxK4bn-q6B-_n_fimgJBuHVF1pJWt5cqNDYb7pCOoJs23MOqLzjy4g4KgD795hHCu-oIkznM/s1590/Screenshot%202024-03-09%20at%205.31.43%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1590" data-original-width="1364" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiup1-pJMSXX0sbGg_4iWVlegFZ1eKqmtli7ay7lHV-xcbw9Gjbpu6tHc3hkntLRg6X3qvQcHLP_7wag2UmyuFyvHr9VxE3BxX6zOjT67bHcxiY5S9kSN9FxK4bn-q6B-_n_fimgJBuHVF1pJWt5cqNDYb7pCOoJs23MOqLzjy4g4KgD795hHCu-oIkznM/w550-h640/Screenshot%202024-03-09%20at%205.31.43%E2%80%AFPM.png" width="550" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Repeat angiogram after intracoronary nitro showing resolution of vasospasm:</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='577' height='480' src='https://www.blogger.com/video.g?token=AD6v5dwbJRPdlgP_3_0_kdW8PwrgsbN-L-qg9pj6YtJTAIfdEvQHAf_QenpCQ2tEmHsWSYgpmphE3kS5fCsa__wjTA' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">The left coronary artery system was angiographically normal. The patient was restarted on amlodipine. Repeat cTnI remained within normal limits and trended down.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">This finding at angiography explains both the present <i>and</i> prior presentations. In his index presentation years prior, he suffered type 2 MI secondary to vasospasm which was suspected but not confirmed at the time, and had resolved by the time angiography was performed. His symptoms were controlled by amlodipine for years, but he stopped taking it and his symptoms returned. At discharge, he was restarted on amlodipine and given a prescription for varenicline to help with smoking cessation. One final ECG was obtained 24 hours after symptoms had resolved.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: medium;">ECG 6</span></b></div><div class="separator" style="clear: both; text-align: center;"><b><span style="font-size: medium;"><br /></span></b></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1TSGdjMC9YVAMRle07O7o1FTi_TromHRr9yoVcdFZHFVSGlUQMm5rOShdmmE8ueqD37d-hD3BQ6BkrwKH-bWzS6ktae8yBx4TByEGeDW0y5RNwcNCCmvq2dETpjLrfNWwf73x38oHQaHLyTXBPveFOKRQqawwa0ktzgnMyKSF-qgysd_QAIQCLF2DL38/s2734/Screenshot%202024-03-09%20at%205.08.22%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1028" data-original-width="2734" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1TSGdjMC9YVAMRle07O7o1FTi_TromHRr9yoVcdFZHFVSGlUQMm5rOShdmmE8ueqD37d-hD3BQ6BkrwKH-bWzS6ktae8yBx4TByEGeDW0y5RNwcNCCmvq2dETpjLrfNWwf73x38oHQaHLyTXBPveFOKRQqawwa0ktzgnMyKSF-qgysd_QAIQCLF2DL38/w640-h240/Screenshot%202024-03-09%20at%205.08.22%E2%80%AFPM.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div style="text-align: left;"><span style="font-size: medium;">This ECG confirms persistent reperfusion of the RCA. Some clinicians who see this ECG mistakenly believe it is worsened compared to ECG 5 since the T wave inversion is "worse." But readers of this blog understand the phenomenon of reperfusion, and recognize this change as reassuring evidence of adequate reperfusion.</span></div><div style="text-align: left;"><span style="font-size: medium;"><br /></span></div><div style="text-align: left;"><b><span style="font-size: medium;">Learning points:</span></b></div><div style="text-align: left;"><ul><li><span style="font-size: medium;">Vasospasm is one cause of MINOCA. It <i>can</i> be tested for, and <a href="https://pubmed.ncbi.nlm.nih.gov/30266608/">CorMicA</a> showed that doing so improves diagnostic accuracy and reduces angina.</span></li></ul><ul><li><span style="font-size: medium;">Calcium channel blockers and smoking cessation improve symptoms in patients with vasospastic angina.</span></li></ul><ul><li><span style="font-size: medium;">"Normal" cath does not rule out OMI, which is a clinical diagnosis.</span></li></ul><ul><li><span style="font-size: medium;">Vasospastic angina is commonly the worst in the morning and at night. Unlike classic angina pectoris, it does not always present as pain that is worse with exertion and improved by rest (since vasospasm can occur and resolve independent of activity and oxygen demand).</span></li></ul></div></div></div>Willy Frickhttp://www.blogger.com/profile/09245005765903652623noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-31282706560938404042024-03-14T10:51:00.004-05:002024-03-14T10:59:31.022-05:00Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?<span style="font-size: medium;"></span><span style="font-size: medium;">Written by Jesse McLaren<span></span></span><span style="font-size: medium;">
</span><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span>Three patients presented with
acute chest pain and ECGs that were labeled by the computer as completely
normal, and which was confirmed by the final cardiology interpretation </span>(which is blinded to patient outcome) also as completely normal. </span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">What do you think?</span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span> </span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Case 1:</span></p><p class="MsoNormal" style="font-family: Cambria;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjQZtE5FnESgR4N-pY47Valg0uKhEZw3Po9C7dPnt-EIzuuXtUhWOePxi_aK1-o-boAJ4iI2VZ02EXtPCz-q9zPL6wr1L3XPryYeJbeihjdC8tC1NU81TUydoUUvd1aGdwhP42uyREcMO8sPkHxBi62Toz2S7bD9oJw_iieAqqztfcNlmqp8XpIyIub8Y/s1642/n1.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="571" data-original-width="1642" height="223" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjQZtE5FnESgR4N-pY47Valg0uKhEZw3Po9C7dPnt-EIzuuXtUhWOePxi_aK1-o-boAJ4iI2VZ02EXtPCz-q9zPL6wr1L3XPryYeJbeihjdC8tC1NU81TUydoUUvd1aGdwhP42uyREcMO8sPkHxBi62Toz2S7bD9oJw_iieAqqztfcNlmqp8XpIyIub8Y/w640-h223/n1.png" width="640" /></span></a></div><span style="font-size: medium;"><br /><span><br /></span></span><p></p><p class="MsoNormal" style="font-family: Cambria;">
</p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Case 2:</span></p><p class="MsoNormal" style="font-family: Cambria;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg38UprvcyhBuvYwyv2qowshAlbh0HGZRvbuGiYX4Gl-I9sLbtsLvY9DBztXTbrt0rbhrXOSI1QXOH4A6XhUoHV-PCfVsFN6xpiTs7IwSdKWHOGi_2WMf1LtO-Bsk8RtWq0dr42UxQtcbdT32J9kHQ_8D-O4Dh5s48LQsg1wC62tIDFljxc9IqcffcKZkQ/s1636/n2.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="622" data-original-width="1636" height="243" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg38UprvcyhBuvYwyv2qowshAlbh0HGZRvbuGiYX4Gl-I9sLbtsLvY9DBztXTbrt0rbhrXOSI1QXOH4A6XhUoHV-PCfVsFN6xpiTs7IwSdKWHOGi_2WMf1LtO-Bsk8RtWq0dr42UxQtcbdT32J9kHQ_8D-O4Dh5s48LQsg1wC62tIDFljxc9IqcffcKZkQ/w640-h243/n2.png" width="640" /></span></a></div><span style="font-size: medium;"><br /><span><br /></span></span><p></p><p class="MsoNormal" style="font-family: Cambria;">
</p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Case 3:<span></span></span></p><span style="font-size: medium;">
</span><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcN2eykNkipwIKeYkuS6EoiG-qC4rulIi2_EMvAUgrK4iqUS3gk7CWeZkmj-Y1hOJCWP3rSuhYGFekzkIOk6PgUtJA3O1qNsZxdUWTvfpwOc7G4LXGRUSDLBAIQUrduAplXy-lFA2KCaUGaIog6VzN4Yh5dkIFCZXNm82Z4qNfoNiCWpGBip9Akal37Qw/s1639/n3.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="598" data-original-width="1639" height="219" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcN2eykNkipwIKeYkuS6EoiG-qC4rulIi2_EMvAUgrK4iqUS3gk7CWeZkmj-Y1hOJCWP3rSuhYGFekzkIOk6PgUtJA3O1qNsZxdUWTvfpwOc7G4LXGRUSDLBAIQUrduAplXy-lFA2KCaUGaIog6VzN4Yh5dkIFCZXNm82Z4qNfoNiCWpGBip9Akal37Qw/w599-h219/n3.png" width="599" /></span></a></div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Triage ECGs labeled ‘normal’<span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">There have been a number of small
studies suggesting that triage ECGs labeled ‘normal’ are unlikely to have
clinical significance, and therefore that emergency physicians should not be interrupted to
interpret them, and that such patients can safely wait to be seen. These have all
been small studies, studying very few patients with ACS, and often used final
cardiology interpretation rather than patient outcome. The <a data-saferedirecturl="https://www.google.com/url?q=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10777178/&source=gmail&ust=1710436930668000&usg=AOvVaw2kVkuypUoGdM6gRSE8kh12" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10777178/" style="color: blue; text-decoration: underline;" target="_blank">most recent study</a>
found a NPV of 100% of triage ECGs labeled ‘normal’ or ‘otherwise normal’ for
final hospital diagnosis of ACS, and concluded that avoiding physician
interruption would “alleviate interruptions in workflow and improve patient
safety.” </span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Smith</b>: This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG. <b>The fact that not a single one of these patients had ACS shows that the population studied could not possibly support their conclusion. </b>It should never have been published.</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">According to this data a triage ECG labeled
‘normal’ rules out the possibility of acute coronary occlusion.<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">This is obviously unreliable
data, as Dr. Smith’s Blog has published <b>51
cases of OMI with ECGs labeled ‘normal’</b>, 35 of which were identified by the
Queen of Hearts – with 10 examples <a data-saferedirecturl="https://www.google.com/url?q=http://hqmeded-ecg.blogspot.com/2024/03/when-conventional-algorithm-diagnoses.html&source=gmail&ust=1710436930668000&usg=AOvVaw3SOzc7yOT-oHEnOTf_nCxd" href="http://hqmeded-ecg.blogspot.com/2024/03/when-conventional-algorithm-diagnoses.html" style="color: blue; text-decoration: underline;" target="_blank">here</a>.
We also studied 7 years of Code STEMI patients requiring emergent reperfusion,
and found that 4% presented with an ECG labeled ‘normal’, often confirmed by
the final blinded interpretation. This was just published in print in this month's Academic Emergency Medicine:<br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><a data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.14795&source=gmail&ust=1710436930668000&usg=AOvVaw30tI9nNTnIfFNzY5axtMH9" href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.14795" style="color: blue; text-decoration: underline;" target="_blank">McLaren,
Meyers, Smith and Chartier. Emergency department Code STEMI patients with
initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year
retrospective review. Acad Emerg Med 2024;31:296-300</a></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Many
of these 'normal' ECGs had signs of OMI, and those that were identified
in real time by the treating emergency physician had faster
reperfusion than those that were missed. This study only included patients admitted as Code
STEMI, which
likely underestimates the false ‘normal’ rate because it doesn’t include
those admitted as ‘non-STEMI’ who had delayed reperfusion for OMI. So not</span><span style="font-size: medium;"> interrupting the
physician, or physician reliance on a computer 'normal' ECG will lead to preventable delays to reperfusion that would
threaten
patient safety. </span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">These three cases are from this
study, and this <a data-saferedirecturl="https://www.google.com/url?q=http://hqmeded-ecg.blogspot.com/2023/10/four-patients-with-chest-pain-and.html&source=gmail&ust=1710436930668000&usg=AOvVaw1TK-gYNnZKYZ299rJ66cvA" href="http://hqmeded-ecg.blogspot.com/2023/10/four-patients-with-chest-pain-and.html" style="color: blue; text-decoration: underline;" target="_blank">prior
post</a> shows 4 more. For all cases, see the supplement from the <a data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14795&source=gmail&ust=1710436930668000&usg=AOvVaw0phtbgwiRCuAuD63KDUtzK" href="https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14795" style="color: blue; text-decoration: underline;" target="_blank">online
version</a> of the article.<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Now let’s see how these patients
were managed in real time, and the patient outcome. These ECGs were not only
labeled normal by the computer but also the final blinded cardiology
interpretation—which according to some studies would designate these ECGs as
not clinically relevant. We can compare these interpretations with the actual patient outcome, and with the blinded interpretation of
the Queen of Hearts which is expert-trained to identify OMI.<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Case 1:<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span><span> </span></span><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjQZtE5FnESgR4N-pY47Valg0uKhEZw3Po9C7dPnt-EIzuuXtUhWOePxi_aK1-o-boAJ4iI2VZ02EXtPCz-q9zPL6wr1L3XPryYeJbeihjdC8tC1NU81TUydoUUvd1aGdwhP42uyREcMO8sPkHxBi62Toz2S7bD9oJw_iieAqqztfcNlmqp8XpIyIub8Y/s1642/n1.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="571" data-original-width="1642" height="208" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjQZtE5FnESgR4N-pY47Valg0uKhEZw3Po9C7dPnt-EIzuuXtUhWOePxi_aK1-o-boAJ4iI2VZ02EXtPCz-q9zPL6wr1L3XPryYeJbeihjdC8tC1NU81TUydoUUvd1aGdwhP42uyREcMO8sPkHxBi62Toz2S7bD9oJw_iieAqqztfcNlmqp8XpIyIub8Y/w599-h208/n1.png" width="599" /></a></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">There’s ST elevation in V1-2. The
large S wave in V1 may account for some of the ST elevation in this lead, and there is no reciprocal ST
depression in V6 (swirl pattern). But the convex ST elevation and bulky T wave
in V2 is disproportionate to voltage and indicates OMI until proven otherwise - either LAD or RCA.
<span style="font-family: Cambria;">The Queen calls this OMI with high confidence:</span> <br /></span></p><p class="MsoNormal" style="font-family: Cambria;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDHHQZ1SnYCtK3wlZVPXC3XOgJJuBu-BKsyCUhh2IJj6AcyUQOyKFeyZQm12GeaUh-KDBTdkKek0gan00MJFokCcOWiHDrWy0Jl56rRMUL1RZOdYJkSvannw5yspmfdSy23C6xt8fIclljAHj1t7q3Rw326AA9ZiAdVlelNHX1AiLFjRU0JH-1DcOMIZg/s570/n1b.jpeg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="311" data-original-width="570" height="242" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDHHQZ1SnYCtK3wlZVPXC3XOgJJuBu-BKsyCUhh2IJj6AcyUQOyKFeyZQm12GeaUh-KDBTdkKek0gan00MJFokCcOWiHDrWy0Jl56rRMUL1RZOdYJkSvannw5yspmfdSy23C6xt8fIclljAHj1t7q3Rw326AA9ZiAdVlelNHX1AiLFjRU0JH-1DcOMIZg/w443-h242/n1b.jpeg" width="443" /></span></a></div><span style="font-size: medium;"></span><p></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">This was missed, and the patient
was only seen after the first troponin came back at 100 ngL (normal < 26 in
males and <16 in females), and a repeat ECG was done:<span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNiU2KLK98psCCgf5ZK58_wPR2MmKqQCCc2HUB9p9mXsjlPKr7-JLYlH3GMxr_wnm96RkUEtTPs7RtjToQ0XHgAchj4m02R1mBRRbUFg85ZjRIrlKSM00x5lskPWVF0-xepBnJoaU-Fr3_VKqFogx_U8-nB85XeJlr2hB3a2WIWueM99ORI3XXqLD2WQE/s1642/n1c.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="581" data-original-width="1642" height="209" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNiU2KLK98psCCgf5ZK58_wPR2MmKqQCCc2HUB9p9mXsjlPKr7-JLYlH3GMxr_wnm96RkUEtTPs7RtjToQ0XHgAchj4m02R1mBRRbUFg85ZjRIrlKSM00x5lskPWVF0-xepBnJoaU-Fr3_VKqFogx_U8-nB85XeJlr2hB3a2WIWueM99ORI3XXqLD2WQE/w592-h209/n1c.png" width="592" /></span></a></div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><span>Some reperfusion T wave inversion not only in V2 but V1-3,
confirming OMI, but still doesn’t meet STEMI criteria. A stat
cardiology consult led to cath lab activation, with door-to-cath time of 202
minutes. Despite some reperfusion at the time of the repeat ECG, at the time of the angiogram there was 100% mid LAD occlusion, with peak troponin of 19,049 ng/L. Queen of Hearts could have reduced reperfusion delay by 2 hours for this 100%
LAD occlusion that was mislabeled ‘normal.’<span></span></span>
</span></div><div><span style="font-size: medium;"><span><br /></span></span></div><div><span style="font-size: medium;"><span><p style="background-color: white; caret-color: rgb(255, 0, 0); font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;"><span style="text-shadow: none;"><span style="color: red;">The Queen of Hearts PM Cardio App</span><span style="color: #333333;"> is now available in the European Union (CE approved) the App Store and on Google Play. </span></span></b></span><span style="color: #333333; font-family: times; text-shadow: none;"><b style="text-shadow: none;">For Americans</b>, you need to wait for the FDA. </span><b style="color: #333333; font-family: times; text-shadow: none;">But in the meantime:</b></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">YOU HAVE THE OPPORTUNITY TO GET EARLY ACCESS TO THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></span></span></b></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br style="text-shadow: none;" /></span></span></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here. It is not yet available, but this is your way to get on the list.</span></span></span></div><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p class="p1" style="background-color: white; color: #333333; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 13px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; text-shadow: none;"><span class="s1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></span></span></a></div></span></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Case 2:<span></span></span></p><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg38UprvcyhBuvYwyv2qowshAlbh0HGZRvbuGiYX4Gl-I9sLbtsLvY9DBztXTbrt0rbhrXOSI1QXOH4A6XhUoHV-PCfVsFN6xpiTs7IwSdKWHOGi_2WMf1LtO-Bsk8RtWq0dr42UxQtcbdT32J9kHQ_8D-O4Dh5s48LQsg1wC62tIDFljxc9IqcffcKZkQ/s1636/n2.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="622" data-original-width="1636" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg38UprvcyhBuvYwyv2qowshAlbh0HGZRvbuGiYX4Gl-I9sLbtsLvY9DBztXTbrt0rbhrXOSI1QXOH4A6XhUoHV-PCfVsFN6xpiTs7IwSdKWHOGi_2WMf1LtO-Bsk8RtWq0dr42UxQtcbdT32J9kHQ_8D-O4Dh5s48LQsg1wC62tIDFljxc9IqcffcKZkQ/w601-h229/n2.png" width="601" /></a></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">There is a subtle biphasic T wave
in aVL, reciprocal to down/up tall T waves inferiorly, suggesting high lateral
reperfusion.<span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIL1wff1UOp1IwnIQ6COR4dRlX-4vAF7BFHSNT5LVkXMIWv0MKzkwL9lqq6Ri7haE-sRiPt9N2FC5FhPn1_ptf5daF5W7VGIogFD9by6HzQyB4xjBoQYWqkt1nztW2nFmFoqHCxkoc6HeKRDobn0x9MbGZMBuMIoiXGXAVo2dTIsnQKfgfTLkkG9dkOSk/s572/n2b.jpeg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="342" data-original-width="572" height="245" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIL1wff1UOp1IwnIQ6COR4dRlX-4vAF7BFHSNT5LVkXMIWv0MKzkwL9lqq6Ri7haE-sRiPt9N2FC5FhPn1_ptf5daF5W7VGIogFD9by6HzQyB4xjBoQYWqkt1nztW2nFmFoqHCxkoc6HeKRDobn0x9MbGZMBuMIoiXGXAVo2dTIsnQKfgfTLkkG9dkOSk/w411-h245/n2b.jpeg" width="411" /></span></a></div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><span>A truly normal or non-OMI ECG
would be labeled "not OMI, high confidence" but instead the Queen calls this
"OMI low confidence", suggesting the ECG is concerning but not yet diagnostic. The
emergency physician who was shown the ECG identified the same concerns and asked
for a repeat ECG, which was done 30 minutes later:<span></span></span>
</span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhe8NX38kAfztFzzYJZsNjJrQgHEgpPTTsbH1nogzka6JOyaaSmjfdwQM1VoaboDIMpO-uAmrY-NwK5swttxUnCeWti8qbjWA0ELgEFe_0eMJTTz6PC1ggW4rlrkdsR39sR-eQ8vlopQJ0RK1Ozm2M9eyn2D1oq2eJkHYvQNP3UOTFvDu43KxxM9FUNtwk/s1636/n2c.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="651" data-original-width="1636" height="234" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhe8NX38kAfztFzzYJZsNjJrQgHEgpPTTsbH1nogzka6JOyaaSmjfdwQM1VoaboDIMpO-uAmrY-NwK5swttxUnCeWti8qbjWA0ELgEFe_0eMJTTz6PC1ggW4rlrkdsR39sR-eQ8vlopQJ0RK1Ozm2M9eyn2D1oq2eJkHYvQNP3UOTFvDu43KxxM9FUNtwk/w590-h234/n2c.png" width="590" /></span></a></div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><span>The reperfusion TWI in aVL is now upright (pseudonormalization) with reciprocal ST depression inferiorly. There is also ST elevation and hyperacute T waves V1-2 with reciprocal ST depression V5-6 (<a href="http://hqmeded-ecg.blogspot.com/2022/10/precordial-swirl-20-cases-of-swirl-or.html">precordial swirl</a>). Now the ECG is STEMI(+)OMI,
diagnostic of proximal LAD occlusion, </span><span><span>and was identified by the computer</span>. Cath lab was activated, with
door-to-cath time of 118 minutes. There was 95% proximal LAD occlusion, with
first troponin of 31 ng/L and peak of 11,894 ng/L. This infarct would have been much worse
if the physician had not been interrupted to interpret the initial ‘normal’ ECG,
and had not identified the subtle abnormalities. <span></span></span>
</span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Case 3:<span></span></span></p><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcN2eykNkipwIKeYkuS6EoiG-qC4rulIi2_EMvAUgrK4iqUS3gk7CWeZkmj-Y1hOJCWP3rSuhYGFekzkIOk6PgUtJA3O1qNsZxdUWTvfpwOc7G4LXGRUSDLBAIQUrduAplXy-lFA2KCaUGaIog6VzN4Yh5dkIFCZXNm82Z4qNfoNiCWpGBip9Akal37Qw/s1639/n3.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="598" data-original-width="1639" height="219" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcN2eykNkipwIKeYkuS6EoiG-qC4rulIi2_EMvAUgrK4iqUS3gk7CWeZkmj-Y1hOJCWP3rSuhYGFekzkIOk6PgUtJA3O1qNsZxdUWTvfpwOc7G4LXGRUSDLBAIQUrduAplXy-lFA2KCaUGaIog6VzN4Yh5dkIFCZXNm82Z4qNfoNiCWpGBip9Akal37Qw/w599-h219/n3.png" width="599" /></a></span></div><div>
<span style="font-size: medium;"><span style="font-family: Cambria;">There’s hyperacute T waves V2-4, with a small Q
in V3 and potentially terminal QRS distortion in V3 (at least by the third beat,
where there is no S wave), indicating LAD occlusion. The Queen calls this OMI with high confidence. <br /></span></span></div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQR1STJmKsmLuchmamJ7hb2dMHtTbla0d1CsW3BU_p8ELCgNoImPu2np4lhb-beK9d9WbKTu8yPlgVnRzh6Vx1BH6-i2G8XZDHrrdeXwQRU6izrCpjAKEfrUA2B-DIpQbvKLddP9HzoOXa_ZHVottfS-hEv5QEbPDS9_LQjyhXf_La7wHLvVsIIdUUOZQ/s566/n3b.jpeg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="324" data-original-width="566" height="258" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQR1STJmKsmLuchmamJ7hb2dMHtTbla0d1CsW3BU_p8ELCgNoImPu2np4lhb-beK9d9WbKTu8yPlgVnRzh6Vx1BH6-i2G8XZDHrrdeXwQRU6izrCpjAKEfrUA2B-DIpQbvKLddP9HzoOXa_ZHVottfS-hEv5QEbPDS9_LQjyhXf_La7wHLvVsIIdUUOZQ/w450-h258/n3b.jpeg" width="450" /></span></a></div><span style="font-size: medium;"><br /></span></div><span style="font-size: medium;"></span><span style="font-size: medium;">Fortunately this was also
identified by the emergency physician, who asked for a repeat ECG immediately:</span><p class="MsoNormal" style="font-family: Cambria;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVOdaANpqGJu47RZafJAFS25AbbaXCBP1UqWWP_FUeR6zqptHQXtCJmzxapm1h3wWOlupTIpOvtG65AIqwqGH0hYwoJx95APKUMKwPVoICF35jv0GMzpryYpcQTCLaIPPrOVuDnZ05agaCKp6DzzZYSTazzWiTrTKurypn3tJyDkZk2HQVM0fEO4Irqks/s1634/n3c.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="591" data-original-width="1634" height="216" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVOdaANpqGJu47RZafJAFS25AbbaXCBP1UqWWP_FUeR6zqptHQXtCJmzxapm1h3wWOlupTIpOvtG65AIqwqGH0hYwoJx95APKUMKwPVoICF35jv0GMzpryYpcQTCLaIPPrOVuDnZ05agaCKp6DzzZYSTazzWiTrTKurypn3tJyDkZk2HQVM0fEO4Irqks/w596-h216/n3c.png" width="596" /></span></a></div><span style="font-size: medium;"><br /></span><p></p><p class="MsoNormal" style="font-family: Cambria;">
</p><p class="MsoNormal" style="font-family: Cambria;"><span><span style="font-size: medium;">Now there’s deWinter waves in
V3-4. Cath lab was activated, with door-to-cath time of only 44 minutes. First
troponin was 4ng/L which is normal and just above the limit of detection of 2.
But peak troponin was greater than 50,000 ng/L despite very rapid reperfusion. This
case could have been a disaster if the emergency physician had not been
interrupted to review the ECG or if they trusted the ‘normal’ interpretation,
and if they waited for and relied on the first troponin which was normal. </span><span></span></span></p><span style="font-size: x-large;">
</span><p class="MsoNormal" style="font-family: Cambria;"><span><span style="font-size: x-large;"><br /></span></span></p><p class="MsoNormal" style="font-family: Cambria;"><span><span style="font-size: x-large;">None of these were Normal!! </span></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: x-large;">All were diagnostic of OMI!! </span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: x-large;">Do not pay attention to the conventional algorithm!</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span><br /></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Take away<span></span></b></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>1.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>ECGs labeled normal by the conventional computer
algorithm are unreliable, even if confirmed by the final blinded interpretation. The reliability of these ECGs should be based on patient outcome.<span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>2.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>Emergency physicians should be interrupted to
review all triage ECGs, even those that labeled ‘normal’, and should
look
beyond STEMI criteria for signs of OMI – including acute Q waves,
terminal QRS distortion, convex ST segments, hyperacute T waves, and
reciprocal change<span></span></span></p><span style="font-size: medium;">
<span><span>3.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>Expert-trained AI can accurately identify OMI
and lead to faster reperfusion </span>Jesse McLarenhttp://www.blogger.com/profile/05809707984126529952noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-2453298805506305952024-03-13T07:45:00.004-05:002024-03-13T07:49:52.237-05:00A man in his 40s with 3 days of stuttering chest pain<p><span style="font-size: medium;">Written by <a href="http://twitter.com/willyhfrick">Willy Frick</a></span></p><p><span style="font-size: medium;">A man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhmIvmwzTDCKLFbiX9FRxv9jV9k84Vs0p5KpkK_g1OflnwfVoMYy1Box7cD5KbWflU4z0kZ3yzLksyq7rAg3zd9lfValFPK-ThVaE0O1ga1_Ap5iOtoTQ1ruEn_97csz6tT2pl-4h1Exc7GA2V6OMTy4d2vymmtmCgtIDEJ_HByQF7w7AnjAGzRoHK-tZY" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="1198" data-original-width="2568" height="299" src="https://blogger.googleusercontent.com/img/a/AVvXsEhmIvmwzTDCKLFbiX9FRxv9jV9k84Vs0p5KpkK_g1OflnwfVoMYy1Box7cD5KbWflU4z0kZ3yzLksyq7rAg3zd9lfValFPK-ThVaE0O1ga1_Ap5iOtoTQ1ruEn_97csz6tT2pl-4h1Exc7GA2V6OMTy4d2vymmtmCgtIDEJ_HByQF7w7AnjAGzRoHK-tZY=w640-h299" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">What do you think?</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Here is the Queen's verdict and translator:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhER8U2z4pvw6jcs_WujlgnzbjIq1K15FqgZZ_S0oMmnOi3MwJ8SWFISKR6VxPuNqFERA-VefpDW9pxQsTILkqvm7DVKIJGcXU1bn3d9avOgfuZhVx161PtKfgvjW0hpSQJ9XV8V3My5njyzkEuJzFiNoXQVdfY5kGfsTr8w9AfjZhzcoLt41seMDIpugs/s2560/1.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="910" data-original-width="2560" height="228" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhER8U2z4pvw6jcs_WujlgnzbjIq1K15FqgZZ_S0oMmnOi3MwJ8SWFISKR6VxPuNqFERA-VefpDW9pxQsTILkqvm7DVKIJGcXU1bn3d9avOgfuZhVx161PtKfgvjW0hpSQJ9XV8V3My5njyzkEuJzFiNoXQVdfY5kGfsTr8w9AfjZhzcoLt41seMDIpugs/w640-h228/1.jpg" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">For me, it is hard to make much of this ECG. The most troublesome lead is aVL which shows abnormal ST flattening and perhaps even a very tiny of depression. With no context, I would call it sinus rhythm with non-specific ST&T wave abnormalities.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><b>Smith</b>: there is a bit of STE in inferior leads, and aVL has not only some STD, but it is downsloping, which is very worrisome for inferior OMI.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">High sensitivity troponin I (hsTnI) obtained around that time was 5548 ng/L (ref. < 35). This is enough to cause serious alarm. Distilling this case into its most salient components, a man with multiple risk factors for coronary disease is presenting with several days of chest pain and markedly elevated troponin with no other reason to explain the lab abnormality (<i>e.g.</i> sepsis). It is impossible to overstate the importance of <span>putting the ECG and troponin into the context of the</span> clinical history.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><b>Smith</b>: at this point, the ECG becomes irrelevant. The patient has ACS by history, active pain, and an elevated troponin. There is acute MI with persistent symptoms. This is an indication for the cath lab regardless of the ECG. <b>Nevertheless</b>, learning these ECGs is critical because the next time such a patient presents, it might be acute, before there is any troponin elevation. Activate the cath lab! Do not wait for repeat troponins or ECGs.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Already, we should be asking ourselves whether this could be OMI. And since the ECG does not define the disease, the answer is <i>of course it could be. </i>Troponin is <i>not</i> specific for acute coronary syndrome, but in a case like this when we have nothing else to explain it, we <b>must</b> rule out the deadliest (reasonably likely) possibility. Repeat ECG was obtained and is shown below:</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHkyg1DZwWLtiD1ZKEgZJ76Lwnd9Fg-XCUXRi73pbHPsZqgy_kRkP8LRDvVmjY9v2TC8anUnrLq1mgJsmuVs0pNx4uiBl0nQ9Fx6lpUndJIQFWJdDvij5HTvzjj-fxSPfBU0w50gXOi1wR4PhqgywXEJRp0n-OXbPDO4Hvt4jZ-3WZ0-iJ8ts5jpka2FM/s2296/Screenshot%202024-03-08%20at%207.32.49%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="606" data-original-width="2296" height="169" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHkyg1DZwWLtiD1ZKEgZJ76Lwnd9Fg-XCUXRi73pbHPsZqgy_kRkP8LRDvVmjY9v2TC8anUnrLq1mgJsmuVs0pNx4uiBl0nQ9Fx6lpUndJIQFWJdDvij5HTvzjj-fxSPfBU0w50gXOi1wR4PhqgywXEJRp0n-OXbPDO4Hvt4jZ-3WZ0-iJ8ts5jpka2FM/w640-h169/Screenshot%202024-03-08%20at%207.32.49%E2%80%AFPM.png" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Here is the Queen's verdict and translator:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLBgKvZH2O0ffhBuOqaHRu6xYgsofzo8hD8UeXRKgMyIFWZseh_4O2vWs0uZo-jb2L48Yx7iVJBeEmWpf8wuGjcgPKJHd12fofgKjCkhO29XdDOAkczuYhcq6J9pEpkwRHqQedcZv7vMQAVlu_-Z9OIv5zJ-9s8B85Vy2uLBAunU_YoC6n5r_Q77Jb75M/s2560/2.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="910" data-original-width="2560" height="228" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLBgKvZH2O0ffhBuOqaHRu6xYgsofzo8hD8UeXRKgMyIFWZseh_4O2vWs0uZo-jb2L48Yx7iVJBeEmWpf8wuGjcgPKJHd12fofgKjCkhO29XdDOAkczuYhcq6J9pEpkwRHqQedcZv7vMQAVlu_-Z9OIv5zJ-9s8B85Vy2uLBAunU_YoC6n5r_Q77Jb75M/w640-h228/2.jpg" width="640" /></span></a></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><span style="font-size: medium;">I sent these ECGs along with the troponin trend to our group chat, and Dr. Nossen said "With those troponins retrospectively, this is an inferoposterior OMI. It would be hard to call without the previous ECG for comparison, but the inferior leads are worrisome." Dr. Hellerman agreed and mentioned the inferior ST elevations with reciprocal depression in aVL. Dr. Smith (catching up on the discussion) saw ECG 1 and commented that it looked like "very subtle inferior OMI."</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Dr. Nossen also pointed out that with voltage this high in the limb leads, you would typically expect some degree of inferior/inferolateral ST depression (the so-called "LVH strain" pattern), and in fact this patient did have severe LVH on subsequent echocardiogram (which Dr. Nossen did not know at the time). Therefore, the finding of <i>any</i> STE inferiorly is doubly alarming.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Here they are side by side:</span></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi13ci25PalAXbv-I_cW6-t0WqnXMiRVB-TGPxsIvGxd7mUOCEF2i87TQcn-t4dJKXwyJ-XicxPxMqphpbkmxtw852-kg5Nj5IZrus7DKEO73URULwFYzyHYlRcdN-KQoPrQXxhu_EVMKID8AbDxXrLqTeaTeTyMvvgpHdatRMpEJKg9aAJvXSv-_nbLss/s2724/Screenshot%202024-03-08%20at%207.59.58%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1574" data-original-width="2724" height="370" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi13ci25PalAXbv-I_cW6-t0WqnXMiRVB-TGPxsIvGxd7mUOCEF2i87TQcn-t4dJKXwyJ-XicxPxMqphpbkmxtw852-kg5Nj5IZrus7DKEO73URULwFYzyHYlRcdN-KQoPrQXxhu_EVMKID8AbDxXrLqTeaTeTyMvvgpHdatRMpEJKg9aAJvXSv-_nbLss/w640-h370/Screenshot%202024-03-08%20at%207.59.58%E2%80%AFPM.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: left;"><span style="font-size: medium;">The T waves in the inferior leads have significantly increased in volume, and the mostly flat ST segment in aVL now has more of a down-up morphology.</span></div></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Around this time, the patient received aspirin 324 mg. Repeat hsTnI was 10497 ng/L, and this was interpreted as "likely NSTEMI." Note that this patient has elevated troponin with dynamic change and chest pain. <a href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000000617">By definition</a>, this is acute myocardial infarction, the only question now is the etiology.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Given radiation of pain into the patient's back, he underwent CTA which showed no evidence of aortic dissection or any other acute pathology. It is not clear <i>exactly</i> what symptoms the patient may have been experiencing at this time, but the notes indicate that he then developed "worsening" pain, suggesting he had likely had ongoing angina the whole time. Recall that medically refractory angina is itself a <a href="https://academic.oup.com/eurheartj/article/44/38/3720/7243210?login=false#441044910">Class I indication</a> for immediate angiography (see Figure 8). (It is hard to call this medically refractory at this point as the patient had not received any anti-anginal therapy.)</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">At this point, the patient was treated with 1 inch of nitro paste <span>(<b>Smith</b>: this is a worthless treatment and the ACC guidelines even say so!)</span> and morphine 4 mg IV <span>(<b>Smith</b>: this is even more worthless, and just hides the fact that the patient is having ongoing ischemia and infarction)</span>, and repeat ECG was obtained. (Treating angina with morphine and continuing non-emergent management is like taking the batteries out of an actively alarming smoke detector during a house fire and going back to sleep.)</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Another ECG was recorded:</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEj5wj8Oj-p1jktUelHwgGn2K_y2_w9JRXe3XQ4ptPJ_19rckvhnYtUocWKd2RtgkNDWiYL1FHyyAXLXjExDXUEJf041IBzcjqQD0Ig1N_lYsqLLNXoz1Q1BB_vMD93GVBZHgwvgInw9B5geIwGXU3Eo4Lc9Yc2PRDA6tXJvF-2hcvLHnlP4cMRkFLuP6os" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="1216" data-original-width="2566" height="304" src="https://blogger.googleusercontent.com/img/a/AVvXsEj5wj8Oj-p1jktUelHwgGn2K_y2_w9JRXe3XQ4ptPJ_19rckvhnYtUocWKd2RtgkNDWiYL1FHyyAXLXjExDXUEJf041IBzcjqQD0Ig1N_lYsqLLNXoz1Q1BB_vMD93GVBZHgwvgInw9B5geIwGXU3Eo4Lc9Yc2PRDA6tXJvF-2hcvLHnlP4cMRkFLuP6os=w640-h304" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Here is the Queen's verdict and translator:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsMQWbTVwDMH_YmvZY7-te-ucu5uJF7rq4hpYw1asnpxJXiCwS7yHllFVKAxeiP5kFDLqMYtnxgCqzC0Df5Qd-PWzro4305nYlsy8-h-iaONk-AE8kycS6Sa6XmuS65d6IAUqCwP7JrGeMkTGez4eq1C6w-ZpkfndrwH79w9VAbcj51YHGrzxWwEQbPYc/s2560/2.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="767" data-original-width="2560" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsMQWbTVwDMH_YmvZY7-te-ucu5uJF7rq4hpYw1asnpxJXiCwS7yHllFVKAxeiP5kFDLqMYtnxgCqzC0Df5Qd-PWzro4305nYlsy8-h-iaONk-AE8kycS6Sa6XmuS65d6IAUqCwP7JrGeMkTGez4eq1C6w-ZpkfndrwH79w9VAbcj51YHGrzxWwEQbPYc/w640-h192/2.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div class="separator" style="clear: both;"><span style="font-size: medium;">Compared to the first two ECGs, and especially in the context of chest pain and rapidly rising troponin, we see progressively increasing area under the curve in the inferior T waves, and the ST segment in aVL now has much clearer reciprocal depression.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">A third hsTnI was 17809 ng/L, and the patient was started on IV heparin as well as sublingual and IV nitroglycerin. Due to persistent pain, he received a second dose of morphine 4 mg IV. Repeat hsTnI was 25763 (<i>ten hours</i> after the initial result).</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><b>Brief aside:</b> Remember that the overwhelming benefit of reperfusion therapy is attained if performed within 2-3 hours. <a href="https://pubmed.ncbi.nlm.nih.gov/15728169/">By 6 hours</a>, most of the salvageable myocardium has infarcted. This is WHY refractory angina should prompt immediate angiography. If you wait until the ECG and troponin are "convincing," you are sacrificing a lot of myocardium.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Due to persistent pain, the patient received a third dose of morphine 4 mg IV. A fourth ECG is shown below.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjAKcWkRnVDqrE4DzD1R7ldL5Ob7IfFagkSsD-N0JqtyMjmsRws9agBlKhGaAZIj0z1vS7XHLLvMp90aOyV58j7AQWlSAlZfL5d89ABVcjHFYfLPEFgVHaMQItbspQ5I8o7klbToNocybHroDiQG_Mtlwn9vvSsnCP4ESuaE4NTOuZ0BUf-OwuFDS2y-hs" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="1214" data-original-width="2568" height="302" src="https://blogger.googleusercontent.com/img/a/AVvXsEjAKcWkRnVDqrE4DzD1R7ldL5Ob7IfFagkSsD-N0JqtyMjmsRws9agBlKhGaAZIj0z1vS7XHLLvMp90aOyV58j7AQWlSAlZfL5d89ABVcjHFYfLPEFgVHaMQItbspQ5I8o7klbToNocybHroDiQG_Mtlwn9vvSsnCP4ESuaE4NTOuZ0BUf-OwuFDS2y-hs=w640-h302" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Here is the Queen's verdict and translator:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6spilST_024Z4aJqFuleEXXm5W4qmwrc0qXtDq5t074W28Qd0oaaOqv0c6l-tH1P5ctoiuoArdrKqW7KMzPYQkXLx9PFb9Jo9US6_hyS71iZpf-a-T-AahgXl0wNDlCtZ3igLZepIXSsCN9dRtiG3ku1FFidjwhwS5JRnf01q10apvKnhUZsJZ2ZNn2g/s2560/2024-03-06%2022.07.53.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="767" data-original-width="2560" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6spilST_024Z4aJqFuleEXXm5W4qmwrc0qXtDq5t074W28Qd0oaaOqv0c6l-tH1P5ctoiuoArdrKqW7KMzPYQkXLx9PFb9Jo9US6_hyS71iZpf-a-T-AahgXl0wNDlCtZ3igLZepIXSsCN9dRtiG3ku1FFidjwhwS5JRnf01q10apvKnhUZsJZ2ZNn2g/w640-h192/2024-03-06%2022.07.53.jpg" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">If any doubt remained, we are now completely certain that the inferior T waves are hyperacute, especially with the reciprocal changes in aVL. Although this ECG is obvious to the Queen of Hearts, it was read by cardiology as sinus rhythm with non-specific ST&T wave abnormality.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">At this point, due to refractory pain, the patient was taken for left heart catheterization. It is not clear why it was only considered refractory after topical, sublingual, and intravenous nitroglycerin plus morphine 12 mg IV over the course of over 10 hours. But unfortunately, this is not surprising, only about <a href="https://pubmed.ncbi.nlm.nih.gov/35266561/">6% of patients</a> with refractory angina receive immediate angiography as recommended.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Thirteen hours after the first troponin was drawn, the following angiogram was performed.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='580' height='482' src='https://www.blogger.com/video.g?token=AD6v5dzQ0wAMNTvhnKwDwnbCXmWzmBwezxpd_umQOvC7HAWYBnoYjbvQoTrIbMt2jyUqBfixvOiNCzSdgWhRicFmVw' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">The troponin peaked at 25749 ng/L. Echocardiogram showed akinesis of the mid to basal inferior and inferoseptal walls, and hypokinesis of the inferolateral wall. One final ECG performed after cath shows obvious inferoposterior reperfusion. (Deep TWI in the inferior leads with reciprocal overly upright T waves in I and aVL, plus posterior reperfusion T waves in V1-2 at least.)</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqA5BPn_JAV9K1ErkhrqimERNvuk77PcljDhbuThCrzjSICtwxuSaGb26JNen5eoJwk6cISY85JS-xTj2UTYRld1pvrlulFqRfSkmSQ4yQm6IpYNvS8I9B3jrbjjC6BcjRZQ_qF3FJ8eYiQ-kgecYe8V-r8pjkEjI_nKoCRIxLcEzoDnHZnqbW1eEsW2s/s2560/Screenshot%202024-03-09%20at%205.47.43%E2%80%AFPM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1172" data-original-width="2560" height="294" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqA5BPn_JAV9K1ErkhrqimERNvuk77PcljDhbuThCrzjSICtwxuSaGb26JNen5eoJwk6cISY85JS-xTj2UTYRld1pvrlulFqRfSkmSQ4yQm6IpYNvS8I9B3jrbjjC6BcjRZQ_qF3FJ8eYiQ-kgecYe8V-r8pjkEjI_nKoCRIxLcEzoDnHZnqbW1eEsW2s/w640-h294/Screenshot%202024-03-09%20at%205.47.43%E2%80%AFPM.png" width="640" /></span></a></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;"><br /></span></b></div><div class="separator" style="clear: both;"><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;"><span style="text-shadow: none;"><br /></span></b></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: large;">False negative by Queen of Hearts: </span><span style="font-size: medium;">All ECGs like this will be reviewed in detail by Powerful Medical, and these "critical misses" will be rectified in the algorithm!</span><span style="font-size: large;"> </span></span></b></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;"><span style="text-shadow: none;">The Queen of Hearts PM Cardio App is now available in the European Union (CE approved) the App Store and on Google Play. </span></b></span><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;">For Americans</b>, you need to wait for the FDA. </span><b style="font-family: times; text-shadow: none;">But in the meantime:</b></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">YOU HAVE THE OPPORTUNITY TO GET EARLY ACCESS TO THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></span></span></b></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br style="text-shadow: none;" /></span></span></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here. It is not yet available, but this is your way to get on the list.</span></span></span></div><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p class="p1" style="background-color: white; color: #333333; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 13px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; text-shadow: none;"><span class="s1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></span></span></a></div></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;"><br /></span></b></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;"><br /></span></b></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;"><br /></span></b></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;">Learning points:</span></b></div><div class="separator" style="clear: both;"><ul><li><span style="font-size: medium;">ECG owes you <i>nothing</i> in OMI, and may be completely normal, or show only impossibly subtle findings.</span></li></ul><ul><li><span style="font-size: medium;">Fortunately, ECG is not the only diagnostic information to clue you into the possibility OMI! There is history, physical, troponin, and bedside echo.</span></li></ul><ul><li><span style="font-size: medium;">There are many causes of elevated troponin, but <i>unexplained</i> troponin elevation in a patient with ongoing chest pain is OMI until proven otherwise.</span></li></ul><ul><li><span style="font-size: medium;">Patients with medically refractory angina should undergo <b>immediate angiography.</b></span></li></ul></div></div></div>Willy Frickhttp://www.blogger.com/profile/09245005765903652623noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-35540582561386319812024-03-09T07:51:00.002-06:002024-03-09T12:17:35.104-06:00Acute chest pain and ST Elevation. CT done to look for aortic dissection.....<p><span style="font-size: medium;">Written by <a href="https://twitter.com/willyhfrick">Willy Frick</a></span></p><p><span style="font-size: medium;">A 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. He had associated nausea, vomiting, and dyspnea.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhe3UmaHbIbdBQCbLXUAaZOH9SfASv1tUTzh_6BqtOjIkB8qEpWTmVr6xJg2DlXRhSbCbfHP6RIJ7gABIDYxJu9nXwaK0GMdhuv0vUFp3KdjmCTOF_Nfpmk4yzjiYZU_9lxtktjQ9z8r3APldndl9zwsERWKyv6tIcORTKoHDEG5Ps1--ZIlgD_xveP8mM" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="726" data-original-width="1281" height="363" src="https://blogger.googleusercontent.com/img/a/AVvXsEhe3UmaHbIbdBQCbLXUAaZOH9SfASv1tUTzh_6BqtOjIkB8qEpWTmVr6xJg2DlXRhSbCbfHP6RIJ7gABIDYxJu9nXwaK0GMdhuv0vUFp3KdjmCTOF_Nfpmk4yzjiYZU_9lxtktjQ9z8r3APldndl9zwsERWKyv6tIcORTKoHDEG5Ps1--ZIlgD_xveP8mM=w640-h363" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">What do you think?</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_yWX3IcoDW2Pq93ecQfVJTcKXkRUWJN9CAq2KgAasCz_OVweBSkgym6dLRayqANabr7X3EBW_OrIG1Jayjf4XEfWo9tjKl7-epz4mlBWCnGDXahUC3FKI4iA3DlaBcCuUOMSgbnO8A0oMlvhsajAXjJ3Q9bga8cZbrooExl2S1qJfxLaCaJTwtMBfuBk/s2560/6BD81DBE-DB69-47A0-B809-46379A490463.jpeg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="481" data-original-width="2560" height="120" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_yWX3IcoDW2Pq93ecQfVJTcKXkRUWJN9CAq2KgAasCz_OVweBSkgym6dLRayqANabr7X3EBW_OrIG1Jayjf4XEfWo9tjKl7-epz4mlBWCnGDXahUC3FKI4iA3DlaBcCuUOMSgbnO8A0oMlvhsajAXjJ3Q9bga8cZbrooExl2S1qJfxLaCaJTwtMBfuBk/w640-h120/6BD81DBE-DB69-47A0-B809-46379A490463.jpeg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div class="separator" style="clear: both;"><span style="font-size: medium;">This ECG together with these symptoms is certainly concerning for OMI, but the ECG is not fully diagnostic, and another consideration could be acute pericarditis. <a href="http://hqmeded-ecg.blogspot.com/2018/06/you-diagnose-pericarditis-at-your-peril.html">Mistaking OMI for pericarditis</a> is a much more harmful error than the converse. Still, in the interest of studying the ECG, here are some findings that could support pericarditis:</span></div><div class="separator" style="clear: both;"><div><span style="font-size: medium;"><br /></span></div><ul><li><span style="font-size: medium;">Absence of large T-waves (flat ST segments)</span></li></ul><ul><li><span style="font-size: medium;">Absence of any STD in aVL (which is seen in <a href="https://pubmed.ncbi.nlm.nih.gov/26542793/">99% of inferior OMIs</a>).</span></li></ul><ul><li><span style="font-size: medium;">There is no reciprocal depression anywhere (except aVR and V1, the rightward facing leads).</span></li></ul><ul><li><span style="font-size: medium;">STE spanning from lead I (0°) all the way to lead III (120°), <i>i.e.</i> diffuse.</span></li></ul><ul><li><span style="font-size: medium;">There is appreciable PR depression in a few leads (I, II, V4-6).</span></li></ul><ul><li><span style="font-size: medium;">There is Spodick's sign (downsloping TP segment) in a few leads (V3, V4).</span></li></ul><ul><li><span style="font-size: medium;">The STE has a more concave morphology (vs the more ischemic coved appearance).</span></li></ul><ul><li><span style="font-size: medium;">Ongoing pain despite terminal TWI in a few leads (II, aVF, V5, V6). If this were OMI, that should indicate reperfusion and improving pain.</span></li></ul><ul><li><span style="font-size: medium;">There is end QRS slurring in II, aVF, V6 (vs the more ischemic <a href="https://pubmed.ncbi.nlm.nih.gov/32222321/">checkmark sign</a>).</span></li></ul><ul><li><span style="font-size: medium;">The STE in II is greater than the STE in III.</span></li></ul><ul><li><span style="font-size: medium;">The rate is tachycardic, which is uncommon in OMI and common in pericarditis.</span></li></ul><div><b><span style="font-size: medium;">There is also low voltage across the ECG.</span></b></div><div><b><span style="font-size: medium;"><br /></span></b></div><div><span style="font-size: medium;"><b>Important note: None of these findings proves pericarditis.</b> All of them <i>can</i> be seen in OMI. But seeing them all together is more suggestive that pericarditis could be possible.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Due to the chest pain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. While awaiting the results of the CT, the physician called cardiology. The cardiologist agreed that the ECG was suggestive of STEMI, but the facility's cath lab was apparently not available and he therefore recommended emergent transfer to a cath capable facility.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">A representative still from the CT scan is shown below:</span></div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEghR8r4Dfx19lC1KT8-nlG6AdKBmzcFzdp9DeW4PLuXJ758S0cW_P4U3fo1mvqOh5mzgkcDZ6cfyASWvRVRY_K5lKRFUuZviet1DgV9RvqlIs_-Hmd_G2HAUES-6Edy5OkUJIQPPyaoNxkgSApJYQsg_xpVGzhHMXcUHnkW2qKUedbtNFjQfUu8eC-23Pc" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="888" data-original-width="1332" height="426" src="https://blogger.googleusercontent.com/img/a/AVvXsEghR8r4Dfx19lC1KT8-nlG6AdKBmzcFzdp9DeW4PLuXJ758S0cW_P4U3fo1mvqOh5mzgkcDZ6cfyASWvRVRY_K5lKRFUuZviet1DgV9RvqlIs_-Hmd_G2HAUES-6Edy5OkUJIQPPyaoNxkgSApJYQsg_xpVGzhHMXcUHnkW2qKUedbtNFjQfUu8eC-23Pc=w640-h426" width="640" /></span></a></div><span style="font-size: medium;"><br />This shows a very large pericardial effusion, which fits with the diagnosis of pericarditis. Recall that pericarditis is diagnosed clinically by any 2 of the following:</span></div><div><ul><li><span style="font-size: medium;">Characteristic pain (pleuritic, worse with deep inspiration and supination)</span></li><li><span style="font-size: medium;">Friction rub</span></li><li><span style="font-size: medium;">New widespread ST elevation</span></li><li><span style="font-size: medium;">New or worsening pericardial effusion</span></li></ul><div><span style="font-size: medium;">This patient now has at least two of the above (effusion plus STE), making the diagnosis of pericarditis quite likely. This would have been fairly easy and much more expedient to diagnose with bedside echocardiogram. <b>The constellation of dyspnea, tachycardia, and (relatively) low voltage on ECG should prompt immediate evaluation for pericardial effusion and tamponade.</b></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">After transfer to a cath capable facility, and before he was taken to lab, repeat ECG was performed and is shown:</span></div></div></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgDQBLy_6UqxtQ9aaffU11TFzB572c0R4XaJZoBdAFRH-mKGvbZao0zsXHKaPFn2PwFKT1f_F9DXXf0XitiNM87ppGiTSnRNhsOd7iCbDIyccrYP3-EBLLLN1hf0QscTyj3QwmqfPpO0dGMdjRGYIgFv3nQyh3VUQzCOFvQeuMvYpHNOLEyPZevHB27e8Q" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="726" data-original-width="1282" height="362" src="https://blogger.googleusercontent.com/img/a/AVvXsEgDQBLy_6UqxtQ9aaffU11TFzB572c0R4XaJZoBdAFRH-mKGvbZao0zsXHKaPFn2PwFKT1f_F9DXXf0XitiNM87ppGiTSnRNhsOd7iCbDIyccrYP3-EBLLLN1hf0QscTyj3QwmqfPpO0dGMdjRGYIgFv3nQyh3VUQzCOFvQeuMvYpHNOLEyPZevHB27e8Q=w640-h362" width="640" /></span></a></div><span style="font-size: medium;"><br /><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE2HDEC0J5z0QG5GShVPrY9aIF-UH7A5rUDTLdL2qEARYLcUwbfMDdd3mnHRxkwDiuv8S8N3eYGcRjWoofnwS1YeXfKnbugo5sm29fmVMXx4NicId2nM9BN-hK5v2o6k5C0XXowA37WW-gKbLqksdqmpRFyLKLalTc4EBaZfOimQ91CWQLLg2fxpC5nc0/s2560/D2ACC141-9558-4E1A-A500-D7E7D0EDB5E6.jpeg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="624" data-original-width="2560" height="156" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE2HDEC0J5z0QG5GShVPrY9aIF-UH7A5rUDTLdL2qEARYLcUwbfMDdd3mnHRxkwDiuv8S8N3eYGcRjWoofnwS1YeXfKnbugo5sm29fmVMXx4NicId2nM9BN-hK5v2o6k5C0XXowA37WW-gKbLqksdqmpRFyLKLalTc4EBaZfOimQ91CWQLLg2fxpC5nc0/w640-h156/D2ACC141-9558-4E1A-A500-D7E7D0EDB5E6.jpeg" width="640" /></span></a></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Over just an hour or so, the Queen's certainty has improved significantly, and she now has mid confidence that this is <b>not OMI</b>. The patient underwent pericardiocentesis with drainage of 1500 mL of serous fluid! No further ECGs were obtained. Troponin I was serially undetectable.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">____________________________</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><b>This is Version 1 of the Queen of Hearts</b>, which was not trained on pericarditis. Version 2, coming soon, was trained on many pericarditis ECGs and version 3 on even more.</span></div><div><span style="font-size: medium;"><br /></span></div><div><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-size: medium;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;"><span style="text-shadow: none;">The Queen of Hearts PM Cardio App is now available in the European Union (CE approved) the App Store and on Google Play. </span></b></span><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;">For Americans</b>, you need to wait for the FDA. </span><b style="font-family: times; text-shadow: none;">But in the meantime:</b></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">YOU HAVE THE OPPORTUNITY TO GET EARLY ACCESS TO THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></span></span></b></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here. It is not yet available, but this is your way to get on the list.</span></span></span></div><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><p class="p1" style="background-color: white; color: #333333; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; text-shadow: none;"><span class="s1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-size: medium;"><span style="font-family: times; text-shadow: none;"></span></span></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></span></span></a></div></div><div><span style="font-size: medium;"><br /></span></div><div><b><span style="font-size: medium;">Learning Points:</span></b></div><div><ul><li><span style="font-size: medium;">Calling OMI pericarditis is much more harmful mistake than the converse</span></li></ul><ul><li><span style="font-size: medium;">Bedside echo demonstrating pericardial effusion can strongly support a diagnosis of pericarditis (and is seen in 60% of cases of acute pericarditis)</span></li></ul><ul><li><span style="font-size: medium;">Pericarditis can only be ruled in after proving</span></li><ul><li><span style="font-size: medium;">Absence of reciprocal changes (other than V1 and aVR), particularly aVL</span></li><li><span style="font-size: medium;">Absence of STE III > II</span></li><li><span style="font-size: medium;">Absence of checkmark sign</span></li><li><span style="font-size: medium;">Presence of PR depression</span></li><li><span style="font-size: medium;">Presence of Spodick's sign</span></li></ul></ul><ul><li><span style="font-size: medium;">When you see dyspnea, tachycardia, and lowish voltage, rule out pericardial effusion and tamponade with bedside echocardiogram </span></li></ul></div>Willy Frickhttp://www.blogger.com/profile/09245005765903652623noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-53086625193356902342024-03-07T12:26:00.007-06:002024-03-15T08:49:00.124-05:00Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart. A case of irregular accelerated idioventricular rhythm (AIVR)<p><span style="font-family: times; font-size: medium;">A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.</span></p><p><span style="font-family: times; font-size: medium;">He got a chest tube and intubation and massive transfusion and stabilized.</span></p><p><span style="font-family: times; font-size: medium;">CT of chest showed the bullet path through his right lung but nowhere near his heart.</span></p><p><span style="font-family: times; font-size: medium;">But he did get an EKG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1pueq_63FsKDJr0ZBdceLPxmoAYTmm8jmZa97tCI9R2ab_uNobj0owc4TBbnfnupiQaszuLZaPkuc2Qu60Dr9ngkF84qHnrJikTpuCMn56dT_EbgF8Z1dCGipVSWPoEa7DcTp2QZU1eSIF0cy4JjME0SekcsgRgq0yjCBeZ2GnnfmAwiT1pLFbNwev4-W/s3400/AIVR-1.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1786" data-original-width="3400" height="336" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1pueq_63FsKDJr0ZBdceLPxmoAYTmm8jmZa97tCI9R2ab_uNobj0owc4TBbnfnupiQaszuLZaPkuc2Qu60Dr9ngkF84qHnrJikTpuCMn56dT_EbgF8Z1dCGipVSWPoEa7DcTp2QZU1eSIF0cy4JjME0SekcsgRgq0yjCBeZ2GnnfmAwiT1pLFbNwev4-W/w640-h336/AIVR-1.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">What is this? There were times when it would be usurped by sinus tachycardia, then return to this rhythm.</div></span><div style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;">There is a wide complex. It is irregular. It is not fast (cannot be VT). There is no atrial activity to suggest atrial fibrillation. </span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;">There are what <u><i>could</i></u> be interpreted as delta waves <u><i>if, and only if,</i></u> there were P-waves or other atrial activity preceding the QRS (pre-excitation can only happen when there is an impulse originating in the atria). <b>Therefore, these are NOT delta waves and this is NOT pre-excitation!</b></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;">I could only conclude that this was an <b>irregular accelerated idioventricular rhythm</b>. I concluded that it is safe and did not require treatment and to leave it alone unless it became too slow, at which point atropine would be indicated to increase the sinus rate to let that sinus rate take over.</span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><b>AIVR should never be treated with anti-dyrrhythmics!! It is a stable rhythm. Atropine is ok to improve the sinus rate if the heart rate is too slow.</b></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><b>All troponins were negative.</b></span></div><div><span style="font-family: times; font-size: medium;"><b><br /></b></span></div><div><span style="font-family: times; font-size: medium;"><b>Formal echo was normal.</b></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;">Here are 4 more ECGs recorded over the ensuing hours:</span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiq9hso6BqO8bDb2HtzCgJLSqWVZuRcbiKperPtNKAW5bKmNz9_cpzUAwX6bm-MPSmyzrOcy0g6CN5wRQ4wVRsv6HoPNRPKBgBjRZzMWZRt99Ou4HK5XNkdWydrEg0zxXskap8s-ajGfzfeiylNKz2kjbFpnpLDX3fbHyKt3D_wc2tjnR97yJQA0KLPu0H/s3402/AIVR-2.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1752" data-original-width="3402" height="330" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiq9hso6BqO8bDb2HtzCgJLSqWVZuRcbiKperPtNKAW5bKmNz9_cpzUAwX6bm-MPSmyzrOcy0g6CN5wRQ4wVRsv6HoPNRPKBgBjRZzMWZRt99Ou4HK5XNkdWydrEg0zxXskap8s-ajGfzfeiylNKz2kjbFpnpLDX3fbHyKt3D_wc2tjnR97yJQA0KLPu0H/w640-h330/AIVR-2.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><div style="text-align: center;"><span style="font-family: times; font-size: medium;">Another irregular AIVR</span></div><div style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSxUQUByEzgKIFQukhHaBejh5JFSRSQl1xRrDXWxIsNv-ju44jUKYMrOhV_pRnsTSRYfSdqn39pLM0tbKI3cLrYsmIzitLmU98864qL6WhxwkLYOcMvtsKFg9iAIkfQU4SxjSxBGkbsG-QdMNdKimNJU9R59XGg0MrfXs80IHyoLLkGNnhTs_OAwkS1Set/s3402/AIVR-3.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1708" data-original-width="3402" height="322" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSxUQUByEzgKIFQukhHaBejh5JFSRSQl1xRrDXWxIsNv-ju44jUKYMrOhV_pRnsTSRYfSdqn39pLM0tbKI3cLrYsmIzitLmU98864qL6WhxwkLYOcMvtsKFg9iAIkfQU4SxjSxBGkbsG-QdMNdKimNJU9R59XGg0MrfXs80IHyoLLkGNnhTs_OAwkS1Set/w640-h322/AIVR-3.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">Back to sinus rhythm</div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZle2RXPE4xtpv03Z_NuaGZ8NIyO5zWX7XAUTJmhAzeitjtt6DQXT1dedYMmKOqKv-YDAjEb27Av2M0ikBmVkF-yoVJurkaVdvb6sZQhP6Tq0HRHt_QkE7eetQ9L6MZiartNv8S5pcu8TzRwJKgui93jfvBpl_SDXIyv72OWd_fURkjrM8yafY2rNx0w_1/s3384/AIVR-4.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1630" data-original-width="3384" height="308" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZle2RXPE4xtpv03Z_NuaGZ8NIyO5zWX7XAUTJmhAzeitjtt6DQXT1dedYMmKOqKv-YDAjEb27Av2M0ikBmVkF-yoVJurkaVdvb6sZQhP6Tq0HRHt_QkE7eetQ9L6MZiartNv8S5pcu8TzRwJKgui93jfvBpl_SDXIyv72OWd_fURkjrM8yafY2rNx0w_1/w640-h308/AIVR-4.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">This is a normal regular AIVR</div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMf1sNYs_n1dNd-PLCGIHdTL9hWkTGUkC69IuE6ZBhSVkA0-GmIIjhacMS5ntttoI5LSifwPeDs7E9bpKhaLKjGxPxvEYdKfBB0Aaa5dfu49k30hNI8_JQEarzdb0Ap4I7nbtbDvw6Dyrhz96JAOiB_KoUO-vaiPmOQv4GCyL5XJwnj8x8OwjSw-vzVkfQ/s3382/AIVR-5.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1510" data-original-width="3382" height="286" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMf1sNYs_n1dNd-PLCGIHdTL9hWkTGUkC69IuE6ZBhSVkA0-GmIIjhacMS5ntttoI5LSifwPeDs7E9bpKhaLKjGxPxvEYdKfBB0Aaa5dfu49k30hNI8_JQEarzdb0Ap4I7nbtbDvw6Dyrhz96JAOiB_KoUO-vaiPmOQv4GCyL5XJwnj8x8OwjSw-vzVkfQ/w640-h286/AIVR-5.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">Another normal regular AIVR</div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">On that first ECG, I was not entirely certain, since <b>I have never seen nor heard of irregular</b> AIVR, nor can I find a report of it in the literature. But I have seen AIVR in young people with trauma (see case below)</span></p><div style="font-family: arial; text-align: justify;"><b><span style="font-family: times; font-size: medium;"><br /></span></b></div><div style="text-align: justify;"><b><span style="font-family: arial; font-size: medium;">So I sent it to Ken Grauer and here are his comments:</span></b></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">============================</span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">For clarity — I've reproduced in <b><u>Figure-1</u></b> the ECG that Dr. Smith sent me (<i style="font-weight: bold;">Ken Grauer, MD — 3/7/2024</i>)<b>.</b></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">============================</span></div><div style="text-align: justify;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB6-qcwEfLpsATV_-6xyo7baHL6LGmcXReZsxVK9T9zD_g6flLF-4yBbE9KngJdpExG4h_Hq39hl7XwhyGD8tVs3BlmHqclr3-es9JfCVXHKfKk4KS-AcCuLFE7RplOCpJm5Ky44BWkeb2Q8u2MDmWLmq1FhhTwbf6tSfcQUna-O-7wfCqJBJ8j_XWeSg/s2870/ECG-2%20%20labeled%20(3-7.1-2024)-USE.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1474" data-original-width="2870" height="328" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB6-qcwEfLpsATV_-6xyo7baHL6LGmcXReZsxVK9T9zD_g6flLF-4yBbE9KngJdpExG4h_Hq39hl7XwhyGD8tVs3BlmHqclr3-es9JfCVXHKfKk4KS-AcCuLFE7RplOCpJm5Ky44BWkeb2Q8u2MDmWLmq1FhhTwbf6tSfcQUna-O-7wfCqJBJ8j_XWeSg/w640-h328/ECG-2%20%20labeled%20(3-7.1-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><span><b style="text-align: justify;"><u>Figure-1:</u></b><span style="text-align: justify;"> </span></span><span>The ECG sent to Ken Grauer (<i>showing some semblance of "group" beating</i>).</span></span></td></tr></tbody></table><span style="font-family: arial; font-size: medium;"><br /><span><br /></span></span></div><div style="text-align: justify;"><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">Hi Steve. This looks VERY bizarre … I don’t see P waves. With a GSW to the chest and what certainly looks like abnormal ST changes (<i>including marked ST elevation in I,aVL</i>) — there is presumably significant cardiac injury that could cause weird rhythms.</span></span></div><div style="text-align: justify;"><ul><li><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">The QRS is VERY wide — and the very wide Q in lead I (<i>showing marked axis deviation</i>) certainly suggest a ventricular etiology. Lots of leads almost look like delta waves — but I hate to diagnose delta waves when there are no P waves.</span></span></li><li><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">This does NOT seem irregularly irregular enough for AFib … Instead — there is almost <i>“group beating”</i> with “Wenckebach periodicity”. That is, R-R intervals are decreasing within groups — and the pauses (ie, <i>between beats #3-4; 8-9; and 13-14</i>) are less than twice the shortest R-R interval. </span></span></li><li><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">My guess is this is an <b><i>irregular</i> Accelerated Ventricular Rhythm (</b><i>which <u>can</u> occur when there is “triggered” activity</i><b>)</b> — perhaps with Wenckebach conduction <i>out of</i> the ectopic ventricular focus.</span></span></li><li><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">That said — it is not impossible for AFib + complete AV block to manifest Wenckebach conduction out of the AV nodal escape (<i>We used to see this when Dig toxicity was common …</i> ) — but my guess in this case is “triggered” activity irregular AVR … </span></span></li><li><span style="text-align: left;"><span style="font-family: arial; font-size: medium;">In any event — I don’t think I’d try and treat this rhythm given the reasonable ventricular rate (<i>and I’d hope the rhythm improves as the GSW to chest is treated …</i> ).</span></span></li></ul></div><p><span style="font-family: arial; font-size: medium;"><span style="text-align: justify;">============================</span></span></p><div><br /></div><p><span style="font-family: times; font-size: medium;"><b>I had a previous case of an adolescent with trauma and chest pain who also had AIVR:</b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2017/06/an-adolescent-with-trauma-chest-pain.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; font-size: medium;">An adolescent with trauma, chest pain, and a wide complex rhythm</span></a></h3><p><span style="background-color: white; color: #222222; font-family: times; font-size: medium;"><b>From this blog post:</b> "AIVR is NOT common in otherwise healthy children. I’ve attached an article and an abstract (that article is in Japanese unfortunately … ) that do document that you CAN however on occasion find AIVR in otherwise healthy children — and I suppose that IS what we have here. Perhaps the circumstances surrounding the ED visit cause slight acceleration in the ventricular escape rate to allow this all to happen."</span></p><div style="background-color: white; color: #222222; text-shadow: none; text-size-adjust: auto;"><span style="text-shadow: none;"><span style="font-family: times; font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #222222; text-shadow: none; text-size-adjust: auto;"><span style="text-shadow: none;"><span style="font-family: times; font-size: medium;"><b>Here the full text of the article:</b></span></span></div><div style="background-color: white; color: #222222; text-shadow: none;"><span style="text-shadow: none;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2803604/" style="color: #2066f5; text-decoration-line: none; text-decoration: none; text-shadow: none;" target="_blank"><span style="font-family: times; font-size: medium;"><b>Accelerated Idioventricular Rhythm: History and Chronology of the Main Discoveries</b></span></a></span></div><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><br /></p></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-12721450938813518092024-03-04T09:00:00.061-06:002024-03-05T21:18:47.981-06:00When the conventional algorithm diagnoses the ECG as COMPLETELY NORMAL, but there is in fact OMI, what does the Queen of Hearts PM Cardio AI app say? (with 10 case examples)<div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size: large; text-align: left;">I have often written about how an ECG interpreted as "normal" by a conventional algorithm may well be manifesting OMI, or even long QT or hyperkalemia.</span></div><p><span style="font-size: medium;">I have collected <b>51 OMI cases</b> that were diagnosed as completely normal by the conventional automated computer algorithm.</span></p><p><span style="font-size: medium;">Shifa Karim and Gabe Keller helped with a project to assess all these ECGs with the Queen of Hearts.</span></p><p><span style="font-size: medium;">Part of the result is back:</span></p><p><b><span style="font-size: large;">Of those 51 cases of OMI with a "completely normal" ECG (not even "nonspecific ST-T abnormalities, but <u>completely normal!</u>), <span style="color: red;">35 were diagnosed by the Queen of Hearts as OMI</span>.</span></b></p><p><span style="font-size: medium;">I wanted to show some of the cases here.</span></p><p><span style="font-size: medium;">You can read all the details in the links if you want.</span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-family: times;"><b><span style="font-size: medium;">The Queen of Hearts PM Cardio App is now available in the European Union (CE approved) the App Store and on Google Play. </span></b></span><span style="font-family: times; font-size: medium;"><b>For Americans</b>, you need to wait for the FDA. </span><b style="font-family: times; font-size: medium;">But in the meantime:</b></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="color: red;"><b><span style="font-family: times;"><span style="font-size: medium;">YOU HAVE THE OPPORTUNITY TO GET EARLY ACCESS TO THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></span></b></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-family: times;"><span style="font-size: medium;"><br /></span></span></div><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-family: times;"><span style="font-size: medium;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here. It is not yet available, but this is your way to get on the list.</span></span></div><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-size: medium;"><span style="font-family: times;"></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-size: medium;"><span style="font-family: times;"></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-size: medium;"><span style="font-family: times;"></span></span></p><p style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><span style="font-size: medium;"><span style="font-family: times;"></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span class="s1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;"><span style="font-family: times; font-size: medium;"></span></span></p><div style="background-color: white; caret-color: rgb(255, 0, 0); color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none;"><span style="font-family: times;"><span style="font-size: medium;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></span></a></div><p><span style="font-size: medium;">Or use the QR code:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWZurdXvU6OxcHFZ880WubA_BSuz-K0O41D74Ah7Ou1lroLt7Lmr5AogULg_KCYgVyR8Lat6ZBHJSwUCfNptcyRMFsq24pGg9LIN7hFZ5S0PS15kdX03bE4oqPBd9JIQ4DzTugkc6X2Ab1kqVAzd_5gBoj-kUgk4UHbwIFqgY2aWsNeQPEeWhEmanDbHFF/s1237/Telegram%20QR%20code.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1125" data-original-width="1237" height="291" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWZurdXvU6OxcHFZ880WubA_BSuz-K0O41D74Ah7Ou1lroLt7Lmr5AogULg_KCYgVyR8Lat6ZBHJSwUCfNptcyRMFsq24pGg9LIN7hFZ5S0PS15kdX03bE4oqPBd9JIQ4DzTugkc6X2Ab1kqVAzd_5gBoj-kUgk4UHbwIFqgY2aWsNeQPEeWhEmanDbHFF/s320/Telegram%20QR%20code.png" width="320" /></a></div><p><br /></p><p><b><u><span style="font-size: x-large;">10 Cases:</span></u></b></p><p><span style="font-size: medium;"><b>Case 1</b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative;"><a href="https://hqmeded-ecg.blogspot.com/2018/03/do-you-want-to-be-interrupted-to-view.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;">Do you want to be interrupted to view what the computer calls normal or nonspecific ECGs? 2 cases at once!</a></h3><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFXWTPscC5DRRPOSC37VAQm0MgLYJ49MD7_4uzrogtx0l-8ckuEeN1o4SIUhm1liwKxIw2I3cv29bymYNuvmLPWgjxBTYmXsTcPNG3e-RqKb4p1-5d_zFIiis-XbmPhvJKv6fHd1Xmys7qVrEq76zDIId7h40_P5Ha8Y8iQSLSmHugk96-7gkFiTBYWrbG/s3198/Called%20normal%20by%20Veritas%20but%20Queen%20gets%20it%20right.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1056" data-original-width="3198" height="212" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFXWTPscC5DRRPOSC37VAQm0MgLYJ49MD7_4uzrogtx0l-8ckuEeN1o4SIUhm1liwKxIw2I3cv29bymYNuvmLPWgjxBTYmXsTcPNG3e-RqKb4p1-5d_zFIiis-XbmPhvJKv6fHd1Xmys7qVrEq76zDIId7h40_P5Ha8Y8iQSLSmHugk96-7gkFiTBYWrbG/w640-h212/Called%20normal%20by%20Veritas%20but%20Queen%20gets%20it%20right.png" width="640" /></a></div><div style="text-align: center;"><span style="font-size: medium;">RCA Occlusion (OMI), called normal by conventional Veritas algorithm.</span></div><div style="text-align: center;"><span style="font-size: medium;">There are inferior hyperacute T-waves, with reciprocal STD and TWI in aVL.</span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;">Algorithm: Veritas (on Mortara machines)</span></div><p style="text-align: center;"><br /></p><p style="text-align: center;"><span style="font-size: medium;"><b>The Queen gets it right</b></span><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_BgNC7sULrfsanFeVMLg0ZJOkcLQfO6QJq5wP3HYD8O5jcyR82F3YTqpHJ1K4N32mhklxsafCMd99W4Djhn4QXZQpYzw_iFl6-Pg6hsVdKMvnp5M4zAZysY-KvBE09wVWnwSGnQ7rbpoeL_4Gh-o50M3qUK3b1pMJrJCngMZoSNQtAoGGJO_z7vAxL4ab/s906/Called%20normal%20by%20Veritas%20but%20Queen%20gets%20it%20right-Queen.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="444" data-original-width="906" height="314" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_BgNC7sULrfsanFeVMLg0ZJOkcLQfO6QJq5wP3HYD8O5jcyR82F3YTqpHJ1K4N32mhklxsafCMd99W4Djhn4QXZQpYzw_iFl6-Pg6hsVdKMvnp5M4zAZysY-KvBE09wVWnwSGnQ7rbpoeL_4Gh-o50M3qUK3b1pMJrJCngMZoSNQtAoGGJO_z7vAxL4ab/w640-h314/Called%20normal%20by%20Veritas%20but%20Queen%20gets%20it%20right-Queen.png" width="640" /></a></p><div><br /></div><br /><p><span style="font-size: large;"><b>Case 2</b></span></p><p><span style="font-family: times; font-size: medium;"><a href="https://hqmeded-ecg.blogspot.com/2017/11/a-middle-aged-woman-with-chest-pain-and.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none;"><b>A middle-aged woman with chest pain and a "normal" ECG in triage</b></a><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="background-color: white; color: #0090ff;"><b>. The OMI was not seen and she arrested in triage. </b> </span></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwQqG7BpdCcX81jhGbUmkTwCCFkab-DyK9mR2dALEP4q1TxOzuBl06LkHKHTflTDv4DXrpi6nDIkfG6wBi8KcThTj7K8DDxWwbfKOOF01FTbM8vBDt6nLOgjWkHVuS-pgJr1-Fbuesw1wgUjmmOsx4MkppwfLk1qvZULqAgNn2X4674NtTubtRDrdduYB1/s2000/Anterior%20LAD%20OMI%20not%20seen%20by%20Marquette%2012%20SL%20patient%20arrested-original.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="580" data-original-width="2000" height="186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwQqG7BpdCcX81jhGbUmkTwCCFkab-DyK9mR2dALEP4q1TxOzuBl06LkHKHTflTDv4DXrpi6nDIkfG6wBi8KcThTj7K8DDxWwbfKOOF01FTbM8vBDt6nLOgjWkHVuS-pgJr1-Fbuesw1wgUjmmOsx4MkppwfLk1qvZULqAgNn2X4674NtTubtRDrdduYB1/w640-h186/Anterior%20LAD%20OMI%20not%20seen%20by%20Marquette%2012%20SL%20patient%20arrested-original.png" width="640" /></a></div><div style="text-align: center;"><span style="font-size: medium;">LAD Occlusion called Normal by the conventional algorithm</span></div><div style="text-align: center;"><span style="font-size: medium;">There are hyperacute T-waves in V3-V5. LAD OMI.</span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;"><b style="background-color: white; color: #333333; font-family: times, "times new roman", serif; text-shadow: none;">GE Marquette 12 SL algorithm<br style="text-shadow: none;" /></b></span></div><p style="text-align: center;"><br /></p><div class="separator" style="clear: both; text-align: center;"><b style="font-size: large;">The Queen gets it right</b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPwIluzXY6mkCmEUAEZG-jPS-h-awqLKCqcO9qzM9w2oQ3teRcX5HTUTUMG7RG_O8aFz12ochn9qxMIqFdNE3-PBBI94TAlrKF2GKdUVFB5rGbcx29YAOMdr7MUBEEqtwkimF6-umhHpOr44niQH1xTh_kwcyI-WCVEYMIdsvamBfuRoYRnn2vSGEh69Ic/s904/Anterior%20LAD%20OMI%20not%20seen%20by%20Marquette%2012%20SL%20patient%20arrested-Queen.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="430" data-original-width="904" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPwIluzXY6mkCmEUAEZG-jPS-h-awqLKCqcO9qzM9w2oQ3teRcX5HTUTUMG7RG_O8aFz12ochn9qxMIqFdNE3-PBBI94TAlrKF2GKdUVFB5rGbcx29YAOMdr7MUBEEqtwkimF6-umhHpOr44niQH1xTh_kwcyI-WCVEYMIdsvamBfuRoYRnn2vSGEh69Ic/w640-h304/Anterior%20LAD%20OMI%20not%20seen%20by%20Marquette%2012%20SL%20patient%20arrested-Queen.png" width="640" /></a></div><br /><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative;"><br /></h3><div><br /></div><div><p><span style="font-size: large;"><b>Case 3</b></span></p></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative;"><a href="https://hqmeded-ecg.blogspot.com/2017/06/should-emergency-physicians-be.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;">Should Emergency Physicians be interrupted by ECGs that are read as "Normal" by the computer?</a></h3><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeFab3rs8wHxgz0FomKCICDqXJdN4zDG5DjdDjxgbrATNwUHEC-fOrzXQlD0kfYuYP63ukkpd6ilw4mNfoMkCJ_YiCbHsNsoNXhbdq02jVOYuapKVV3CXnGiZOk_y5DGiK2qykbg2k9L0TmbCL9PSg_IBiRpqhBqKRkxUtrrc2EKuLYjsvyIOEsI7J9KNx/s3194/Called%20normal%20by%20algorithm.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1004" data-original-width="3194" height="202" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeFab3rs8wHxgz0FomKCICDqXJdN4zDG5DjdDjxgbrATNwUHEC-fOrzXQlD0kfYuYP63ukkpd6ilw4mNfoMkCJ_YiCbHsNsoNXhbdq02jVOYuapKVV3CXnGiZOk_y5DGiK2qykbg2k9L0TmbCL9PSg_IBiRpqhBqKRkxUtrrc2EKuLYjsvyIOEsI7J9KNx/w640-h202/Called%20normal%20by%20algorithm.png" width="640" /></a></div><span style="font-size: medium;"><div style="text-align: center;">Inferolateral OMI diagnosed as "Normal" by the conventional algorithm</div><div style="text-align: center;">There is STE in lead III and aVF, with reciprocal STD in aVL</div><div style="text-align: center;">Subtle STE in V5 and V6.</div><div style="text-align: center;"><br /></div><div style="text-align: center;">Unknown algorithm</div></span><p style="text-align: center;"><br /></p><div class="separator" style="clear: both; text-align: center;"><b style="font-size: large;">The Queen gets it right</b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0zmh6e6XanvTcE_u3A1N9BLt3qYzynG729vBtueJ05_4It2LEQEw5ll_jv3i8sM1oCCpeSBoM9Ld-EIX9siwCpGNAO2w8190iltkQFMM4mk_t-eFi9aLKwnKR1jkfwPA0fZ5K18b5Pgq61RjSOr0vBLp4dBVuoLSHgJ1Sh9QYQ5PLRIPKu-MQFsO0XDfS/s922/Called%20normal%20by%20algorithm--Queen%20gets%20it%20right.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="922" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0zmh6e6XanvTcE_u3A1N9BLt3qYzynG729vBtueJ05_4It2LEQEw5ll_jv3i8sM1oCCpeSBoM9Ld-EIX9siwCpGNAO2w8190iltkQFMM4mk_t-eFi9aLKwnKR1jkfwPA0fZ5K18b5Pgq61RjSOr0vBLp4dBVuoLSHgJ1Sh9QYQ5PLRIPKu-MQFsO0XDfS/w640-h300/Called%20normal%20by%20algorithm--Queen%20gets%20it%20right.png" width="640" /></a></div><br /><p><br /></p><p><span style="font-size: large;"><b>Case 4</b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative;"><a href="https://hqmeded-ecg.blogspot.com/2017/03/how-unreliable-are-computer-algorithms.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none;">How unreliable are computer algorithms in the Diagnosis of STEMI?</a></h3><div><span style="font-size: medium;">Pain was resolving. Diagnosed as Normal by the computer. Troponin negative. The patient's prehospital ECG showed that there was massive STEMI and these are hyperacute T-waves "on the way down" as they normalize.</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5OeEGzgzpr0E8hSEjSEwqjgyVGb3BwnsBk9AqifBxNdFKhIfL-RUsnOxOFVZ2djaWoMaHQfU1KEY8IlVntlpeBHXea-v7OcF7Ckr2ftazSUHeS5Nck4Y4h_nuy8RYwU3hP5ErOzwBGDDDWyKqKSrToZgF4ZySVT3yBpO659jYq30jcGFNuBo8H2ZT4DqC/s2490/Old%20OMI%20LAD%20case%20called%20normal%2012%20SL.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="930" data-original-width="2490" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5OeEGzgzpr0E8hSEjSEwqjgyVGb3BwnsBk9AqifBxNdFKhIfL-RUsnOxOFVZ2djaWoMaHQfU1KEY8IlVntlpeBHXea-v7OcF7Ckr2ftazSUHeS5Nck4Y4h_nuy8RYwU3hP5ErOzwBGDDDWyKqKSrToZgF4ZySVT3yBpO659jYq30jcGFNuBo8H2ZT4DqC/w640-h240/Old%20OMI%20LAD%20case%20called%20normal%2012%20SL.png" width="640" /></a></div><div style="text-align: center;"><span style="font-size: medium;">This was called normal but has hyperacute T-waves in V2-V5. </span></div><div style="text-align: center;"><span style="font-size: medium;">LAD OMI.</span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;">Unknown algorithm</span></div><p style="text-align: center;"><br /></p><div class="separator" style="clear: both; text-align: center;"><b style="font-size: large;">The Queen gets it right</b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg67FKF0mX7rRFpufdkSCjX63Chti8ymDaj_lTPeaz8hmWpUTBoJvHnkWpndM0CM9G6SBrtbH0mJzZ5cLISH4Mc09kR68t206mF23S6duaUTHHCDB1R-r9GEWhpUAzi7eVjD_OfxEOI3K6J7aac5X_1W9o7S-KkklUDSpwLtEVLovXnEJbbmAopqaLJgPqR/s890/Old%20OMI%20LAD%20case%20called%20normal%2012%20SL-Queen%20Dx.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="492" data-original-width="890" height="354" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg67FKF0mX7rRFpufdkSCjX63Chti8ymDaj_lTPeaz8hmWpUTBoJvHnkWpndM0CM9G6SBrtbH0mJzZ5cLISH4Mc09kR68t206mF23S6duaUTHHCDB1R-r9GEWhpUAzi7eVjD_OfxEOI3K6J7aac5X_1W9o7S-KkklUDSpwLtEVLovXnEJbbmAopqaLJgPqR/w640-h354/Old%20OMI%20LAD%20case%20called%20normal%2012%20SL-Queen%20Dx.png" width="640" /></a></div><br /><p><br /></p><p><span style="font-size: large;"><b>Case 5</b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative;"><a href="https://hqmeded-ecg.blogspot.com/2017/03/subtle-dynamic-t-waves-followed-by-lad.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none;">Subtle Dynamic T-waves, Followed by LAD Occlusion and Arrest</a></h3><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEwQ2V_5F-FWPVegYKJMJHZiHqUxEBKvzknLQQiaGw98eEpAmVHLo4sOPxKYWjKLVm2i5m_aF_s93v0cxqyyi2UE_4Hw0iCWu3waPWWl1ULiuBOG2rB0eAcwOJ7tEyewaDlhsdAhKC-uPlTMWITbnnqO16fRX_zxJ9rR6rQTBadnaI4VyS0wS4hsq2Da_H/s1996/Wellens%20called%20normal%20by%20computer%20patient%20arrested.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="740" data-original-width="1996" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEwQ2V_5F-FWPVegYKJMJHZiHqUxEBKvzknLQQiaGw98eEpAmVHLo4sOPxKYWjKLVm2i5m_aF_s93v0cxqyyi2UE_4Hw0iCWu3waPWWl1ULiuBOG2rB0eAcwOJ7tEyewaDlhsdAhKC-uPlTMWITbnnqO16fRX_zxJ9rR6rQTBadnaI4VyS0wS4hsq2Da_H/w640-h238/Wellens%20called%20normal%20by%20computer%20patient%20arrested.png" width="640" /></a></div><div style="text-align: center;"><span style="font-size: medium;">These are Wellens' waves in V2-V4, which represent an LAD thrombus that is open (reperfused OMI) at this time, but could close at any time. The computer called it "normal." the physicians did not see it. </span></div><div style="text-align: center;"><b style="font-size: large;">He did re-occlude and arrest but was resuscitated.</b></div><div style="text-align: center;"><b style="font-size: large;"><br /></b></div><div style="text-align: center;"><b style="font-size: large;">Unknown algorithm</b></div><p style="text-align: center;"><br /></p><div class="separator" style="clear: both; text-align: center;"><b style="font-size: large;">The Queen gets it right</b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC_7ElJs7HPKmHi7Ns92f2_Ukqy8sQhwkXhaqSRITG6bdzYyT3QAAhHg0D051FrmpUJSJXaJw6cd95jJWWESDtlw6NiYO-54_cEHo7fLqnf04KXkxoEfAzrBDpgiygc4Is1FWkRQyrAvL0VKr2Ep8nnOWIJJHpjhvMCwVWHCVm2fNv6SG1qKHdtZyLAXim/s906/Wellens%20called%20normal%20by%20computer%20patient%20arrested---queen%20mid%20confidence.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="482" data-original-width="906" height="340" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC_7ElJs7HPKmHi7Ns92f2_Ukqy8sQhwkXhaqSRITG6bdzYyT3QAAhHg0D051FrmpUJSJXaJw6cd95jJWWESDtlw6NiYO-54_cEHo7fLqnf04KXkxoEfAzrBDpgiygc4Is1FWkRQyrAvL0VKr2Ep8nnOWIJJHpjhvMCwVWHCVm2fNv6SG1qKHdtZyLAXim/w640-h340/Wellens%20called%20normal%20by%20computer%20patient%20arrested---queen%20mid%20confidence.png" width="640" /></a></div><div style="text-align: center;"><span style="font-size: medium;">The Queen has been taught the difference between ACTIVE occlusion and REPERFUSED. So she knows that this is reperfused. </span></div><div style="text-align: center;"><span style="font-size: medium;">But in Version 1 the output is only OMI vs. Not OMI, with confidence level.</span></div><div style="text-align: center;"><span style="font-size: medium;">(Version 1 does not report Active vs. Reperfused)</span></div><p style="text-align: center;"><br /></p><p><span style="font-size: large;"><b>Case 6</b></span></p><h3 class="post-title entry-title"><a href="https://hqmeded-ecg.blogspot.com/2016/06/an-elderly-male-with-indigestion.html">An Elderly Male with "Indigestion"</a></h3><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPqPo1PmvGWYFB5Oj6j_mcMsw8qbZKk6w1AkT8gj0NAQX-tBi7hZPP5JIP99gFcCQgm8cUsmRgm47MOTqgAkyCqdVFdkX1zz-G3-lj32fIIbSsZprBlA9lRUhyphenhyphenBgcf1SCSY8b79K3ox4MPeocDddxtNN6IKCGShJ-4xXLKRjWMJ2EHo25oxgHs6h-0-6iT/s3188/TQRSD%20called%20normal%20by%20conventional%20algorithm.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1116" data-original-width="3188" height="224" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPqPo1PmvGWYFB5Oj6j_mcMsw8qbZKk6w1AkT8gj0NAQX-tBi7hZPP5JIP99gFcCQgm8cUsmRgm47MOTqgAkyCqdVFdkX1zz-G3-lj32fIIbSsZprBlA9lRUhyphenhyphenBgcf1SCSY8b79K3ox4MPeocDddxtNN6IKCGShJ-4xXLKRjWMJ2EHo25oxgHs6h-0-6iT/w640-h224/TQRSD%20called%20normal%20by%20conventional%20algorithm.png" width="640" /></a></div><div style="text-align: center;"><b><span style="font-size: medium;">This is diagnostic of LAD Occlusion with Terminal QRS distortion and hyperacute T-waves in V3.</span></b></div><div style="text-align: center;"><b><span style="font-size: medium;"><br /></span></b></div><div style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin-bottom: 0.5em; margin-left: auto; margin-right: auto; padding: 4px; position: relative; text-align: center; text-shadow: none;"><tbody style="text-shadow: none;"><tr style="text-shadow: none;"><td class="tr-caption" style="text-shadow: none;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-shadow: none;"><span style="text-shadow: none;"><span style="font-family: times; font-size: medium;">Algorithm is either Glasgow or Marquette 12 SL</span></span></div></td></tr></tbody></table><br /><span style="background-color: white; color: #333333; font-family: "Open Sans"; text-align: left; text-shadow: none;"></span></div><div style="text-align: center;"><br /></div><p></p><div class="separator" style="clear: both; text-align: center;"><b style="font-size: large;">The Queen gets it right</b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu7qKGYnOpbRUgD07jRLR2uNA2T3FmVrX9N3RtL05r61AuaHuDhE4O0iMD1ih0dIFzAQZG0-nk6e6HfxmpaQFe7j9LB9m6NdSgDNklxTWyZAlpyNwOTyz-Mw53z29q73kYsBBJQgBu5F187MkY-OaXdJ8kwaYmn4T6nyhp_1jO4KNcMKishBboHXl296we/s888/TQRSD%20called%20normal%20by%20conventional%20algorithm--Queen%20gets%20it.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="422" data-original-width="888" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu7qKGYnOpbRUgD07jRLR2uNA2T3FmVrX9N3RtL05r61AuaHuDhE4O0iMD1ih0dIFzAQZG0-nk6e6HfxmpaQFe7j9LB9m6NdSgDNklxTWyZAlpyNwOTyz-Mw53z29q73kYsBBJQgBu5F187MkY-OaXdJ8kwaYmn4T6nyhp_1jO4KNcMKishBboHXl296we/w640-h304/TQRSD%20called%20normal%20by%20conventional%20algorithm--Queen%20gets%20it.png" width="640" /></span></a></div><br /><p><br /></p><p><span style="font-size: large;"><b>Case 7</b></span></p><h3 class="post-title entry-title"><a href="https://hqmeded-ecg.blogspot.com/2014/12/chest-pain-relieved-by-maalox-and.html">Chest pain relieved by Maalox and viscous lidocaine</a>. <span style="font-weight: normal;">Diagnosed as Normal by the computer. Troponin negative. Patient was being discharged with a diagnosis of GERD when he arrested.</span></h3><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV7bQavKLJRwRQk8nmfAgfGmbD7pWKMYORDCCdEZTshtsmtxAZQbR8DbjIoboTRuu3ZfJHdFhKnwSROaH3ni0Z_zrezcGJyN7jO2AnhIkNnsFAmEvYAc3OdHMKD-Qyc78tT0EjUWKHuvZlEAcuCHpiiLnvOzPuT4V1RnWERYYbey1GeQKlhH3UIAdqiBD7/s2396/Original%20called%20normal%20by%20computer%20algorithm%20LAD%20OMI.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="952" data-original-width="2396" height="254" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV7bQavKLJRwRQk8nmfAgfGmbD7pWKMYORDCCdEZTshtsmtxAZQbR8DbjIoboTRuu3ZfJHdFhKnwSROaH3ni0Z_zrezcGJyN7jO2AnhIkNnsFAmEvYAc3OdHMKD-Qyc78tT0EjUWKHuvZlEAcuCHpiiLnvOzPuT4V1RnWERYYbey1GeQKlhH3UIAdqiBD7/w640-h254/Original%20called%20normal%20by%20computer%20algorithm%20LAD%20OMI.png" width="640" /></a></div><div style="text-align: center;"><b><span style="font-size: medium;">These are hyperacute T-waves.</span></b></div><p style="text-align: center;"><span style="font-size: medium;">Unknown algorithm</span></p><div class="separator" style="clear: both; text-align: center;"><b style="font-size: large;">The Queen gets it right</b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJUSIBXq61XPl80jcv6mmUKVoBZDk3OxFNk_q_hKCYQwGwkzPQCSNn2CQfuZr2HduHMWjRS_VWt-8drBdV36h1JOxZotmIqygf8SkxqkHw6qx4ynn8MpFu6cX9Ty4mvg5n0_S3GHpMRv4AL0UmIE43eSppq1m3cC07HMeEbvK6gNAPjAqzMFlnYGEH2IDf/s900/Original%20called%20normal%20by%20computer%20algorithm%20LAD%20OMI--queen.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="480" data-original-width="900" height="342" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJUSIBXq61XPl80jcv6mmUKVoBZDk3OxFNk_q_hKCYQwGwkzPQCSNn2CQfuZr2HduHMWjRS_VWt-8drBdV36h1JOxZotmIqygf8SkxqkHw6qx4ynn8MpFu6cX9Ty4mvg5n0_S3GHpMRv4AL0UmIE43eSppq1m3cC07HMeEbvK6gNAPjAqzMFlnYGEH2IDf/w640-h342/Original%20called%20normal%20by%20computer%20algorithm%20LAD%20OMI--queen.png" width="640" /></a></div><br /><p><br /></p><p><span style="font-size: large;"><b>Case 8</b></span></p><div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div style="text-align: left;"><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-align: start;"><a href="https://hqmeded-ecg.blogspot.com/2018/10/another-inadequate-paper-published-on.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;">Another Inadequate Paper Published on Triage ECGs, whose Conclusions Need Scrutiny.</a></h3><div class="separator" style="clear: both; color: red; font-family: arial; font-size: large; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAPmSiDORLx2Slx0R7ywTzbUpoIXASXVgp31_kFfuRgskTwbMf6gYRxkkWl_rzF-yD-0bdaTYx-vn0k1FaSNKjp2DRYbfW2Iw3HS4ih099A0FPGEkFTcyfifrtsYO80Kz1IA-Esy_UGz0v9ZGnKpZ4MUK1UreORFbMYDJ4BWmKw3gJbshAHNC7sHfZ4RI0/s3196/Screenshot%202023-12-09%20at%205.51.25%20PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1340" data-original-width="3196" height="268" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAPmSiDORLx2Slx0R7ywTzbUpoIXASXVgp31_kFfuRgskTwbMf6gYRxkkWl_rzF-yD-0bdaTYx-vn0k1FaSNKjp2DRYbfW2Iw3HS4ih099A0FPGEkFTcyfifrtsYO80Kz1IA-Esy_UGz0v9ZGnKpZ4MUK1UreORFbMYDJ4BWmKw3gJbshAHNC7sHfZ4RI0/w640-h268/Screenshot%202023-12-09%20at%205.51.25%20PM.png" width="640" /></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">Proximal LAD Occlusion with STE in I and aVL, and hyperacute T-waves in V2-V6.</div><div style="text-align: center;"><br /></div><div style="text-align: center;"><b>Algorithm: Marquette 12 SL (GE)</b></div></span><div style="color: red; font-family: arial; font-size: large; text-align: center;"><br /></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: center;"><span style="color: red; font-family: arial; font-size: medium;"><b style="color: black; font-family: Times;">The Queen gets it right</b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhH0-hhyEQAZVU-Y0xrM4xYmZ5cXKansossWRXlXNjZ4dJuqjXGuq5cHCnye519XXHHbFmQjYjqXCMGA1RNImcyA-QduHvtSkBkZxrREf4YdU9nGUhwCqxYBLS7vgeVT2ICCZ6Q9RYLF1gSsW-x-2O4nlNqXLOnkDb8PlCMljcR8AVCDFkRxPsRpnqqWwqM/s888/Screenshot%202023-12-09%20at%205.53.15%20PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="406" data-original-width="888" height="292" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhH0-hhyEQAZVU-Y0xrM4xYmZ5cXKansossWRXlXNjZ4dJuqjXGuq5cHCnye519XXHHbFmQjYjqXCMGA1RNImcyA-QduHvtSkBkZxrREf4YdU9nGUhwCqxYBLS7vgeVT2ICCZ6Q9RYLF1gSsW-x-2O4nlNqXLOnkDb8PlCMljcR8AVCDFkRxPsRpnqqWwqM/w640-h292/Screenshot%202023-12-09%20at%205.53.15%20PM.png" width="640" /></a></div><br /><span style="color: red; font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial;"><p style="color: black; font-family: Times; text-align: left;"><span style="font-size: large;"><b>Case 9 (prehospital and ED ECGs). </b></span></p></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-align: start;"><a href="https://hqmeded-ecg.blogspot.com/2017/03/echocardiography-even-or-especially.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;">Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.</a> <a href="https://hqmeded-ecg.blogspot.com/2022/10/30-yo-woman-with-trapezius-pain-heart.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal;">30 yo woman with trapezius pain. HEART Pathway = 0. Computer "Normal" ECG. Reality: ECG is Diagnostic of LAD Occlusion.</a></h3></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: arial; font-size: medium;">Prehospital ECG:</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhq69e8VHFk2-MCE_UVwkUzoiBcuO0gjDebLFTgfHxevtz0h7d9VLjO1apMd3cAsze1hShROx4E_hiTMUqMjeXJdXEmmb-F-si6Lmf1LdVDIfJuzxL1Y0tULy7vM-bKdJBC6qKn8-3cl2jElCuVisqR4n6dCwIZbJnSqkgsgD0sWBvZoRWtj9ia6I6H8pvC/s1107/time%20zero.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="297" data-original-width="1107" height="172" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhq69e8VHFk2-MCE_UVwkUzoiBcuO0gjDebLFTgfHxevtz0h7d9VLjO1apMd3cAsze1hShROx4E_hiTMUqMjeXJdXEmmb-F-si6Lmf1LdVDIfJuzxL1Y0tULy7vM-bKdJBC6qKn8-3cl2jElCuVisqR4n6dCwIZbJnSqkgsgD0sWBvZoRWtj9ia6I6H8pvC/w640-h172/time%20zero.png" width="640" /></a></div><div style="text-align: center;">There are hyperacute T-waves in V3-V5.</div><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><div style="color: black; font-family: Times; font-size: medium; margin: 0in 0in 0.0001pt; text-align: center;"><span style="color: red; font-family: arial; font-size: medium;"><b style="color: black; font-family: Times;">The Queen gets it right</b></span></div><div style="color: black; font-family: Times; font-size: medium; margin: 0in 0in 0.0001pt;"></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMsBua3Ysw0ArdRcwoPIix2ThyphenhyphenKYO7xs-4tyrOlZvWLxKxseG5Y2Tqi8d34n9ExCZ-rr050R566QUOq0hOlxqHuPcyru9MrntjlaO6bGdCB46XuYrtW6Hn-vyM724Q1Qb5PNHcKbuc1m-OUgayKYh6H2wrfcV7uZQXSQBgyJZw43OQG92AroACtNCNsYPm/s882/time%20zero-Queen.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="404" data-original-width="882" height="294" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMsBua3Ysw0ArdRcwoPIix2ThyphenhyphenKYO7xs-4tyrOlZvWLxKxseG5Y2Tqi8d34n9ExCZ-rr050R566QUOq0hOlxqHuPcyru9MrntjlaO6bGdCB46XuYrtW6Hn-vyM724Q1Qb5PNHcKbuc1m-OUgayKYh6H2wrfcV7uZQXSQBgyJZw43OQG92AroACtNCNsYPm/w640-h294/time%20zero-Queen.png" width="640" /></a></div><br /></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;">First ED ECG:</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiR4zCFil4hQjZ8XXP6TPYeV8oVXirMTiibCJg7A-tiriQ7l_F0zHLX_z3OFWeiCC6A7Bb7Lgfmz_sAFiBaVOTUawIS1VazRVGNKk3C9BRFsR3j5AZw7l-EawT7Lvq7mcodSD-fjMiEWoDqnoEAshF9GjGmQPryKvhwVZKGHkxWuQZ496ltSvTCYljP83BH/s1600/30-something%20yo%20with%20neck%20pain%20and%20large%20T-waves.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="536" data-original-width="1600" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiR4zCFil4hQjZ8XXP6TPYeV8oVXirMTiibCJg7A-tiriQ7l_F0zHLX_z3OFWeiCC6A7Bb7Lgfmz_sAFiBaVOTUawIS1VazRVGNKk3C9BRFsR3j5AZw7l-EawT7Lvq7mcodSD-fjMiEWoDqnoEAshF9GjGmQPryKvhwVZKGHkxWuQZ496ltSvTCYljP83BH/w640-h214/30-something%20yo%20with%20neck%20pain%20and%20large%20T-waves.png" width="640" /></a></div><span style="font-size: medium;"><div style="text-align: center;">Hyperacute T-waves persist. </div><div style="text-align: center;"><br /></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-size: medium;">Called normal again!</span></div><div style="margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-size: medium;"> </span><b style="font-size: large;">Algorithm: Veritas (on Mortara machines)</b></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div style="margin: 0in 0in 0.0001pt;"><span style="color: red; font-family: arial; font-size: medium;"><div style="color: black; font-family: Times; font-size: medium; margin: 0in 0in 0.0001pt; text-align: center;"><span style="color: red; font-family: arial; font-size: medium;"><b style="color: black; font-family: Times;">The Queen gets it right</b></span></div><div style="color: black; font-family: Times; font-size: medium; margin: 0in 0in 0.0001pt;"></div></span></div><div style="margin: 0in 0in 0.0001pt;"></div></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiK6ndntMmzFcTCM_gPyLQrIoxfmiAgLiyJkS1oD6QVZl-sxEBeo6O4QRQL47WryLrSE17nUtD74lHIQDZVG_aoV-A1Oliy_cez2ZKYXe09MAbN3HTvQbENWVyqk_-3aFglNRElx702D8Hu2HpjE0NfnlOLzo7Np3n2cNyo_LKpTYyJlrFM7LKbaD91BJoI/s890/30-something%20yo%20with%20neck%20pain%20and%20large%20T-waves--Queen.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="458" data-original-width="890" height="330" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiK6ndntMmzFcTCM_gPyLQrIoxfmiAgLiyJkS1oD6QVZl-sxEBeo6O4QRQL47WryLrSE17nUtD74lHIQDZVG_aoV-A1Oliy_cez2ZKYXe09MAbN3HTvQbENWVyqk_-3aFglNRElx702D8Hu2HpjE0NfnlOLzo7Np3n2cNyo_LKpTYyJlrFM7LKbaD91BJoI/w640-h330/30-something%20yo%20with%20neck%20pain%20and%20large%20T-waves--Queen.png" width="640" /></a></div><br /><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><br /></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size: large;"><span style="font-family: times;"><b>Case 10: </b></span></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size: large;"><a href="https://hqmeded-ecg.blogspot.com/2022/07/a-middle-aged-male-diagnosed-with.html" style="font-family: times;">A Middle Aged Male diagnosed with Gastroesophageal Reflux</a></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times;"><div class="separator" style="clear: both; color: red; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEh3P87vZJECqvkTx3HTgPHtuuQsA6KOWZYqHYCB3k_B6nX58pUAg0eH9QFRtJvJs5OPlaxlpqcShSCrj_1e5fJz4Lt08gIxkfu_u5TWm790opGJh4PIWPGOrtJlmol0p56h7vqN9Sok19hysrdI8ysRZWyxpFgLs_luiPKc49IVQTZmqxp-zIQcSIb2o-3l" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1928" data-original-width="5226" height="236" src="https://blogger.googleusercontent.com/img/a/AVvXsEh3P87vZJECqvkTx3HTgPHtuuQsA6KOWZYqHYCB3k_B6nX58pUAg0eH9QFRtJvJs5OPlaxlpqcShSCrj_1e5fJz4Lt08gIxkfu_u5TWm790opGJh4PIWPGOrtJlmol0p56h7vqN9Sok19hysrdI8ysRZWyxpFgLs_luiPKc49IVQTZmqxp-zIQcSIb2o-3l=w640-h236" width="640" /></a></div><div style="margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-family: times; font-size: medium;">There is minimal STE in lead III with some T-wave inversion, and reciprocal STD in aVL, also minimal but clearly real. There is also STD in V2-V4. This inferior-posterior OMI.</span></div><div style="margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-family: times;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times;"><div style="font-family: Times; margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-size: medium;">Called normal again!</span></div><div style="font-family: Times; margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="font-family: Times; margin: 0in 0in 0.0001pt; text-align: center;"><span style="font-size: medium;"> </span><b style="font-size: large;">Algorithm: Veritas (on Mortara machines)</b></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times;"><br /></span></div><br /><div style="text-align: center;"><span style="font-size: medium;">The Queen gets it Right</span></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: arial; font-size: medium;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjEabYEsCXJ0x4YxezF1gKEisx8zITSV5CGULSa073yeFRZquVoSnkVKP87NKwMzpI2fJKkyHkZBnJi1vmLuQvAWle2Q0YBsL8KQRkrf1N39Bs7iSbLIQ2L5vtzU89caNqVNl9YTK7raMlKEq3jgS1FFWEL2zDTfrIad98tl8p7Kdz4TGgBPxmTj86OUz2r" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="498" data-original-width="892" height="358" src="https://blogger.googleusercontent.com/img/a/AVvXsEjEabYEsCXJ0x4YxezF1gKEisx8zITSV5CGULSa073yeFRZquVoSnkVKP87NKwMzpI2fJKkyHkZBnJi1vmLuQvAWle2Q0YBsL8KQRkrf1N39Bs7iSbLIQ2L5vtzU89caNqVNl9YTK7raMlKEq3jgS1FFWEL2zDTfrIad98tl8p7Kdz4TGgBPxmTj86OUz2r=w640-h358" width="640" /></a></div><br /><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: large;"><b>Get Queen of Hearts PM Cardio app or Telegram version of the Queen:</b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><b><br /></b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><b><u>App</u></b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;">If you live in the EU, the Queen of Hearts is integrated into the entire PM Cardio app and is CE approved. The full app has the whole range of ECG diagnoses. </span><span style="font-family: times; font-size: large;">You will get 5 free uses, then will need to pay</span><span style="font-family: times; font-size: large;"> [If you live outside the EU, you can also get this if, during registration, you state that you live in the EU.]</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><a href="https://apps.apple.com/gb/app/pmcardio-ecg-analysis/id1640037895">PM Cardio app on iOS (Apple iPhone) </a></span></div><div style="margin: 0in 0in 0.0001pt; text-align: left;"><br /></div><div style="margin: 0in 0in 0.0001pt; text-align: left;"><span style="font-family: times; font-size: medium;"><a href="https://play.google.com/store/apps/details?id=com.powerfulmedical.pmcardio&hl=en_US&gl=US&pli=1">PM Cardio app on Google Play (Android)</a></span></div><div style="margin: 0in 0in 0.0001pt; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><a href="https://www.youtube.com/watch?v=BtniwQCxGO0">Watch full demo on how to use the app here.</a></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><b><u>Telegram</u></b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><b>If you live in the U.S.</b>, it is not yet FDA approved and you will need to fill out this form to get access to the Queen as it is housed on Telegram (but without all the other features). You can use it an unlimited amount.</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</a></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: times; font-size: medium;">Or use QR code to get the telegram version:</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMUbSd8dXU_c9GugRmXHYvPuxwZOjfGeccqTYiSULS0s2bRxx3q7ofveelTTGuBF1Hr75yHAxentQ1a4GWRGdnitwc6SC4xe1fwJJvn2dDn54-R36ElNXugbjuT3lxWdKG4bhK-gFt3IAmIFkzOAODws01e8WzR1TCM6Gk4XYaWHUCpcx0t8RcEOSyvYJe/s1237/Telegram%20QR%20code.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1125" data-original-width="1237" height="291" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMUbSd8dXU_c9GugRmXHYvPuxwZOjfGeccqTYiSULS0s2bRxx3q7ofveelTTGuBF1Hr75yHAxentQ1a4GWRGdnitwc6SC4xe1fwJJvn2dDn54-R36ElNXugbjuT3lxWdKG4bhK-gFt3IAmIFkzOAODws01e8WzR1TCM6Gk4XYaWHUCpcx0t8RcEOSyvYJe/s320/Telegram%20QR%20code.png" width="320" /></a></div><br /><span style="color: red; font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><br /></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><div style="caret-color: rgb(0, 0, 0); color: black;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div><br /></div><div><br /></div></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;">==================================</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: arial; font-size: medium;"><span><b><span face=""arial" , sans-serif" style="color: #454545;"><i>My Comment</i> by </span></b><b><span face=""arial" , sans-serif" style="color: red;">K</span></b><b><span face=""arial" , sans-serif" style="color: #454545;">EN </span></b><b><span face=""arial" , sans-serif" style="color: red;">G</span></b><b><span face=""arial" , sans-serif" style="color: #454545;">RAUER, MD (</span></b><span face=""arial" , sans-serif" style="color: #454545;"><i>3/4</i></span></span><span style="color: #454545;"><i>/2024</i></span><b style="color: #454545;">):</b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;">==================================</span></div></div><div><span style="font-family: arial; font-size: medium;">In today's Blog post — Dr. Smith justifiably laments the inaccuracy of conventional ECG interpretation programs for recognizing acute OMI.</span></div><div style="text-align: left;"><ul><li style="text-align: justify;"><span style="font-family: arial; font-size: medium;">As we have so frequently documented on Dr. Smith's Blog for well over a decade now — <b><i>all-too-many</i> clinicians (</b><i>including all-too-many cardiologists</i><b>) — remain "stuck" in the STEMI Paradigm</b>, as well as ignoring increasing data in support of cardiac <i>cath-validated</i> studies showing <b><i>at least</i> 30% of <i>acute</i> OMIs (</b><i><u>O</u>cclusion <u>M</u>yocardial <u>I</u>nfarctions</i><b>) are missed if one depends solely on <i>millimeter-based</i> criteria</b> from the <i>outdated</i> STEMI Paradigm.</span></li></ul><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">As a result — it is <u><i>not</i></u> in the least surprising that <b>conventional ECG interpretation programs are <i>inadequate</i> for identifying acute OMIs</b>. </span></div><div style="text-align: justify;"><ul><li><span style="font-family: arial; font-size: medium;">The above said — <b><i>the fault is <u>not</u> in the computer</i></b> — since computer programs merely do what they are programmed to do.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-size: medium;"><span style="font-family: arial;"><b>Conventional ECG interpretation programs (</b>ie, <i>virtually <u>all</u> computer interpretation programs <u>prior</u> to the QOH AI Bot app</i><b>) </b>— <b>have been programmed according to STEMI criteria</b> — <i><u>without</u></i> co</span><span style="font-family: arial;">nsideration of clinical context</span><span style="font-family: arial;"> </span><b style="font-family: arial;">(</b><span style="font-family: arial;">ie,</span><span style="font-family: arial;"> </span><i style="font-family: arial;">correlation of the presence and relative severity of symptoms with <u>each</u> of the serial ECGs that are done</i><b style="font-family: arial;">)</b><span style="font-family: arial;"> </span><span style="font-family: arial;">— and</span><span style="font-family: arial;"> </span><i style="font-family: arial;"><u>without</u></i><span style="font-family: arial;"> </span><span style="font-family: arial;">consideration of the additional ECG findings that we routinely emphasize on this ECG Blog that correlate with OMI</span><span style="font-family: arial;"> </span><b style="font-family: arial;">(</b><i style="font-family: arial;">See </i><b style="font-family: arial;"><u>Figure-1</u>)</b><span style="font-family: arial;">.</span></span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">As a result — We should <u style="font-style: italic;">not</u> expect conventional ECG interpretation programs to manifest even a reasonable degree of accuracy for recognizing acute OMI. And, as a result — <b><i>We should <u>not</u> be using conventional ECG interpretation programs for this purpose</i>.</b></span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><u>Finally</u> — <b>Clinicians (</b><i>including cardiologists</i><b>) who in 2024 remain "stuck" in the STEMI Paradigm (</b><i>and who continue to ignore other ECG findings shown to more reliably identify acute OMI, as noted in</i> <u>Figure-1</u><b>) </b>— <b>such clinicians will <i><u>continue</u></i> to delay (</b><i>if not completely overlook</i><b>) the need for prompt cardiac catheterization of acute OMIs that could (</b><i>and should</i><b>) benefit from prompt revascularization</b>.</span></li></ul></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">===========================</span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">The clinical examples of OMIs missed by conventional ECG interpretation programs that Dr. Smith provides in his discussion today — <b><i><u>confirms</u></i> our need to <i><u>ignore</u></i> these conventional algorithms</b>.</span></div><div style="text-align: justify;"><ul><li><span style="font-family: arial; font-size: medium;">Optimal clinical ECG interpretation for identification of acute OMI can be attained by attention to the principles reviewed in the 90-minute <b><u>Webinar</u></b> by Drs. Smith, Meyers and Herman <b>(</b><i>in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2023/12/webinar-beyond-stemi-diagnosing-acute.html" target="_blank">December 5, 2023</a> post</b> <i>of Dr. Smith's ECG Blog</i><b>)</b> — many of which are summarized in <u>Figure-1</u> — and, all of which are routinely discussed in cases presented on this ECG Blog.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">The <b>QOH (</b><i><u>Q</u>ueen <u>O</u>f <u>H</u>earts</i><b>)</b> <b>PMcardio OMI AI model </b>offers proof that the fault of conventional ECG interpretation programs is <i><u>not</u></i> the fault of the computer. On the contrary — because QOH has been programmed through guidance by Drs. Smith and Meyers <b>(</b><i>with an ever expanding data base of more than 18,000 tracings with cath-finding validation</i><b>)</b> — <b>QOH already manifests <i><u>superior</u></i> accuracy for identifying acute OMI compared to the use of standard STEMI critieria</b> <b>(</b><i>Herman, Meyers, Smith et al — </i><b><a href="https://academic.oup.com/ehjdh/advance-article/doi/10.1093/ehjdh/ztad074/7453297?utm_medium=email&_hsmi=79746848&_hsenc=p2ANqtz-9GVemae1PjpWmd00ke3NbuVeWw0DAO6bzr8wVF_j_iHxN1NJr9YPhvpG2VWboZjHIPyxWiibaYy9WTdZchrWZpcj2Oxw&utm_content=79746848&utm_source=hs_email" target="_blank">Eur Heart J Digital Health — November, 2023</a>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><b><u><i>MY Thought:</i></u></b> Optimal clinical ECG interpretation will probably be <i>BEST</i> attained by a <b><i><u>combination</u></i></b> of expertise from experienced clinicians <u style="font-style: italic;">with</u> the already impressive, but continually improving accuracy of QOH. <b>Some degree of clinician oversight will probably always be needed to <i>ensure</i> optimal performance of QOH</b> — but the additional opinion QOH provides can clearly be of great assistance to clinicians as a teaching tool, and <b><i>for increasing clinician confidence </i><u>and</u><i> accuracy</i></b> for rapid identification of which patients need prompt cath.</span></li></ul></div></div></div></div><div><div style="text-align: justify;"><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCA6N414XrIxJldFDqJsKoLDWJnNMHYXw8VMqwW-V5hk5ieQHbrAlIZbmiDzLCld_wLX6syPl_DI73s7y-uUdriATKoyUrqmOfYiHph53lpy0TB0rH8o6hSpV5pYncmgEj-c_IfLaaJjNnj_v3unyeGVbCUwRkdb9vo_Z3PKyRkCaE6zN6e-nY4Rc9UMk/s2872/Figure-1%20-%20ECG%20Findings%20to%20Look%20For%20(12-9.1-2023).png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2310" data-original-width="2872" height="514" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCA6N414XrIxJldFDqJsKoLDWJnNMHYXw8VMqwW-V5hk5ieQHbrAlIZbmiDzLCld_wLX6syPl_DI73s7y-uUdriATKoyUrqmOfYiHph53lpy0TB0rH8o6hSpV5pYncmgEj-c_IfLaaJjNnj_v3unyeGVbCUwRkdb9vo_Z3PKyRkCaE6zN6e-nY4Rc9UMk/w640-h514/Figure-1%20-%20ECG%20Findings%20to%20Look%20For%20(12-9.1-2023).png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b style="text-align: justify;"><u><span style="color: #333333;">Figure-1:</span></u></b><span style="color: #333333; text-align: justify;"> ECG findings to look for <b>when your patient</b> with <i>new-onset</i> cardiac symptoms <b>does <i><u>not</u></i> manifest <i>STEMI-criteria</i> ST elevation</b> on ECG. <br /></span><span style="color: #333333; text-align: justify;">For my clarifying Figure illustrating <b>T-QRS-D</b> (<i>2nd bullet</i>) — See <i><u>My</u> <u>Comment</u></i> at the <u>bottom</u> of the page in Dr. Smith’s <b><a href="http://hqmeded-ecg.blogspot.com/2019/11/a-50-something-with-left-shoulder-pain.html" target="_blank">November 14, 2019</a> post</b>.</span></span></td></tr></tbody></table><span style="font-family: arial; font-size: medium;"><br /><span><br /></span></span></div><div><span style="font-family: arial; font-size: medium;">=========================</span></div><div><b><u><span style="font-family: arial; font-size: medium;">MY <i>Editorial</i> NOTE re <i>Computer</i> Interpretations:</span></u></b></div><div><span style="font-family: arial; font-size: medium;">As one who has followed the evolution of conventional ECG interpretation programs over recent decades — I have offered my thoughts in a number of prior posts in Dr. Smith's ECG Blog, regarding what these <b><i>conventional</i> ECG interpretation algorithms</b> <i>can</i> <u>and</u> <i>cannot</i> do. For those interested — Check out <b><i>My Comments</i></b> at the bottom of the page in the following posts:</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">The <b><a href="https://hqmeded-ecg.blogspot.com/2023/03/a-50-something-with-chest-pain-what-to.html" target="_blank">March 31, 2023</a> post</b> —</span></li><li><span style="font-family: arial; font-size: medium;">The <b><a href="https://hqmeded-ecg.blogspot.com/2022/02/this-ecg-was-interpreted-as-completely.html" target="_blank">February 4, 2022</a> post</b> —</span></li><li><span style="font-family: arial; font-size: medium;">The <b><a href="https://hqmeded-ecg.blogspot.com/2023/05/a-man-in-his-early-40s-with-chest-pain.html" target="_blank">May 23, 2023</a> post</b> —</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div><div><span style="font-family: arial; font-size: medium;"><u style="font-weight: bold;"><br /></u></span></div><div><span style="font-family: arial; font-size: medium;"><u style="font-weight: bold;">BOTTOM Line:</u> </span></div><div><span style="font-family: arial; font-size: medium;">I find the following true <i><u>regardless</u></i> of whether your availability is with a conventional ECG interpretation program <u>or</u> QOH:</span></div><div><ul><li><span style="font-family: arial; font-size: medium;"><u style="font-style: italic;">Never</u> look at what the computer says until <u style="font-style: italic;">after</u> you have forced yourself to interpret the patient's ECG in conjunction with available clinical information. </span></li><li><span style="font-family: arial; font-size: medium;"><i>Only THEN — </i>Look at what the computer said. <i>Do you agree?</i></span></li><li><span style="font-family: arial; font-size: medium;">Realize that IF the program available to you is based on a conventional ECG algorithm — that these are <u style="font-style: italic;">not</u> reliable programs for identification of acute OMI <b>(</b>ie, <i>Far too many false positives <u>and</u> false negatives!</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">IF you <i><u>do</u></i> have availability of QOH — <b>You can feel <u style="font-style: italic;">reassured</u> IF your clinical impression matches that of QOH</b>.</span></li><li><span style="font-family: arial; font-size: medium;">IF on the other hand, your interpretation differs from that rendered by QOH — <i>GO BACK to the drawing board, </i>realizing<i> </i>that<i> <u>unless</u> </i>you can come up with a valid reason for why QOH may be mistaken <b>(</b>ie, <i>artifact, your availability of serial or prior tracings</i><b>)</b> — that <b><i>the QOH AI app is usually accurate</i></b>.</span></li><li><span style="font-family: arial; font-size: medium;">Keep in mind that the QOH PMcardio OMI AI model will continue to get better as it gets programmed with thousands of additional ECGs <b>(</b><i>all with cath-validated data</i><b>)</b> — and as QOH becomes capable, as it will with time — of integrating prior and serial tracings, as well as historical information into its interpretations.</span></li></ul></div><div><span style="font-size: medium;"> </span></div><div style="font-family: arial;"><span style="font-size: medium;"><div><br /></div></span></div></div></div><p><br /></p><p><br /></p>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-71314933679078166562024-03-01T10:00:00.004-06:002024-03-01T11:52:37.910-06:00"Seizure" in a 60 year old male<p></p><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">This 60 yo male had an apparent tonic clonic seizure. He had no history of seizures. He was unconscious for 8 minutes and slowly awoke in the ambulance, complaining of nausea only. First responders found him to be <b>very tachycardic</b>, confused, perserverating and with no memory of the event. There was tongue biting. Lightheadedness continued.</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">The tachycardia was gone by the time paramedics arrived.</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">He had a prehospital ECG:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgehPr7DkuWUAdBFvjxPQk3ud_XnOBUaAEUxwRoAmWhWNiwBwimSw90SgSFpiYlD83aRpyjMPvnuvxQZzT8NHMoZWqjVIhTmOP1l3DYOC1QruppPVY6wY29keNKMQl3PVd8PKp2M5bAw4dE-lBEM8MvSCwopzI1m1-rn0_Ed8yrEtzlSJ5IjkPpYO3NYASB/s3378/prehospital%20Wellens.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="974" data-original-width="3378" height="185" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgehPr7DkuWUAdBFvjxPQk3ud_XnOBUaAEUxwRoAmWhWNiwBwimSw90SgSFpiYlD83aRpyjMPvnuvxQZzT8NHMoZWqjVIhTmOP1l3DYOC1QruppPVY6wY29keNKMQl3PVd8PKp2M5bAw4dE-lBEM8MvSCwopzI1m1-rn0_Ed8yrEtzlSJ5IjkPpYO3NYASB/w640-h185/prehospital%20Wellens.png" width="640" /></span></a></div><div style="text-align: center;"><span style="font-family: times; font-size: medium;">What do you think?</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><div style="text-align: left;"><span style="font-family: times; font-size: medium;"><b>Interpretation</b>. There is terminal T-wave inversion in V2, highly suggestive of Wellens' pattern. But syncope or seizure alone, without chest pain, is not enough to call it Wellens syndrome. </span></div><div style="text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="text-align: left;"><span style="font-family: times; font-size: medium;">There might also be some subtle ST depression, suggestive of <a href="https://hqmeded-ecg.blogspot.com/search/label/de%20Winter%27s%20T-waves">de Winter</a> or <a href="https://hqmeded-ecg.blogspot.com/search/label/Precordial%20swirl">Precordial Swirl</a> pattern.</span></div><div style="text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="text-align: left;"><b><span style="font-family: times; font-size: medium;">Without chest pain, the pretest probability is not very high.</span></b></div><div style="text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div style="text-align: left;"><span style="font-family: times; font-size: medium;">Here is the Queen's interpretation (the Queen always assumes a fairly high pretest probability of OMI):</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyU5aonQQ1bfr2uRXN6gX42G9Bc7EheVN31W80vvxVv5Rb6lSsRm9Wl183OuA3Q8oxXHOO7QnrQ-MR0uRRqsleQ1XpurqitnvhNP1yFRqKcNjVJGbOQa0kDEw5Qyf1XGuXJLjH8p2j_Vv5yXTXqYRiNzAT9i3OLygZHVG0NBboJSAnBYW7tBSz7SamQbJj/s970/Screenshot%202024-02-28%20at%202.53.57%20PM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="420" data-original-width="970" height="278" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyU5aonQQ1bfr2uRXN6gX42G9Bc7EheVN31W80vvxVv5Rb6lSsRm9Wl183OuA3Q8oxXHOO7QnrQ-MR0uRRqsleQ1XpurqitnvhNP1yFRqKcNjVJGbOQa0kDEw5Qyf1XGuXJLjH8p2j_Vv5yXTXqYRiNzAT9i3OLygZHVG0NBboJSAnBYW7tBSz7SamQbJj/w640-h278/Screenshot%202024-02-28%20at%202.53.57%20PM.png" width="640" /></span></a></div><div style="text-align: center;"><span style="font-family: times; font-size: medium;">This version of the Queen (version 1) does not differentiate between active and reperfused OMI. So she will call Wellens' ECG "OMI".</span></div><div style="text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">With explainability:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgV2DyTkSO8I4df4cBk0B4i0T1jT_ACmkNrE2SDO54JnnPP8may0GNtDrSC7NLqLsfU5o60YBdMRxsMMed1_PPWC1Zgaasj1IuvIzY1WtHSGu5F5HT4-HtCIjqd4Eva-E2YTlSWrlkggnEYD7BHL1rHJay4LyAEbKYl73B7iwZsgwAgT4LZLggx_M5nDXre/s2552/Screenshot%202024-02-28%20at%202.54.22%20PM.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="632" data-original-width="2552" height="158" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgV2DyTkSO8I4df4cBk0B4i0T1jT_ACmkNrE2SDO54JnnPP8may0GNtDrSC7NLqLsfU5o60YBdMRxsMMed1_PPWC1Zgaasj1IuvIzY1WtHSGu5F5HT4-HtCIjqd4Eva-E2YTlSWrlkggnEYD7BHL1rHJay4LyAEbKYl73B7iwZsgwAgT4LZLggx_M5nDXre/w640-h158/Screenshot%202024-02-28%20at%202.54.22%20PM.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">She also sees that terminal T wave inversion.</div></span><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">__________</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br /></span></b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br style="text-shadow: none !important;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">This is for the version housed on Telegram:</span></span></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="text-shadow: none;"></span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><span style="text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></a></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br style="text-shadow: none !important;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><b style="text-shadow: none !important;">You can get the full PM Cardio app here:</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none !important;"><br style="text-shadow: none !important;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="font-size: medium; text-shadow: none !important;"><a href="https://qrco.de/bebW8d" style="color: #2066f5; text-decoration-line: none; text-shadow: none !important;">https://qrco.de/bebW8d</a></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;">________________</div></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">He arrived in the ED and had another ECG recorded because of the abnormal prehospital EKG: </span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times; font-size: medium;">Here was the ED ECG:</span></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjF2J7AMHbsm2PrPKvHFkBbDpIq0kLvSz6GdR0ReaVzZpQi5fEruns0rX_afj_6Oxz-OONxLPvcybeIXYdratKgZnPVOhigKTNaeQfKA_2kmeyGU0POj2-hfgDwx6665oS3N14L-LcpiDYu44_nIbIsDJv_UDkZAjiMQZx5Q5em7k7wQrk0oIFC00vi4DHw/s1600/Single%20lead%20Wellens.PNG" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="743" data-original-width="1600" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjF2J7AMHbsm2PrPKvHFkBbDpIq0kLvSz6GdR0ReaVzZpQi5fEruns0rX_afj_6Oxz-OONxLPvcybeIXYdratKgZnPVOhigKTNaeQfKA_2kmeyGU0POj2-hfgDwx6665oS3N14L-LcpiDYu44_nIbIsDJv_UDkZAjiMQZx5Q5em7k7wQrk0oIFC00vi4DHw/w640-h297/Single%20lead%20Wellens.PNG" width="640" /></span></a></div></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: times; font-size: medium;"><b>Now: obvious classic Wellens' morphology Pattern A (terminal T-wave inversion), </b><b>but only in lead V2. </b> </span></div><div style="text-align: center;"><b><span style="font-family: times; font-size: medium;">Upsloping ST segment with sharp downturn into negative T-wave.</span></b></div><p></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;">Notice also the <b>slight STE in aVL with terminal T-wave inversion</b>, and reciprocally upright large T-waves in inferior leads.</span></p><p><span style="font-size: medium;"><span style="font-family: times;">Further review of systems with the patient fully awake revealed </span><span style="font-family: times;">that <b><u>the patient had been having </u></b></span><b style="font-family: times;"><u>chest pain on and off all week</u>.</b></span></p><p><span style="font-family: times; font-size: medium;">The ECG in the context of intermittent/resolved chest pain suggests proximal LAD lesion with open artery. With the chest pain history, this is now Wellens' syndrome. <u>It is likely that the patient had <b>ventricular tachyardia</b> as a cause of prolonged syncope</u>. </span></p><p><span style="font-family: times; font-size: medium;">Head CT was normal, as were electrolytes.</span></p><p><span style="font-family: times; font-size: medium;">Here is the Queen of Hearts interpretation:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-FBR43_ex1cvRh6dZT7pWU9IhNuaLeMM75GCUbl4oMvkCT9Kd0EFnSo-1m2i-VYp_OhBTODSRJG9cYfjo1qhJPCvL_pLNPsYOGSLZ7qYjvoJh-fczINYe0RjcYD8iAABFk6H1FVVycGXuLALR647WCzLUhx3_b2a7C0SfQ9nzIKe6EKLD9cmtp_Fy_uWj/s494/Queen%20by%20email.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="293" data-original-width="494" height="380" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-FBR43_ex1cvRh6dZT7pWU9IhNuaLeMM75GCUbl4oMvkCT9Kd0EFnSo-1m2i-VYp_OhBTODSRJG9cYfjo1qhJPCvL_pLNPsYOGSLZ7qYjvoJh-fczINYe0RjcYD8iAABFk6H1FVVycGXuLALR647WCzLUhx3_b2a7C0SfQ9nzIKe6EKLD9cmtp_Fy_uWj/w640-h380/Queen%20by%20email.png" width="640" /></span></a></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-family: times; font-size: medium;">Again, this version of the Queen (version 1) does not differentiate between active and reperfused OMI. So she will call a Wellens' ECG "OMI".</span></div><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"> Initial trop I = 1848 ng/L, up to 4533 at 6 hours.</span></p><p><b><span style="font-family: times; font-size: medium;">Echo</span></b></p><p><span style="font-family: times; font-size: medium;">The estimated left ventricular ejection fraction is 40 %. </span></p><p><span style="font-family: times; font-size: medium;">Regional wall motion abnormality-distal septum anterior and apex akinetic large.</span></p><p><span style="font-family: times; font-size: medium;">Regional wall motion abnormality-distal inferior wall .</span></p><div><b><span style="font-family: times; font-size: medium;">Angiogram</span></b></div><p><span style="font-family: times; font-size: medium;">"Culprit Lesion (s): Uncertain culprit, as the myocardial territory served by the apical LAD is disproportionately large compared to troponin elevation. Diagonal branch supplying collaterals to the apical LAD could also represent a culprit."</span></p><p><span style="font-family: times; font-size: medium;">_______</span></p><p><span style="font-family: times; font-size: medium;"><b>Smith comment:</b> It is not contradictory to have a large territory at risk and a relatively low troponin when it is Wellens' syndrome. This is a syndrome of spontaneous reperfusion and if the occlusion is of short duration, there is not a lot of infarction. In Wellens' syndrome, there can be a huge territiory at risk and a troponin just barely elevated.</span></p><p><span style="font-family: times; font-size: medium;">Here is a case in which the peak troponin was only 364 ng/L. It can be much lower.</span></p><p><span style="font-family: times; font-size: medium;"></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2013/03/first-ed-ecg-is-wellens-pain-free-what.html" style="color: #6391f6; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-size: medium;">First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?</span></a></h3><div><span style="font-family: times; font-size: medium;">________</span></div><p><span style="font-family: times; font-size: medium;"><b><span>Cardiology:</span></b><span> culprits for the patient's non-ST elevation myocardial infarction and <b>syncopal event with possible arrhythmic etiology</b> include occlusion of the distal LAD (chronicity uncertain) and severe stenosis of the proximal first diagonal branch.</span></span></p><p><span style="font-family: times; font-size: medium;">Successful PCI of the distal and mid LAD.</span></p><p><span style="font-family: times; font-size: medium;">Successful PCI of the ostial/proximal first diagonal branch.</span></p><p><span style="font-family: times; font-size: medium;">Excellent angiographic results with TIMI-3 antegrade flow throughout the LAD territory</span></p><div><br /></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-30117044554404638202024-02-22T11:33:00.005-06:002024-02-22T11:38:20.089-06:00How will you save this critically ill patient? A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.<p><span style="font-size: medium;">Written by Pendell Meyers</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">A woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. </span></p><p><span style="font-size: medium;">An ECG was performed:</span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkEHZgwmD_L640X0NQVEyVH6H6JggExe_SBCAd0gjAbhiNAy9tyGEwErXLH-Yo608mHaax7bFTh202CInfjZwFyf3Qzxezk2ddAA2kzN5QDi1E14KE6CJ7OPbm4KK30Z93ONZQPwBZIyp7h4hO66nwSc2wMapYy9x-2KbpQZhgTibE63vIfl2fEmEjlbvm/s2293/IMG_2106%20(4).jpg" style="margin-left: auto; margin-right: auto;"><span style="font-size: medium;"><img border="0" data-original-height="728" data-original-width="2293" height="203" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkEHZgwmD_L640X0NQVEyVH6H6JggExe_SBCAd0gjAbhiNAy9tyGEwErXLH-Yo608mHaax7bFTh202CInfjZwFyf3Qzxezk2ddAA2kzN5QDi1E14KE6CJ7OPbm4KK30Z93ONZQPwBZIyp7h4hO66nwSc2wMapYy9x-2KbpQZhgTibE63vIfl2fEmEjlbvm/w640-h203/IMG_2106%20(4).jpg" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">What do you think?</span></td></tr></tbody></table><span style="font-size: medium;"><br /></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Extremely wide complex monomorphic rhythm just over 100 bpm. The QRS is so wide and <b>sinusoidal</b> that the only real possibilities left are hyperkalemia or Na channel blockade. Hyperkalemia is by far more common.</span></p><p><span style="font-size: medium;">Indeed, further history revealed two missed dialysis sessions. And of course on exam she has a dialysis fistula.</span></p><p><span style="font-size: medium;">EMS reportedly gave 4 grams of calcium (unknown whether CaCl or gluconate) and 50 mEq of sodium bicarbonate. There was concern that the rhythm might represent ventricular tachycardia, so lidocaine was given and one attempt at cardioversion was performed. It is unclear what changes happened to the rhythm based on the EMS interventions, but the patient arrived to the ED remaining critically ill and with a very wide complex reported (no ECGs from ED available sadly).</span></p><p><span style="font-size: medium;">Hyperkalemia was diagnosed and more treatment was given including more calcium, bicarb, insulin/dextrose, and albuterol.</span></p><p><b><span style="font-size: medium;">The potassium level returned at 9.7 mEq/L.</span></b></p><p><span style="font-size: medium;">Emergent dialysis was prioritized after stabilization. </span></p><p><span style="font-size: medium;">She did well and stabilized after dialysis. </span></p><p><span style="font-size: medium;">Here is her ECG the next day with normal potassium level:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8O9m3NH5-JeuGeGyeqXz8zUOooUzY_GYTs0l7toC3_3ZJc0n36fB_6qfADaHqvpvl7_AhH4HyWWZcH5OfhXRvL9EuWg5YXYt-iDZ0gxPTrFaqoSlS33MwgYhrEwLD6T5F8_qkTX-zs2FK1pYKR2idz57mUqgT3xsM06XNBy30auUe829OeVs-Hankw2S1/s1558/next%20day.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="785" data-original-width="1558" height="322" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8O9m3NH5-JeuGeGyeqXz8zUOooUzY_GYTs0l7toC3_3ZJc0n36fB_6qfADaHqvpvl7_AhH4HyWWZcH5OfhXRvL9EuWg5YXYt-iDZ0gxPTrFaqoSlS33MwgYhrEwLD6T5F8_qkTX-zs2FK1pYKR2idz57mUqgT3xsM06XNBy30auUe829OeVs-Hankw2S1/w640-h322/next%20day.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;">She did well.</span></p><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;">See our other countless hyperkalemia cases below:</span></p><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><b style="text-shadow: none;"><u style="text-shadow: none;"><span style="font-size: medium;">General hyperkalemia cases:</span></u></b></span></p><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><b style="text-shadow: none;"><u style="text-shadow: none;"><span style="font-size: medium;"><span style="text-shadow: none;"></span></span></u></b></p><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2021/10/a-50s-year-old-man-with-lightheadedness.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A 50s year old man with lightheadedness and bradycardia</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><a href="https://hqmeded-ecg.blogspot.com/2019/06/patient-with-dyspnea-you-are-handed.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">Patient with Dyspnea. You are handed a triage ECG interpreted as "normal" by the computer.</a> (Physician also reads it as normal)</span></span></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/11/severe-shock-obtunded-and-diagnostic.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2020/12/a-woman-with-near-syncope-bradycardia.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A woman with near-syncope, bradycardia, and hypotension</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2020/10/what-happens-if-you-do-not-recognize.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">What happens if you do not recognize this ECG instantly?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2020/01/a-woman-in-her-50s-with-dyspnea-and.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A woman in her 50s with dyspnea and bradycardia</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/02/a-patient-with-cardiac-arrest-rosc-and.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A patient with cardiac arrest, ROSC, and right bundle branch block (RBBB).</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2018/04/is-this-just-right-bundle-branch-block.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Is this just right bundle branch block?</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2012/04/is-this-simple-right-bundle-branch.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Is This a Simple Right Bundle Branch Block?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/07/a-60-something-who-has-non-specific.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A 60-something who has non-specific generalized malaise and is ill appearing.</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2010/01/peaked-t-waves-hyperacute-stemi-vs.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">HyperKalemia with Cardiac Arrest. </span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2010/01/peaked-t-waves-hyperacute-stemi-vs.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Peaked T waves: Hyperacute (STEMI) vs. Early Repolarizaton vs. Hyperkalemia</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/01/what-will-you-do-for-this-altered-and.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">What will you do for this altered and bradycardic patient?</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/01/i-saw-this-computer-normal-ecg-in-stack.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">I saw this computer "normal" ECG in a stack of ECGs I was reading</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/01/what-is-diagnosis.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">What is the diagnosis?</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2018/12/found-comatose-with-prehospital-ecg.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Found comatose with prehospital ECG showing "bigeminal PVCs" and "Tachycardia at a rate of 156"</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2018/06/an-elderly-woman-found-down-with.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">An elderly woman found down with bradycardia and hypotension</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2018/04/a-middle-aged-man-with-unwitnessed.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A middle aged man with unwitnessed cardiac arrest</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2017/10/test-almost-all-of-your-most-important.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Test almost all of your most important ECG rhythm interpretation skills with this case.</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2017/08/sinus-rhythm-with-new-wide-complex-qrs.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Sinus rhythm with a new wide complex QRS</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2015/10/this-ecg-is-pathognomonic-and-you-must.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">This ECG is pathognomonic and you must recognize it.</span></span></a></h3></div><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2014/08/a-very-wide-complex-tachycardia-what-is.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A Very Wide Complex Tachycardia. What is the Rhythm? Use Lewis Leads!!</span></span></a></h3><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2014/08/a-very-wide-complex.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A Very Wide Complex</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2014/07/are-these-peaked-t-waves-patients.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Are these peaked T-waves the patient's baseline T-waves?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><p class="MsoNormal" style="text-shadow: none;"><span style="font-size: medium;"><span style="font-family: "Times New Roman", serif; line-height: 17.12px; text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2014/07/bradycardia-sob-in-dialysis-patient.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Bradycardia, SOB, in a Dialysis Patient</span></span></a></h3></div><p style="text-shadow: none;"><span style="font-size: medium;"><br style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;" /></span></p><p style="text-shadow: none;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-family: "Times New Roman", serif; line-height: 17.12px; text-shadow: none;"><b style="text-shadow: none;"><u style="text-shadow: none;"><span style="font-size: medium;">Cases of hyperkalemia mimicking OMI:</span></u></b></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><b style="text-shadow: none;"><u style="text-shadow: none;"><span style="font-size: medium;"><span style="font-family: "Times New Roman", serif; line-height: 17.12px; text-shadow: none;"></span></span></u></b></p><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2022/01/acute-respiratory-distress-correct.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.</span></a></h3><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2017/11/steve-what-do-you-think-of-this-ecg-in.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">"Steve, what do you think of this ECG in this Cardiac Arrest Patient?"</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2013/06/hyperkalemia-and-st-segment-elevation.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Hyperkalemia and ST Segment Elevation, Post 1</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2013/06/a-tragic-case-related-to-last-post.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A Tragic Case, related to the last post</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2020/09/a-patient-with-chest-pain-and-st.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">A patient with chest pain and ST Elevation in V1 and V2</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2013/11/you-must-recognize-this-pattern-even-if.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">You MUST recognize this pattern, even if it is not common</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2016/07/a-young-woman-was-down-unresponsive.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">ST Elevation. What is it?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2021/07/this-ecg-pattern-told-story-when.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">This ECG Pattern Told the Story When the Patient Could Not</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2021/05/what-are-these-st-elevations-st.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">What are these ST elevations, ST depressions, and tall T waves diagnostic of?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2020/04/another-shark-fin-with-twist.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Another Shark Fin. With a twist.</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/09/do-you-recognize-this-ecg-yet.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Do you recognize this ECG yet?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2013/02/right-bundle-branch-block-with-st.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Right Bundle Branch Block with ST Elevation in V1?</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2018/01/st-elevation-in-avl-with-depression-in.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">ST elevation in aVL with reciprocal ST depression in the inferior leads</span></span></a></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/12/shock-bradycardia-st-elevation-in-v1.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Shock, bradycardia, ST Elevation in V1 and V2. Activate the Cath Lab?</span></span></a></h3><div><span style="font-size: medium;"><br /></span></div></div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2022/05/another-deadly-and-confusing-ecg-are.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?</span></a></h3><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><br /></p><p style="text-align: left;"><br /></p><p style="text-align: left;"><br /></p>Pendellhttp://www.blogger.com/profile/06506068475871794508noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-19325950901696808332024-02-20T09:50:00.004-06:002024-02-20T10:53:49.326-06:00Tachycardia and hyperkalemia. What will happen after therapy with 1 gram of Ca gluconate and some bicarbonate?<p><span style="font-size: medium;">A 20-something type, 1 diabetic presented by EMS with altered mental status. Blood pressure was 117/80, pulse 161, Resp 45, SpO2 100 on oxygen.</span></p><p><span style="font-size: medium;">Here is the 12-lead ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5r_yb4SW3xoYbc6J23LNYtuyNPpOHrFA292gNZQMCqVNFPO-tQ_vFad0bLXnz5reEzUXtMI1aOUvfHzqfturvB47yZMlxv6U5tZPTq-A-HfA9a_Wvw9XNpH7JoNpzuaSNOqcj076aUsYDRga7Jz4xWMAXpRKF8Q16VZ_laF0gh9Asgwn76CVcATsZ0g/s3384/VT%20from%20hyperK%207.0.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1664" data-original-width="3384" height="315" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5r_yb4SW3xoYbc6J23LNYtuyNPpOHrFA292gNZQMCqVNFPO-tQ_vFad0bLXnz5reEzUXtMI1aOUvfHzqfturvB47yZMlxv6U5tZPTq-A-HfA9a_Wvw9XNpH7JoNpzuaSNOqcj076aUsYDRga7Jz4xWMAXpRKF8Q16VZ_laF0gh9Asgwn76CVcATsZ0g/w640-h315/VT%20from%20hyperK%207.0.png" width="640" /></span></a></div><div style="text-align: center;"><span style="font-size: medium;">Wide complex tachycardia</span></div><div style="text-align: center;"><span style="font-size: medium;">What do you think?</span></div><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The providers thought that this wide QRS was purely due to (severe) hyperkalemia. They treated with 4 ampules (200 mL) of bicarb and 1 gram of calcium gluconate. </span></p><p><span style="font-size: medium;"><b>Note</b>: 1 g of calcium gluconate is insufficient. 1 g of calcium chloride has 3x as much calcium and is indeed a good start.</span></p><p><span style="font-size: medium;">His pulse on the monitor suddenly went down to 140 and another 12-lead ECG was recorded:</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-zdUiUvgCJLBT7cNsPSDK7h0-SDLU-weEyS4F2QcM3dJLZUetnQAY7k3-avitWgf12q3VmRFePG4hLNc3eoH5Q7DwC7Dmx-6V83mW1wTsAarUf2ZcZtmJZDI9qcp6cXUnDdHigTMdzJqT0VvPC-GNHS0fBbfllBM0xK3tDPEAWTM1M-HganE5S2UCDQ/s3364/After%20conversion%20from%20VT%20due%20to%20hyperK.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1630" data-original-width="3364" height="310" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-zdUiUvgCJLBT7cNsPSDK7h0-SDLU-weEyS4F2QcM3dJLZUetnQAY7k3-avitWgf12q3VmRFePG4hLNc3eoH5Q7DwC7Dmx-6V83mW1wTsAarUf2ZcZtmJZDI9qcp6cXUnDdHigTMdzJqT0VvPC-GNHS0fBbfllBM0xK3tDPEAWTM1M-HganE5S2UCDQ/w640-h310/After%20conversion%20from%20VT%20due%20to%20hyperK.png" width="640" /></span></a></div><div style="text-align: center;"><span style="font-size: medium;">Sinus tachycardia at a rate of 143</span></div><div style="text-align: center;"><span style="font-size: medium;">There are peaked T-waves typical of hyperkalemia</span></div><p></p><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The K returned at 6.9 mEq/L.</span></p><p><span style="font-size: medium;"><b>What do YOU think happened here?</b> What is the diagnosis on the top ECG? Do you think that this was simply hyperkalemia with a wide complex that resolved with bicarb and calcium?</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><b>That top ECG with a wide complex tachycardia has all the features of ventricular tachycardia (VT):</b> slow onset of the QRS, absence of P-waves, very wide, absence of any LBBB or RBBB morphology. It is VT until proven otherwise and electrical cardioversion is indicated. </span></p><p><span style="font-size: medium;">When I was told that this was hyperkalemia that resolved with bicarb and calcium, I told them that, <b>no</b>, <b>this is VT induced by hyperkalemia and that it just happened to coincidentally spontaneously convert</b> at the same time as the administration of (inadequate) hyperkalemia medicines.</span></p><p><b><span style="font-size: medium;">How do I know that it is VT?</span></b></p><p><span style="font-size: medium;">1. It just looks like VT</span></p><p><span style="font-size: medium;">2. First part of QRS has slow onset: look at lead II. </span></p><p><span style="font-size: medium;">From onset of QRS to nadir of S-wave is a very long 140 ms. This is possible with HyperK only, but unlikely. </span></p><p><span style="font-size: medium;">In V6, from onset of QRS to nadir of S-wave is 160 ms</span></p><p><span style="font-size: medium;">3. It does not look like simple hyperkalemia, especially at a level of 6.9 mEq/L. It might possibly have that appearance with such a wide complex if the K was at a much higher level.</span></p><p><span style="font-size: medium;">4. It would not resolve with only bicarb and 1 g of calcium gluconate (= 1/3 of a gram of calcium chloride). That is minimal therapy for hyperK.</span></p><p><span style="font-size: medium;">5. The heart rate changed instantly from 168 to 143. That is typical of conversion from a re-entrant rhythm. </span></p><p><span style="font-size: medium;">6. P-waves appear on the followup ECG and they would not go from absent to present with such minimal therapy</span></p><p><span style="font-size: medium;">Months later, when I was writing this up, I found the prehospital ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1eP7fcO4ogQ9lWv3hoVLUxjKCNbmaQZ8sWIOeSEoSMhMOIkePC3P2hpDTI-QcljMfQVdBnCtAgHn7DimU6wh1QbzRNJccgyEomqYoH-Qxfr1rqs7nOVi0Sl2qcpk8DLyRz-tzJmVKMhtPQbXHIhyphenhyphenVzDKZnbM-OPVznrvRz5AfAPyqTuotETTOdsFNVkVC/s3715/IMG_2841.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1132" data-original-width="3715" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1eP7fcO4ogQ9lWv3hoVLUxjKCNbmaQZ8sWIOeSEoSMhMOIkePC3P2hpDTI-QcljMfQVdBnCtAgHn7DimU6wh1QbzRNJccgyEomqYoH-Qxfr1rqs7nOVi0Sl2qcpk8DLyRz-tzJmVKMhtPQbXHIhyphenhyphenVzDKZnbM-OPVznrvRz5AfAPyqTuotETTOdsFNVkVC/w640-h195/IMG_2841.jpg" width="640" /></span></a></div><p></p><p><span style="font-size: medium;">This is typical hyperkalemia without VT. Classic. Notice the heart rate is approximately 130</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">This EMS ECG proves that the rhythm of the top ECG is VT. It is not sinus tachycardia with hyperkalemia, or even sinoventricular rhythm.</span></p><p><span style="font-size: medium;">What is sinoventricular rhythm?</span></p><p><a href="https://hqmeded-ecg.blogspot.com/search/label/Sinoventricular%20Rhythm"><b><span style="font-size: medium;">Here are 4 cases of sinoventricular rhythm.</span></b></a></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">2 hours later</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYgZLm47jCqumuDo1bxamdbgpq_3XNj5matPt9nV4KnQGghgQarIWRirjqxf9H2ySw8e5Ga8y-v7vsOB395MboFtOPKsglOn99T6InYO0R9F8jlAoXX2FuURdozQ6A4yEsztfznh02hQxhRC0_3-JRc3C0Exx1s1Wno2WyO4RyynkuZf7zltkkwQrW6Q/s3382/2%20hours%20later%20hyperK%20is%20better.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1520" data-original-width="3382" height="288" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYgZLm47jCqumuDo1bxamdbgpq_3XNj5matPt9nV4KnQGghgQarIWRirjqxf9H2ySw8e5Ga8y-v7vsOB395MboFtOPKsglOn99T6InYO0R9F8jlAoXX2FuURdozQ6A4yEsztfznh02hQxhRC0_3-JRc3C0Exx1s1Wno2WyO4RyynkuZf7zltkkwQrW6Q/w640-h288/2%20hours%20later%20hyperK%20is%20better.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;"><br /></span></p><p><br /></p><p><br /></p><p><br /></p><p><br /></p><p><br /></p><p><br /></p>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-80573129873188020912024-02-18T09:00:00.001-06:002024-02-18T10:39:11.830-06:00Acute dyspnea in an older woman, is it OMI? <p><span style="font-size: medium;"> Written by <a href="https://twitter.com/willyhfrick">Willy Frick</a></span></p><p><span style="font-size: medium;">A woman in her 90s with a history of end stage renal disease and complete heart block status post dual chamber pacemaker presented from home with acute onset dyspnea. ECG is shown below.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEihovhGBCgIrhcK_ezw3H5Xo7NcDG_I0AViXKL2FKevgd4V6MFuP_gpEdwR1iPWIXbhchyn4HVeinLAkAth1WkTlQ091SG2PWqN0CtAwQhyQia0OLZ2k7SZ6L1hCuVVcxULDwgJvynCQZEiDn7o06JuZOJx57ZnV4tPS88AntfCnid_ZsGMhqbUIdLjA7A" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="594" data-original-width="1544" height="246" src="https://blogger.googleusercontent.com/img/a/AVvXsEihovhGBCgIrhcK_ezw3H5Xo7NcDG_I0AViXKL2FKevgd4V6MFuP_gpEdwR1iPWIXbhchyn4HVeinLAkAth1WkTlQ091SG2PWqN0CtAwQhyQia0OLZ2k7SZ6L1hCuVVcxULDwgJvynCQZEiDn7o06JuZOJx57ZnV4tPS88AntfCnid_ZsGMhqbUIdLjA7A=w640-h246" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">What do you think?</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">The ST and T wave abnormalities jump off the page, but let's set that aside just for a moment to review the tracing systematically. </span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">The rate is 60 (and remember, slower heart rates are often seen in OMI). </span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Close inspection reveals <b>ventricular pacing spikes</b>, best seen in aVL. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it is still <b>critical</b> to determine the atrial rhythm. In this case, it is <b>atrial fibrillation</b>. This could be easily overlooked since there is complete heart block, but recognizing the atrial arrhythmia may mean prescribing anticoagulation to prevent stroke.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;">See this case: </span></b></div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2019/02/computer-often-fails-to-diagnose-atrial.html" style="color: #6391f6; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-size: medium;">Computer often fails to diagnose atrial fibrillation in ventricular paced rhythm, and that can be catastrophic</span></a></h3><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">Given that this is a ventricular paced rhythm, we judge the presence or absence of OMI using <a href="https://hqmeded-ecg.blogspot.com/2023/05/a-man-in-his-70s-with-acute-chest-pain.html">Smith Modified Sgarbossa Criteria</a>. It is hard to identify exactly how deep the S waves in I and aVL are, but there could be disproportionate ST elevation and hyperacute T waves with reciprocal changes in III and aVF, altogether concerning for high lateral OMI.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">The ER immediately contacted cardiology for consideration of emergent catheterization. Cardiology felt that there was baseline artifact and recommended immediate repeat ECG which is shown below.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgqVOoTjxvIvR7YU2tews-XL_ANTuTUNp1auXnEN1JbHJs7sVBTdq_Lm_l0M36IcE9g-P1u4GxYYpv-65I04g0jRcz5J460PH9WYvAhpbZyMH5141hSFnI0cce6ZOUGOVYcZRlEyx8VvQgNM2_AsZRL7PevMMq7J6uzoyMRjh6FS2VHMJE_MtR8PddRuBI" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="567" data-original-width="1537" height="236" src="https://blogger.googleusercontent.com/img/a/AVvXsEgqVOoTjxvIvR7YU2tews-XL_ANTuTUNp1auXnEN1JbHJs7sVBTdq_Lm_l0M36IcE9g-P1u4GxYYpv-65I04g0jRcz5J460PH9WYvAhpbZyMH5141hSFnI0cce6ZOUGOVYcZRlEyx8VvQgNM2_AsZRL7PevMMq7J6uzoyMRjh6FS2VHMJE_MtR8PddRuBI=w640-h236" width="640" /></span></a></div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">This ECG actually has <i>even more</i> baseline wander than the first. In addition to having a particularly bizarre T wave morphology, it is curious that among the limb leads, lead II seems to look relatively normal, just as it did in the first ECG. What could explain this very bizarre looking ST-T morphology which completely spares lead II?</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;">Answer: <a href="https://hqmeded-ecg.blogspot.com/2018/01/bizarre-hyperacute-t-waves.html">Arterial pulse tapping artifact!</a></span></b></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-size: medium;">The vector mathematics are explained in detail in the above post, but the important point for localization is recognition that lead II is spared. Lead II connects the R arm and L leg, therefore by process of elimination, the problem is with the L arm electrode. (Remember that the R leg is the ground electrode.) On exam, the L arm electrode was overlying the patient's AV fistula. After repositioning the electrode, repeat ECG was obtained showing resolution of the artifact.</span></div><div class="separator" style="clear: both;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgAgheVEJoT4Mqwu2ns2sGeAoMwTqBLOe7BaGqnGrjtu89azX_QFnfdRPGD3i53e_69bnRp6ZUlRxMngp6cuHWHVi75qgFLdnF46ayKmCwPwfm84cYjau7c-izlWNGt0Ntds59qBu9DxD06YneSDHlKyvOCaniipH066YvP_hYauh-O8gkn-8uZa0HAKh8" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img alt="" data-original-height="568" data-original-width="1532" height="238" src="https://blogger.googleusercontent.com/img/a/AVvXsEgAgheVEJoT4Mqwu2ns2sGeAoMwTqBLOe7BaGqnGrjtu89azX_QFnfdRPGD3i53e_69bnRp6ZUlRxMngp6cuHWHVi75qgFLdnF46ayKmCwPwfm84cYjau7c-izlWNGt0Ntds59qBu9DxD06YneSDHlKyvOCaniipH066YvP_hYauh-O8gkn-8uZa0HAKh8=w640-h238" width="640" /></span></a></div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both;"><b><span style="font-size: medium;">Learning points:</span></b></div><div class="separator" style="clear: both;"><ul><li><span style="font-size: medium;">Arterial pulse tapping artifact causes bizarre ST-T morphology</span></li></ul><ul><li><span style="font-size: medium;">It also characteristically spares exactly one of the limb leads, and the spared lead tells you which electrode is causing the artifact</span></li></ul><ul><li><span style="font-size: medium;">Repeat ECG will reproduce the artifact if the electrodes are not repositioned</span></li></ul><ul><li><span style="font-size: medium;">Ventricular paced rhythm is an incomplete rhythm analysis, you must also determine the atrial rhythm</span></li></ul><div><br /></div><div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><div style="caret-color: rgb(0, 0, 0); color: black;"><div class="separator" style="clear: both; font-family: arial; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div style="font-family: -webkit-standard;"><br /></div><div><span style="font-size: medium;"><br /></span></div><div><div style="text-align: justify;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>2/18</i></span><span style="color: #454545;"><i>/2024</i><b>): </b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div style="text-align: justify;"><span style="font-size: medium;">Today's patient is a woman in her 90s with a dual-chamber pacemaker — who presents with acute dyspnea. I focus <i>My Comment</i> on a few additional thoughts to Dr. Frick's excellent discussion regarding ECG findings in today's <b><i><u>initial</u></i></b> <b>ECG (</b><i>that I have reproduced in</i> <b><u>Figure-1</u></b><b>)</b>.</span></div><div style="text-align: justify;"><ul><li><span style="font-size: medium;">Being told that today's patient has a permanent pacemaker is extremely helpful in keying us in to <b><i>the need to look especially close for pacemaker</i> spikes (</b><i>that had we not been told the patient had a pacemaker — might be extremely easy to overlook</i><b>)</b>.</span></li><li><span style="font-size: medium;">As I discussed in detail in <i>My Comment</i> at the bottom of the page in the <b><a href="https://hqmeded-ecg.blogspot.com/2024/01/orthostatic-hypotension-onset-after.html" target="_blank">January 13, 2024</a> post</b> in Dr. Smith's ECG Blog — <b><i>pacemaker</i></b> <b>spikes</b> tend to be a <b><i><u>high</u></i></b> <b>frequency signal</b>. As a result — they are often effectively filtered out by a <i>monitor</i> mode setting of 0.5-to-40 Hz. If this is the filter setting used — then pacer spikes may simply <i><u>not</u></i> be visible on ECG. </span></li><li><span style="font-size: medium;">Instead — a <b><i>broader</i></b> <b>passband</b> <b>(</b><i>typically from</i> <b>0.05 Hz</b> <i>to</i> <b>150 Hz)</b> is recommended for <b><i>diagnostic</i></b> <b>mode</b>, for which emphasis is on optimally accurate ST segment analysis <b>(</b><i>and for a much better chance of seeing pacemaker spikes on ECG</i><b>)</b>. We were not told the frequencies used in today's ECGs.</span></li><li><span style="font-size: medium;">As per Dr. Frick — <b><i>pacemaker</i></b> <b>spikes</b> are best seen in <b>lead aVL</b> of <u>ECG #1</u>. Knowing this relative location of pacemaker spikes in lead aVL with respect to the QRS complex in this lead facilitates recognizing the even smaller pacemaker spikes present in a number of other leads <b>(</b><i>within the GREEN circles in Figure-1</i><b>)</b>.</span></li></ul></div><div style="text-align: justify;"><p></p><p style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; min-height: 15px;"><span style="font-size: medium;"><br /></span></p><div><span style="font-size: medium;"><u><b><i>Recognition of</i></b> </u><b><u>PTA</u> (</b><i><u>P</u>ulse-<u>T</u>ap <u>A</u>rtifact</i><b>):</b></span></div><div><span style="font-size: medium;">Dr. Frick highlights a number of essential points for recognizing PTA. These include:</span></div><div><ul><li><span style="font-size: medium;">Realization that artifact often produces <b><i>bizarre</i></b> <b>ST-T wave morphology</b>.</span></li><li><span style="font-size: medium;">Awareness that <b><i>one of the 3 standard limb leads is often </i>"<u>spared</u>"</b> from this bizarre ST-T wave morphology <b>(</b><i>which is lead II in Figure-1</i><b>)</b>.</span></li><li><span style="font-size: medium;">Remembering to <u style="font-style: italic;"><b>look</b></u> at the patient <b>for</b> a <b><i>potential</i></b> <b>cause</b> of <b>artifact</b> <b>(</b><i>which was the presence of the patient's dialysis AV fistula in her left arm in today's case</i><b>)</b>.</span></li><li><span style="font-size: medium;"><b><i>Repeating</i></b> <b>the ECG</b> after <b><i>repositioning</i></b> and verifying correct electrode lead placement.</span></li></ul></div><div><span style="font-size: medium;"><br /></span></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjz-mOlaPM04Hl0DeVpETZRdC6mbN5Ss4eXw0auFuq_xw_YUFUSNvlbZeH3PnREc7AQ4OG6zoa0XUGFWXGTeFywQA1QbW0QOrFgG5OwvZSCFTOZZsRprhWSuGrY2ydefQULjgTciNgT8iDRl8FfnxHWg3m9zD-QS5XFI618GHdyYJ_oZBQPy0upd-otovg/s3780/Figure-1%20%20ECG-1%20%20(1-26.22-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-size: medium;"><img border="0" data-original-height="1696" data-original-width="3780" height="288" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjz-mOlaPM04Hl0DeVpETZRdC6mbN5Ss4eXw0auFuq_xw_YUFUSNvlbZeH3PnREc7AQ4OG6zoa0XUGFWXGTeFywQA1QbW0QOrFgG5OwvZSCFTOZZsRprhWSuGrY2ydefQULjgTciNgT8iDRl8FfnxHWg3m9zD-QS5XFI618GHdyYJ_oZBQPy0upd-otovg/w640-h288/Figure-1%20%20ECG-1%20%20(1-26.22-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;"><b style="text-align: justify;"><u>Figure-1:</u></b><span style="text-align: justify;"> I've labeled the artifact in today's initial ECG.</span></span></td></tr></tbody></table><span style="font-size: medium;"><br /></span><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><b><u>Finding the <i>"Culprit"</i> Extremity:</u></b> </span></div><div style="text-align: left;"><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div><span style="font-family: arial; font-size: medium;">As per Dr. Frick — the <b><i>"<u>culprit</u>"</i></b> <b>extremity</b> in today's case is the <b>LA electrode</b>. As I review in the <b><a href="https://hqmeded-ecg.blogspot.com/2022/08/acute-chest-pain-and-bizarre-ecg.html" target="_blank">August 26, 2022</a> post</b> of Dr. Smith's ECG Blog — when the cause of artifact is attributable to a <i><u>single</u></i> extremity, it is <i>EASY</i> to quickly determine the "culprit" extremity:</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">A <b><i><u>single</u></i></b> <b>extremity</b> is suggested as the <b><i>cause</i></b> of artifact when the amount of artifactual ST segment deviation is approximately equal in 2 of the 3 standard limb leads <b>(</b>ie, <i>outlined in RED in leads I and III of</i> <u>ECG #1</u><b>)</b> — and essentially <i><u>not</u></i> seen in the 3rd standard limb lead <b>(</b>ie, <i>there is minimal ST segment deviation in lead II of ECG #1</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">By <b><i>Einthoven's</i></b> <b>Triangle (</b><i>See</i> <b><u>Figure-2</u>)</b> — the finding of <i>equal</i> ST segment amplitude artifact in <b>Lead I</b> and <b>Lead III</b>, localizes the <b><i>"<u>culprit</u>"</i></b> <b>extremity</b> to the <b><u>LA</u> (</b> = <i><u>L</u>eft <u>A</u>rm</i><b>) electrode</b>.</span></li><li><span style="font-family: arial; font-size: medium;">The <i><u>absence</u></i> of ST elevation or depression in <b>lead II</b> is consistent with this — because, derivation of the standard <i><u>bipolar</u></i> limb lead II is determined by the electrical difference between the <b>RA</b> and <b>LL electrodes</b>, which will <i><u>not</u></i> be affected if the source of the artifact is the left arm <b>(</b><i>as in </i><u>Figure-2</u><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">By <i><u>Einthoven's</u></i> Triangle — the finding of <i>maximal</i> amplitude artifact in <i><u>unipolar</u></i> <b>lead aVL</b> confirms that the <b><i><u>left</u></i></b> <b>arm</b> is the <b><i>"<u>culprit</u>"</i></b> <b>extremity (</b><i>highlighted in RED in lead aVL of</i> <u>ECG #1</u><b>)</b>.</span></li><li><span style="font-size: medium;"><span style="font-family: arial;">By the electrophysiologic principles of Rowlands & Moore <b>(</b><i>J Electrocardiology 40:475, 2007</i><b>)</b> — t</span><span style="font-family: arial;">he amplitude of the artifact in the other 2 augmented leads </span><b>(</b><span style="font-family: arial;">ie, </span><i><b>leads aVR</b> and </i><b><i>aVF</i>)</b><span style="font-family: arial;"> — is about </span><b>1/2</b><span style="font-family: arial;"> the </span><b>amplitude</b><span style="font-family: arial;"> of the artifact in <b>lead aVL</b> </span><b>(</b><i>BLUE outline of the depressed ST segments in leads aVR and aVF of ECG #1</i><b>)</b><span style="font-family: arial;">.</span></span></li></ul><div><span style="font-size: medium;">= = = = = = = = = = = = = = = = = = = = = </span></div><ul><li><span style="font-size: medium;"><span style="font-family: arial;"><b><u><i>KEY Take-Home </i>POINT:</u></b> When the cause of artifact originates from a <i>single</i> extremity — the relative <i>amount</i> of artifact will be <i>maximal</i> in 2 of the 3 standard limb leads — <i>absent</i> in the 3rd standard limb lead — and <b><i>maximal</i> in the unipolar <i>augmented</i> electrode </b>of the<b> <i>"<u>culprit</u>"</i> extremity (</b><i>which as per the RED outline in</i> <u>Figure-1</u> — <i>is </i><b><i>lead aVL</i>)</b>. App</span>reciation of these electrophysiologic principles allowed me to <u style="font-style: italic;">instantly</u> identify <b>lead aVL</b> as the "culprit" extremity in today's case — because this is the augmented lead with maximal artifact!</span></li></ul><div><span style="font-size: medium;">= = = = = = = = = = = = = = = = = = = = = </span></div></div></div></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiE8StcQSD_Wnvxdzp4mKGxblXAi5GkZC2pNIou6uDK33o2So6xwq96xDNcWWpwJz5I6nVA-D8PrBkEqqEtGYsdFxKQr9N_HE-YbTj_ejMDsN277XunCRv0AfO8i6W3FLEdloLdrS6Cho/s1788/Einthoven%2527s+Triangle.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1234" data-original-width="1788" height="442" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiE8StcQSD_Wnvxdzp4mKGxblXAi5GkZC2pNIou6uDK33o2So6xwq96xDNcWWpwJz5I6nVA-D8PrBkEqqEtGYsdFxKQr9N_HE-YbTj_ejMDsN277XunCRv0AfO8i6W3FLEdloLdrS6Cho/w640-h442/Einthoven%2527s+Triangle.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b style="text-align: justify;"><u>Figure-2:</u></b><span style="text-align: justify;"> Use of <b><i>Einthoven's</i></b> <b>Triangle</b> to determine the electrical voltages in the 3 standard limb leads</span><span style="text-align: justify;">.</span></span></td></tr></tbody></table></div><p class="MsoNormal" style="margin: 0in; text-align: start;"><br /></p><span style="font-family: arial; font-size: medium;"><div><span style="font-family: arial;"><br /></span></div><div>================================ </div><div><span style="color: #333333;"><b><u>Links to <i>Examples</i> <i>of</i> ARTIFACT:</u></b></span></div><div><span style="color: #333333;">What follows below is an expanding list of technical "misadventures" — most from Dr. Smith's ECG Blog — some from other sources <b>(<u>NOTE:</u> </b><i>As I did not previously keep track of these — there are additional examples of artifact sprinkled through Dr. Smith's ECG Blog that I have not yet included here ... </i><b>)</b>.</span></div><div><ul style="text-align: left;"><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2024/01/noisy-low-amplitude-ecg-in-patient-with.html" target="_blank">January 15, 2024</a> post </b>— for an <b>OMI</b> <u style="font-style: italic;">despite</u> lots of <b>artifact!</b></span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2023/09/a-60-year-old-diabetic-with-chest-pain.html" target="_blank">September 15, 2023</a> post</b> — for </span><b>PTA (</b><i>Pulse-Tap Artifact</i><b>)</b><span style="font-family: arial;">.</span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2023/04/rbbb-and-lafb-is-it-trifascicular-block.html" target="_blank">April 6, 2023</a> post</b> — excessive <b><i>baseline</i></b> <b>artifact</b> misdiagnosed as <b>AFib</b> <b>(</b><i>instead of <b>sinus</b> rhythm with <b>AV Wenckebach</b> — as in Figure-4 in this post</i><b>)</b>.</span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2023/03/a-woman-in-her-50s-with-chest-pain-and.html" target="_blank">March 17, 2023</a> post</b> — for <b>PTA</b>.</span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2023/01/a-60-year-old-with-chest-pain.html" target="_blank">January 17, 2023</a> post </b>— for <b>PTA</b>.</span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2022/10/what-is-this-rhythm-back-to-basics.html" target="_blank">October 21, 2022</a> post</b> — for <b><i>"<u>artifactual</u> VT"</i></b>.</span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2020/11/a-30-something-man-with-chest-pain-and.html" target="_blank">November 10, 2020</a> post</b> — for <b>PTA</b>.</span></li><li style="text-align: justify;"><span style="font-family: arial;">The <b><a href="https://hqmeded-ecg.blogspot.com/2020/10/a-70-something-woman-with-very-wide.html" target="_blank">October 17, 2020</a> post</b> — for a 70-year old woman with <b>"<i><u>Artifactual</u></i> VT</b>".</span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">The</span><span face="Arial, sans-serif"> </span><b><a href="http://hqmeded-ecg.blogspot.com/2019/09/chest-pain-with-nondiagnostic-ecg-but.html" target="_blank">September 27, 2019</a> post</b><span face="Arial, sans-serif"> </span><span face="Arial, sans-serif">— for the <b><i>Rowlands & Moore article</i></b> with the above-noted formulas for recognizing the “culprit” extremity.</span></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">The <b><a href="https://hqmeded-ecg.blogspot.com/2019/09/a-40-something-healthy-male-with.html" target="_blank">September 22, 2019</a> post</b> — <i>intermittent</i> <b>ST-T wave artifact</b>.</span></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">The <b><a href="https://hqmeded-ecg.blogspot.com/2019/08/an-ecg-sent-to-me-with-concern-for.html" target="_blank">August 26, 2019</a> post </b>— <b><i>baseline</i></b> <b>artifact</b>.</span></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">The</span><span face="Arial, sans-serif"> </span><b><a href="https://hqmeded-ecg.blogspot.com/2018/01/bizarre-hyperacute-t-waves.html" target="_blank">January 30, 2018</a> post</b><span face="Arial, sans-serif"> </span><span face="Arial, sans-serif">— for <b>PTA</b>. </span></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif"><br /></span></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">Brief review by</span><span face="Arial, sans-serif"> </span><b><a href="https://www.aclsmedicaltraining.com/blog/guide-to-understanding-ecg-artifact/" target="_blank">Tom Bouthillet</a></b><span face="Arial, sans-serif"> </span><span face="Arial, sans-serif">on some common causes of artifact.</span></span></li><li style="text-align: justify;"><span style="font-family: arial;">Additional review of ECG artifacts by Pérez-Riera et al <b><i>(<a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/anec.12494" target="_blank">Ann Noninvasic Electrocardiol 23:e12494, 2018</a></i></b>)</span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">VT Artifact — by Knight et al:</span><span face="Arial, sans-serif"> </span><b><a href="https://www.nejm.org/doi/full/10.1056/nejm199910213411704" target="_blank">NEJM 341:1270-1274, 1999</a>.</b></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">Artifact <i>simulating</i> VFib —</span><span face="Arial, sans-serif"> </span><b><a href="http://ecg-interpretation.blogspot.com/2018/03/ecg-blog-148-ventricular-fibrillation.html" target="_blank">CLICK HERE</a>.</b></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">More VT-VFib artifact —</span><span face="Arial, sans-serif"> </span><b><a href="http://ecg-interpretation.blogspot.com/2016/12/ecg-blog-132-ventricular-tachycardia-vt.html" target="_blank">CLICK HERE</a>.</b></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">Artifact <i>simulating</i> AFlutter —</span><span face="Arial, sans-serif"> </span><b><a href="http://ecg-interpretation.blogspot.com/2016/12/ecg-blog-139-atrial-flutter-av-block.html" target="_blank">CLICK HERE</a>.</b></span></li><li style="text-align: justify;"><span style="font-family: arial;"><span face="Arial, sans-serif">Parkinsonian Tremor <i><u>vs</u></i> AFlutter — </span><b><a href="http://ecg-interpretation.blogspot.com/2012/06/ecg-interpretation-review-44-afib.html" target="_blank">CLICK HERE</a>.</b></span></li><li style="text-align: justify;"><span style="font-family: arial;">Left Leg artifact — <b><a href="https://ecg-interpretation.blogspot.com/2021/10/ecg-blog-255-ecg-mp-18-why-av.html" target="_blank">CLICK HERE</a></b>.</span></li><li style="text-align: justify;"><span style="font-family: arial;">Should the cath lab be activated? — <b><a href="https://ecg-interpretation.blogspot.com/2021/03/ecg-blog-201-ecg-mp-18-should-cath-lab.html" target="_blank">CLICK HERE</a></b>. </span></li></ul></div></span></div></div></div></span></span></div><div><p style="font-family: arial; text-align: justify;"></p><p style="font-family: arial; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; min-height: 15px; text-align: justify;"><span style="font-family: arial;"><br /></span></p><p style="font-family: arial; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; min-height: 15px; text-align: justify;"><span style="font-family: arial;"><br /></span></p><p style="font-family: arial; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; min-height: 15px; text-align: justify;"><br /><span style="font-family: arial;"></span></p></div></div></div><p></p>Willy Frickhttp://www.blogger.com/profile/09245005765903652623noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-84552012724359528842024-02-16T13:46:00.003-06:002024-02-16T13:46:42.255-06:00A young man with persistent palpitations<p><span style="font-size: medium;">Written by Pendell Meyers</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">A teenager was playing basketball when he suddenly developed palpitations and lightheadedness. He presented soon afterward at the Emergency Department with ongoing symptoms. </span></p><p><span style="font-size: medium;">Mentation and blood pressure were normal. He had no chest pain or shortness of breath. Heart rates on the monitor fluctuated from 180-250 bpm.</span></p><p><span style="font-size: medium;">Here is his triage ECG:</span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUN-8n_ZoSK8_3dBSEY9KUUq6DlExAXb-QrvbfWoljpuumGPec4sVK6QaDnrttUGfIIjuuRya6HTrGKExMugSxo2Dcr7O12NQG0Kn-8uJVQx2_TukHaar3BXGdZx_a-Dv5QaVQWDi-lso9dqd2S8AHo_KIY8YCBTCUtk0gUjQle4aW_lFfKLcmriGpOHhh/s1816/IMG_5054.jpg" style="margin-left: auto; margin-right: auto;"><span style="font-size: medium;"><img border="0" data-original-height="1146" data-original-width="1816" height="404" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUN-8n_ZoSK8_3dBSEY9KUUq6DlExAXb-QrvbfWoljpuumGPec4sVK6QaDnrttUGfIIjuuRya6HTrGKExMugSxo2Dcr7O12NQG0Kn-8uJVQx2_TukHaar3BXGdZx_a-Dv5QaVQWDi-lso9dqd2S8AHo_KIY8YCBTCUtk0gUjQle4aW_lFfKLcmriGpOHhh/w640-h404/IMG_5054.jpg" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">What do you think?</span></td></tr></tbody></table><span style="font-size: medium;"><br /></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The ECG shows an irregularly irregular polymorphic wide complex rhythm, with some R-R intervals as short as approximately 220 msec or even less. But it is not disorganized enough to be polymorphic ventricular tachycardia. The rhythm is therefore atrial fibrillation with WPW until proven otherwise.</span></p><p><span style="font-size: medium;">What do you want to do?</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><b>Smith</b>: I always cardiovert. It is far less toxic than any medication. And quicker. You only need to know how to do procedural sedation.</span></p><p><span style="font-size: medium;">1gm procainamide was given over 20 minutes without successful change in rhythm.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Sedation and cardioversion was then performed:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7UrrWWwEf6UUzNmKxVDHyzJMVtdUYMRSQvqByEDqL9MjVdYY8QgpcXhcPiIu_ySXCR1ovrRhVxge0u-zyv8DsZr9YtuAF5yw5QEXSqZ0pY0maZEMSL3RiOszZ36Y4KTB8f5LbxwI_RaBoNw1UTeY9cHoA0FP4bFJHvnGJK5PPgvMKk49FI3ahzqN5h0CW/s2276/IMG_8514.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="299" data-original-width="2276" height="84" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7UrrWWwEf6UUzNmKxVDHyzJMVtdUYMRSQvqByEDqL9MjVdYY8QgpcXhcPiIu_ySXCR1ovrRhVxge0u-zyv8DsZr9YtuAF5yw5QEXSqZ0pY0maZEMSL3RiOszZ36Y4KTB8f5LbxwI_RaBoNw1UTeY9cHoA0FP4bFJHvnGJK5PPgvMKk49FI3ahzqN5h0CW/w640-h84/IMG_8514.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;">Here is the repeat ECG after conversion:</span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgy_orPMuNqggOcAN6Z1myLwNo9Gtz3Aa-SztYza_Th3uWgudgMDu7dAAhgxmqB3u7EDRe71NtkhPBV-8btLxNYZrNNtfPdzcc8DwpN0rUP23WtYTY8nQVfrUDGR8Z8TwhVt8SiFgos-2ilFeOYCpmihvDCBYzVx9JmoyzkgvQauA4SveqYpHecDNZ1Z8t1/s4032/IMG_8512.jpg" style="margin-left: auto; margin-right: auto;"><span style="font-size: medium;"><img border="0" data-original-height="2466" data-original-width="4032" height="392" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgy_orPMuNqggOcAN6Z1myLwNo9Gtz3Aa-SztYza_Th3uWgudgMDu7dAAhgxmqB3u7EDRe71NtkhPBV-8btLxNYZrNNtfPdzcc8DwpN0rUP23WtYTY8nQVfrUDGR8Z8TwhVt8SiFgos-2ilFeOYCpmihvDCBYzVx9JmoyzkgvQauA4SveqYpHecDNZ1Z8t1/w640-h392/IMG_8512.jpg" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">Sinus rhythm with delta waves.</span></td></tr></tbody></table><span style="font-size: medium;"><br /></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The patient did well and was referred for ablation. </span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><b><u><span style="font-size: medium;">Learning Points:</span></u></b></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">Wide complex irregularly irregular tachycardias include PMVT, AF with WPW, and AF with aberrancy. </span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">AF with WPW can sometimes be differentiated from AF with aberrancy because AF with WPW may show polymorphic QRS complexes and very short R-R intervals (200 msec or less, but any R-R interval less than 240 ms -- 6 little boxes -- is likely to be AF with WPW).</span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">WPW can simulate particular aberrancies such as LBBB, and confuse the reader into missing the diagnosis of WPW.</span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">The way to differentiate Atrial fib with LBBB or other aberrancy from Atrial fib WPW is to look for polymorphic QRS complexes, as are clearly seen in the first ECG, and to look for the very short R-R intervals.</span></span></p><p><span style="font-size: medium;"><br /></span></p><p><b><u><span style="font-size: medium;">See our other cases of AF with WPW:</span></u></b></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2023/06/a-young-man-with-another-episode-of.html" style="color: #6391f6; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-size: medium;">A young man with another episode of tachycardia. What is it? And why give adenosine in sinus rhythm?</span></a></h3><div><span style="font-size: medium;"><br /></span></div><div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2022/04/a-woman-in-her-60s-with-palpitations.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium;">A woman in her 60s with palpitations</span></a></h3></div><div><span style="font-size: medium;"><br /></span></div><div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2021/01/a-47-year-old-man-with-abdominal-pain.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium;">A 47-year-old man with abdominal pain and heart rates approaching 300 bpm</span></a></h3></div><div><span style="font-size: medium;"><br /></span></div><div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2020/03/a-clinical-scenario-to-recognize.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium;">A Clinical Scenario to Recognize- Irregular WCT</span></a></h3></div><div><span style="font-size: medium;"><br /></span></div><div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2016/03/wide-complex-tachycardia.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium;">Wide Complex Tachycardia, and What is Latent Conduction and "Concealed Conduction?"</span></a></h3></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><p><br /></p><p><br /></p><p><br /></p><p><br /></p><p><br /></p>Pendellhttp://www.blogger.com/profile/06506068475871794508noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-33766615924335815252024-02-14T08:57:00.004-06:002024-02-14T08:57:53.943-06:00A 40-something with 2 hours of new active chest pain and new T-wave inversion<p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"><span>A 41-year-old male who presents to the emergency department with chest pain. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling. No shortness of breath. No recent travel. No cough. No cardiac history.</span> </span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">Here is his ECG:</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivn1w7tiwjsPyyrUeHYMbVhFIPISeazMOGyo_X3B-2atA5O1c1qMRTCnXk5kAV2PC7ldgewbbiexNW3S0-CCEeAlhFuW0RL9NZHR9IXkRGL-63ORO5nqNw4D7wYXbjVzzWL_HvrQ4iEaYizHBHozK9Ab4Kv5iDZqEnNHTty2xPG-b-gDPFw5kvQw3mjhwQ/s3398/Active%20CP%20with%20TW%20inversion.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1562" data-original-width="3398" height="294" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivn1w7tiwjsPyyrUeHYMbVhFIPISeazMOGyo_X3B-2atA5O1c1qMRTCnXk5kAV2PC7ldgewbbiexNW3S0-CCEeAlhFuW0RL9NZHR9IXkRGL-63ORO5nqNw4D7wYXbjVzzWL_HvrQ4iEaYizHBHozK9Ab4Kv5iDZqEnNHTty2xPG-b-gDPFw5kvQw3mjhwQ/w640-h294/Active%20CP%20with%20TW%20inversion.png" width="640" /></a></span></div><span style="font-family: arial; font-size: medium;"><br /><span class="Apple-converted-space"><br /></span></span><p></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">He had a previous ECG on file, from many years prior:</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlve9XWvleohfX-WxWDpiXrwXV6YxMqVsK-Q4JCygfTgAH-zxfJEBqMJ2Ml1GTa6RAoDk0LjMBwq4wkBy__Ttm-MrNkgkWDa_3wO5Z1HvRai6eFYrn3neZ5Y77RyfcvfVatjI5gbLgefmTWoMQtf0iKBIlpwlpV4ygZLW6K6-sWaKNvscj2GykWa16o0WJ/s3386/Previous%20ECG%20of%20Active%20CP%20with%20TW%20inversion.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1580" data-original-width="3386" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlve9XWvleohfX-WxWDpiXrwXV6YxMqVsK-Q4JCygfTgAH-zxfJEBqMJ2Ml1GTa6RAoDk0LjMBwq4wkBy__Ttm-MrNkgkWDa_3wO5Z1HvRai6eFYrn3neZ5Y77RyfcvfVatjI5gbLgefmTWoMQtf0iKBIlpwlpV4ygZLW6K6-sWaKNvscj2GykWa16o0WJ/w640-h298/Previous%20ECG%20of%20Active%20CP%20with%20TW%20inversion.png" width="640" /></a></span></div><span style="font-family: arial; font-size: medium;"><div style="text-align: center;">What do you think?</div><span class="Apple-converted-space"><div style="text-align: center;"><br /></div></span></span><p></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">There is new T-wave inversion in inferior leads and V3-V6. This is recorded during pain. The faculty physician thought this is highly <u>likely</u> to be ACS. </span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">However, most T-wave inversion during pain is nonspecific. T-wave inversion AFTER resolution of anginal type pain is highly likely to be due to reperfusion.</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">On occasion, unstable angina can present with reversible T-wave inversion during pain. When the ischemia is resolved, if there is no infarction, the T-wave can normalize. This is in contrast to Wellens' syndrome, which involves at least a small amount of infarction (troponin elevation) and in which the T-wave inversion evolves into deeper and deeper T-wave inversion.</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><b>See these 2 contrasting cases:</b></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"></span></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2011/03/classic-evolution-of-wellens-t-waves.html" style="color: #6391f6; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-family: arial; font-size: medium;">Classic Evolution of Wellens' T-waves over 26 hours</span></a></h3><div><br /></div><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><b><span class="Apple-converted-space" style="font-family: arial;"></span></b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2018/12/dynamic-reversible-ischemic-t-wave.html" style="color: #6391f6; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-shadow: none;"><span style="font-family: arial; font-size: medium;">Dynamic, Reversible, Ischemic T-wave inversion mimics Wellens'. All trops negative.</span></a></h3><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">This case directly above was not in the era of high sensitivity troponin. <a href="https://hqmeded-ecg.blogspot.com/search/label/Unstable%20Angina%20in%20the%20era%20of%20High%20sensitivity%20troponin">Unstable angina in the era of hs trop still exists</a>. I have never seen it with <u>undetectable</u> hs trops, but acute MI is possible after a single initial hs trop below the limit of detection. </span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><br /></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><a href="https://www.sciencedirect.com/science/article/abs/pii/S0002934317302577">In our study of a single initial hs troponin I below the limit of detection (1.9 ng/L, Abbott Architect), the NPV and sensitivity for acute MI was not 100%, rather 99.6% and 98.8%</a>. In other words, it is possible for a subsequent troponin to be elevated above the 99% URL when the first one is undetectable, but is very uncommon. I do not think it is possible for a 2nd trop to remain undetectable in a patient then goes on to rule in for acute MI, unless there is a 2nd event. </span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">I know of no data on unstable angina/30-day adverse events/acute MI after 2 serial <b><i><u>undetectable</u></i></b> trops. Unstable angina would be exceedingly rare in such a situation, but still possible. Acute MI would not be possible unless there was another event. </span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><br /></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"><b>Back to this case:</b></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">These T-wave inversions do not look ischemic to me. They look very nonspecific. When I see a case like this, I am skeptical that the ECG is manifesting acute ischemia or reperfused OMI. Unless the patient on history and exam clearly looks like he/she is having an acute MI, I am satisfied to wait for the troponin.</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">Here is the Queen's interpretation:</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4P0ridkbaWZdkTx7UGfYHf1ufY_S7QKLT8nxrDVvPsZ779QOOp6LXKMjDoBmiMBtSuE5vsNXc4yEW_ML27tYmOB5bknhnbmNpfylUlrN3AFDUKiZEV6Pnv3S6FhRluoIYWpOwdb9fVFlNg3tX3hF1D0by0iTx5eYkWcS6FcH_12fiUxSRCKA6-88M-3zc/s876/Queen%20interpretation.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="542" data-original-width="876" height="396" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4P0ridkbaWZdkTx7UGfYHf1ufY_S7QKLT8nxrDVvPsZ779QOOp6LXKMjDoBmiMBtSuE5vsNXc4yEW_ML27tYmOB5bknhnbmNpfylUlrN3AFDUKiZEV6Pnv3S6FhRluoIYWpOwdb9fVFlNg3tX3hF1D0by0iTx5eYkWcS6FcH_12fiUxSRCKA6-88M-3zc/w640-h396/Queen%20interpretation.png" width="640" /></a></span></div><span style="font-family: arial; font-size: medium;"><div style="text-align: center;">The Queen agrees. The Queen does not even know if there is active pain or pain that has resolved. She only sees the morphology of these T-wave inversions and does not think that they look ischemic. </div><div style="text-align: center;">In Version 1, if the Queen sees reperfusion T-waves, she calls it OMI.</div><div style="text-align: center;"><b>But in this case, she knows that these are not reperfusion T-waves; she knows that the morphology is nonspecific.</b></div><div style="text-align: center;"><b>Therefore, she says "Not OMI"</b></div></span><div style="text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><b>I think this is remarkable that she knows the difference between ischemic T-waves and Non-ischemic T-waves from morphology alone!<br /></b><span class="Apple-converted-space"><br /></span></span><p></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">She explains here:</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1cudR1vpStGm6jMo_YIScIWm6TrOos9ZGFUfxOi186CC1bGCWvBePzyh5J2vnVrxND82XFRDfD3i7NNiSWE8zXo2odcQ3x9p_FY2la8tawgM39JuiRCLuHf-v2OhqEWl2sR0-QUoIX0P4tHydxZiyFHXGyYMob3he7iLtepHa2ThUIEgsnMXoY0BEEU5L/s3368/Explainability%20on%20TW%20inversion%20case.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1390" data-original-width="3368" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1cudR1vpStGm6jMo_YIScIWm6TrOos9ZGFUfxOi186CC1bGCWvBePzyh5J2vnVrxND82XFRDfD3i7NNiSWE8zXo2odcQ3x9p_FY2la8tawgM39JuiRCLuHf-v2OhqEWl2sR0-QUoIX0P4tHydxZiyFHXGyYMob3he7iLtepHa2ThUIEgsnMXoY0BEEU5L/w640-h264/Explainability%20on%20TW%20inversion%20case.png" width="640" /></a></span></div><span style="font-family: arial; font-size: medium;"><div style="text-align: center;">I don't think this explanation tells me why she is not convinced by this T-wave inversion. For most of the leads with T-wave inversion, she just says "OMI - low confidence". But her overall impression is "Not OMI with High confidence".</div><span class="Apple-converted-space"><div style="text-align: center;"><br /></div></span></span><p></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: arial; font-size: medium;"><b>Outcome:</b></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;">All hs troponin I ﹤ 3 ng/L (undetectable). There was no repeat ECG. Again, although T-waves can reversibly invert with unstable angina, unstable angina with 2 high sensitivity trops below the limit of detection could possibly occur, but is extremely unlikely.</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><b>My impression was correct and so was the Queen's: this is NOT ischemic T-wave inversion.</b></span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><b><br /></b></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">This is for the version housed on Telegram:</span></span></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"></span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></a></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><b style="text-shadow: none;">You can get the full PM Cardio app here if you live in the UK or EU (or say you do upon registration):</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"></span></span></p><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="font-size: medium; text-shadow: none;"><a href="https://qrco.de/bebW8d" style="color: #2066f5; text-decoration-line: none; text-shadow: none;">https://qrco.de/bebW8d</a></span></div></div><div><span style="font-size: medium;"><span class="Apple-converted-space" style="font-family: arial;"><br /></span></span></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-23213844678231931262024-02-12T09:57:00.000-06:002024-02-12T09:57:53.424-06:00Vomiting, Diarrhea, and "Bubbles in my Chest"<p><span style="font-size: medium;">A 60-something complained of vomiting, diarrhea overnight, and "bubbles in my chest" that started just prior to calling 911.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">He had this ECG recorded prehospital:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgggdGjNsnhLoNJjmqCsj7nLjWvY912zJ1sDSaVRi-9ClkKi40xPYn-t0OMf2R75hCs1_z2_WuHl9qJpYTtiYMmCqPcfgl7HmbIYJ9KysnUzbn1aJsvGmnxfek59OqcXWWbJM34iwNwxA3T4hifponajQ-gExByF0PB0P5p3WhxNJ320qfiHI8fMp8IR_sz/s3478/IMG_4367.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="834" data-original-width="3478" height="153" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgggdGjNsnhLoNJjmqCsj7nLjWvY912zJ1sDSaVRi-9ClkKi40xPYn-t0OMf2R75hCs1_z2_WuHl9qJpYTtiYMmCqPcfgl7HmbIYJ9KysnUzbn1aJsvGmnxfek59OqcXWWbJM34iwNwxA3T4hifponajQ-gExByF0PB0P5p3WhxNJ320qfiHI8fMp8IR_sz/w640-h153/IMG_4367.jpg" width="640" /></span></a></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><b>Smith interpretation: </b>There are hyperacute T-waves in III and aVF, and reciprocal STD in aVL with a reciprocally inverted T-wave in aVL. There are also hyperacute T-waves in V3 and V4. There is STD in V1 and V2. </span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">So it appears to be diagnostic of OMI, but it is hard to figure out what exact territory and artery. It could be a proximal RCA with both inferior OMI, posterior OMI (pulling ST down in V1/V2), and RV OMI causing large ischemic T-waves in V3-4.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Here is what the Queen of Hearts AI app says:</span></div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiE13RjgGvf8Z9MwTLM4hdAbHvw5TOnvIQTJ-JeweoQeXJl3x1SBAkIy6eOrq5wX53FbnFsx5_9x-hnqjqkM3zjv7FNuCwOUPo6-gSBIZK0iI2r9lEkCOEjzv_zghLeTV_b5M1zRIWknzagwAYAGvDZ_RUaQy-ooteJ9fgUfSxE_dP8U0ohNCl0piCqe6N3/s951/IMG_2776.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="533" data-original-width="951" height="358" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiE13RjgGvf8Z9MwTLM4hdAbHvw5TOnvIQTJ-JeweoQeXJl3x1SBAkIy6eOrq5wX53FbnFsx5_9x-hnqjqkM3zjv7FNuCwOUPo6-gSBIZK0iI2r9lEkCOEjzv_zghLeTV_b5M1zRIWknzagwAYAGvDZ_RUaQy-ooteJ9fgUfSxE_dP8U0ohNCl0piCqe6N3/w640-h358/IMG_2776.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;">The patient received aspirin and NTG prehospital, and was transported to the ED.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">This ECG was recorded on arrival in the ED:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhY6Zelv7-knwUg2x72VvjNbGu-1wiIhdUhuu2NedtQLBImycD52YeSaOKaeFlUtwUs3viW4ozpVSd33X0cClZ5nRzQunw7YJd3pE2wPxHgRGxcU6kXk37bgQ35AbIsRxedtwiVzWeClugLz4NLk4h6pFNCc4hRmjWnuSiqOIbt2SxYAn0un-U4oCtzVb83/s3451/IMG_4365.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="2040" data-original-width="3451" height="378" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhY6Zelv7-knwUg2x72VvjNbGu-1wiIhdUhuu2NedtQLBImycD52YeSaOKaeFlUtwUs3viW4ozpVSd33X0cClZ5nRzQunw7YJd3pE2wPxHgRGxcU6kXk37bgQ35AbIsRxedtwiVzWeClugLz4NLk4h6pFNCc4hRmjWnuSiqOIbt2SxYAn0un-U4oCtzVb83/w640-h378/IMG_4365.jpg" width="640" /></span></a></div><div style="text-align: center;"><span style="font-size: medium;"><div style="font-size: medium;"><span style="font-size: medium;"><b>Here is the interpretation of the conventional algorithm (Veritas):</b></span></div><div style="font-size: medium;"><span style="font-size: medium;"><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; text-align: start;"></p><div><span style="font-family: times;">SINUS BRADYCARDIA</span></div><div><span style="font-family: times;">ST ELEVATION, PROBABLY EARLY REPOLARIZATION [ST ELEVATION WITH NORMALLY INFLECTED T-WAVE]</span></div><div><span style="font-family: times;">BORDERLINE ECG</span><span class="Apple-converted-space" style="font-family: Arial; font-size: 11px;"> </span></div><div><span class="Apple-converted-space" style="font-family: Arial; font-size: 11px;"><br /></span></div></span></div><div style="font-size: medium;"><span style="font-size: medium;"><b>What do you think?</b></span></div></span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;"><b>Smith interpretation:</b> Same analysis, except that the STD in V1-2 is gone and replaced by hyperacute T-waves</span></div><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Here is the interpretation of the Queen of Hearts:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzN00BBAZfHwjEixplzBGuos56zbnaTuf0bK6c4PSwLdXHdlNcfLI5nx2n4MWBHBzjW7jrYZp0_Dc6r1IB3nEkh-3cgdTGz-CjxrpPYNO-EBFtV3YME9F5ONU7jmL1brYBwjA7XYBw2vqqDMdzM6XdsqTlZkylcw6lap6zVnIImfDjZdZrqcDI6AlL1hGI/s951/IMG_2776.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="533" data-original-width="951" height="358" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzN00BBAZfHwjEixplzBGuos56zbnaTuf0bK6c4PSwLdXHdlNcfLI5nx2n4MWBHBzjW7jrYZp0_Dc6r1IB3nEkh-3cgdTGz-CjxrpPYNO-EBFtV3YME9F5ONU7jmL1brYBwjA7XYBw2vqqDMdzM6XdsqTlZkylcw6lap6zVnIImfDjZdZrqcDI6AlL1hGI/w640-h358/IMG_2776.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;"><br /></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">This is for the version housed on Telegram:</span></span></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"></span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></a></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><b style="text-shadow: none;">You can get the full PM Cardio app here if you live in the UK or EU (or say you do upon registration):</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="font-size: medium; text-shadow: none;"><a href="https://qrco.de/bebW8d" style="color: #2066f5; text-decoration-line: none; text-shadow: none;">https://qrco.de/bebW8d</a></span></div><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><b>Case Continued</b></span></p><p><span style="font-size: medium;">The cath lab was activated and the patient received 180 mg of ticagrelor, and then was transported to the cath lab.</span></p><p><b><span style="font-size: medium;">Angiogram:</span></b></p><p><span style="font-size: medium;">Severe 95% hazy distal LM</span></p><p><span style="font-size: medium;">Severe 80% ostial LAD, 100% occluded distal LAD thought to be due to distal embolization from the lesion in the proximal LAD.</span></p><p><span style="font-size: medium;">Mild CAD in LCX</span></p><p><span style="font-size: medium;">70% eccentric proximal RCA</span></p><p><b><span style="font-size: medium;">Management</span></b></p><p><span style="font-size: medium;">Given the persistent CP despite IV TNG and given the severe LM disease, a 50 CC Intra-Aortic Balloon Pump (IABP) 1:1 was placed in the CCL under Xray guidance via the Rt CFA</span></p><p><span style="font-size: medium;">CP is 6/10 after IABP</span></p><p><span style="font-size: medium;"><u>No PCI was done, since the occlusion was an embolus</u></span></p><p><span style="font-size: medium;">Case discussed for urgent revascularization with bypass surgery.</span></p><p><b><span style="font-size: medium;">Troponins:</span></b></p><div><span style="font-size: medium;">First trop returned later at 14 ng/L. 2 hour trop 403. 4 hour trop 593 ng/L.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">No further troponins were ordered</span></div><p><b><span style="font-size: medium;">Echo</span></b></p><p><span style="font-size: medium;">Normal estimated left ventricular ejection fraction, 72%.</span></p><p><span style="font-size: medium;">Regional wall motion abnormality-apical septum and inferior wall.</span></p><p><span style="font-size: medium;">Regional wall motion abnormality-apex, dyskinetic.</span></p><div><b><span style="font-size: medium;">Further management</span></b></div><p><span style="font-size: medium;">Underwent emergent 4 vessel CABG. </span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Post op chest pain</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtGUIZiSDlwQ-FvA9fBJCAEcJBdbgWWW4KniWnReh7hddei-D9DGURZJGuBDrdjz_X8O4XIksIC8QBbvwcrO1TsGu6DXzO_dSjnHWmHTzfQVuZox-06BsR2DZrBd8yTMgaH4MU9FaQVcmYWNK5dzqfy2sK17lT2-AXCvkf-GBe_IWKvANUohwEZ8-t-DH3/s1468/post%20op%20pericarditis.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="682" data-original-width="1468" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtGUIZiSDlwQ-FvA9fBJCAEcJBdbgWWW4KniWnReh7hddei-D9DGURZJGuBDrdjz_X8O4XIksIC8QBbvwcrO1TsGu6DXzO_dSjnHWmHTzfQVuZox-06BsR2DZrBd8yTMgaH4MU9FaQVcmYWNK5dzqfy2sK17lT2-AXCvkf-GBe_IWKvANUohwEZ8-t-DH3/w640-h298/post%20op%20pericarditis.png" width="640" /></span></a></div><span style="font-size: medium;"><div style="text-align: center;">Typical of post-op pericarditis <b>(postpericardiotomy syndrome)</b></div><div style="text-align: center;">There is ST Elevation in II > III, and STE in V3-5, but with flat T-wave. The ST elevation is far more prominent than the T-wave and this is what I see as the defining feature differentiating OMI from pericarditis.</div><div style="text-align: center;"><br /></div><div style="text-align: center;">An alternative explanation would be re-occlusion, but this is unlikely after bypass surgery and the T-wave would be more prominent than the STE</div></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Post op 2</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrnuR1QtnTZSyP93caNzai9Gm5XH_h8Wnw7FjLGm0rYYU7hBu7f8qdADazZrLPVe_HGylxfQWvEMCXqDNx4BPmE9Jg-MSNTxQibTsLT9wHJNvH_lwXUwmREzJQFF0VRyNGp6hq7sSvAy3aGBFNqQ668K9uRaK9M51SBI5HjX_o7Yz-c9MBpCRvIvO3yus6/s1470/post%20op%20pericarditis-2.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="680" data-original-width="1470" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrnuR1QtnTZSyP93caNzai9Gm5XH_h8Wnw7FjLGm0rYYU7hBu7f8qdADazZrLPVe_HGylxfQWvEMCXqDNx4BPmE9Jg-MSNTxQibTsLT9wHJNvH_lwXUwmREzJQFF0VRyNGp6hq7sSvAy3aGBFNqQ668K9uRaK9M51SBI5HjX_o7Yz-c9MBpCRvIvO3yus6/w640-h296/post%20op%20pericarditis-2.png" width="640" /></span></a></div><span style="font-size: medium;"><div style="text-align: center;">Remains typical of Post Op pericarditis.</div></span><p style="text-align: center;"><br /></p><p></p><div id="rTfKZYWaA9Lgp84Pgf-KOA__20" style="-webkit-text-stroke-width: 0px; background-color: white; color: #202124; font-family: Roboto, arial, sans-serif; font-size: medium; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; text-decoration-thickness: initial; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px;"><div class="g pp-webimport-pub-3" style="clear: both; font-family: Roboto, arial, sans-serif; font-size: 14px; line-height: 1.58; margin-bottom: 4px; margin-top: 0px; padding-left: 0px; padding-right: 0px; position: relative; text-align: left; width: 600px;"><div data-hveid="CBAQAA" data-ved="2ahUKEwjFpLHAjaaEAxVS8MkDHYG_AgcQFSgAegQIEBAA"><div class="tF2Cxc" style="position: relative;"><div class="yuRUbf" style="font-size: small; font-weight: normal; line-height: 1.58;"></div></div></div></div></div><p></p><div id="rTfKZYWaA9Lgp84Pgf-KOA__19" style="-webkit-text-stroke-width: 0px; color: #202124; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; text-decoration-thickness: initial; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px;"><div class="wDYxhc" data-md="61" style="clear: none;"><div aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBoQAA" role="heading" style="overflow: hidden; padding-bottom: 20px;"><span class="ILfuVd" color="var(--bbQxAb)" lang="en" style="line-height: 24px;"><span class="hgKElc" style="background-color: white; padding: 0px 8px 0px 0px;"><span style="font-family: times; font-size: medium;">Postpericardiotomy syndrome (PPS) is a clinical syndrome consisting of <b style="color: #040c28; font-weight: 500;">worsening or new formation of pericardial and/or pleural effusion, pericardial rub, chest pain with or without dyspnea, fever, and elevated inflammatory markers</b>.</span></span></span></div></div></div><p><br /></p><p><br /></p><p><br /></p><p><br /></p></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-75070013944365003962024-02-11T10:20:00.000-06:002024-02-11T10:20:37.873-06:00See What PM Cardio Digitization can do with this ECG<p><span style="font-size: medium;">This was a patient with chest pain. The ECG was faxed to a cardiologist. But it was very difficult for him to see.</span></p><p><span style="font-size: medium;">He showed this to me the next day.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8GQH6FOglmal5QU41rdJfkhaREjHUeGd1y_TMCRRcVFxhvJlgg4kvhhyg4dtmsULVunsxXODbhaHjarDPv70MtQNMrWGroQSK_KzOkkwDqNLqeYGruNkxgHn2AR0gp1UIff_zuKfFfG3xLC2NPz0DK5ArBXwAF8ER1QL0RtbU4FNEKEDeNl4VY9K7eaJS/s3837/FullSizeRender.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="2210" data-original-width="3837" height="368" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8GQH6FOglmal5QU41rdJfkhaREjHUeGd1y_TMCRRcVFxhvJlgg4kvhhyg4dtmsULVunsxXODbhaHjarDPv70MtQNMrWGroQSK_KzOkkwDqNLqeYGruNkxgHn2AR0gp1UIff_zuKfFfG3xLC2NPz0DK5ArBXwAF8ER1QL0RtbU4FNEKEDeNl4VY9K7eaJS/w640-h368/FullSizeRender.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">I told him that he could make it legible AND get an OMI diagnosis from the Queen of Hearts and sent this ECG to the Queen right before his eyes:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5aKXvr9jvrgMOW4T8eyqHl02xpDcEFiy7iZ5bJm84_4yr8It0VxTyJtUqNiwVgHta5xQKWepwwQQTBii71ADRslaGkjFK1OvfSHwqb7tU78fXLT2-f8DcVotx-qnJ2KJniVw_hjlwnzibZpRR5oAFNaebqPV3hnsAvWMpFtxe51kdAApJE8P3lkYm78rF/s2223/IMG_2767.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1290" data-original-width="2223" height="372" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5aKXvr9jvrgMOW4T8eyqHl02xpDcEFiy7iZ5bJm84_4yr8It0VxTyJtUqNiwVgHta5xQKWepwwQQTBii71ADRslaGkjFK1OvfSHwqb7tU78fXLT2-f8DcVotx-qnJ2KJniVw_hjlwnzibZpRR5oAFNaebqPV3hnsAvWMpFtxe51kdAApJE8P3lkYm78rF/w640-h372/IMG_2767.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">She correctly rules out OMI:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMUjRzZCc-DIYl-nmMkOlShdTy_q-iu6iRXcV0HIYhQ7nWu-TmkwVjbBTH2GZee44PV7CqTkcy0kuvitxk3TS2kAL0994POypd6lbKkYNRRnCwphIPGwX2-I7rOFjjXShfpuVtHyV6NXRPhIFQwEfiKEPmEe_RvWcpBez0d76im8KNjtUpA_CgfzAXwS2n/s968/IMG_2803.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="796" data-original-width="968" height="526" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMUjRzZCc-DIYl-nmMkOlShdTy_q-iu6iRXcV0HIYhQ7nWu-TmkwVjbBTH2GZee44PV7CqTkcy0kuvitxk3TS2kAL0994POypd6lbKkYNRRnCwphIPGwX2-I7rOFjjXShfpuVtHyV6NXRPhIFQwEfiKEPmEe_RvWcpBez0d76im8KNjtUpA_CgfzAXwS2n/w640-h526/IMG_2803.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;">And the outcome was Not OMI</span></p>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-5480510927312088662024-02-09T07:29:00.007-06:002024-02-09T11:12:05.652-06:00Chest pain with anterior ST depression: look what happens if you use posterior leads.<p><span style="color: red; font-size: medium;"><b>Don't forget to watch the <u>Webinar</u>: </b></span></p><p><span style="font-size: medium;">Smith and Pendell Meyers interpret ECGs for OMI or not OMI on Monday Feb 12 at 11 AM U.S. Central time. Register here:</span></p><p><span style="font-size: medium;"><b style="background-color: white; color: #222222; font-family: Arial, Helvetica, sans-serif;"><span style="color: blue;"><a data-saferedirecturl="https://www.google.com/url?q=https://zoom.us/webinar/register/7617067094184/WN_LMN0vPb1Rz-HZu12K-QuYQ&source=gmail&ust=1707584924383000&usg=AOvVaw1-z5W4YAu05t2UqbHhcv4J" href="https://zoom.us/webinar/register/7617067094184/WN_LMN0vPb1Rz-HZu12K-QuYQ" style="color: #1155cc;" target="_blank">https://zoom.us/webinar/<wbr></wbr>register/7617067094184/WN_<wbr></wbr>LMN0vPb1Rz-HZu12K-QuYQ</a></span></b></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><b>Written by Jesse McLaren<br /></b></span></p><b><span style="font-size: medium;">
</span><span style="font-size: medium;">
</span></b><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">A 65 year old
with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented
with 3 days of fluctuating chest pain, which was ongoing at triage. What do you
think? Do you need posterior leads?</span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span></span></span></span></p><span style="font-size: medium;">
</span><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOr6I8pQamjkzhW3AVu8FCDpuRUIi4hv20ECs31LrPrRI7UJAc4DHbjSF40puGT_JSMQZvCFcMcrGmjXAr2Pmlob4fa92GmcRWO-Xm3vI2DNldNidumxSyvdYFOgNHgnBI5YEZpc_0UGnt4cK1QCVyAR1-17o1FOBkkiKTQxtLVBwopsjBHeVmRU2BZGk/s1641/1.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="604" data-original-width="1641" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOr6I8pQamjkzhW3AVu8FCDpuRUIi4hv20ECs31LrPrRI7UJAc4DHbjSF40puGT_JSMQZvCFcMcrGmjXAr2Pmlob4fa92GmcRWO-Xm3vI2DNldNidumxSyvdYFOgNHgnBI5YEZpc_0UGnt4cK1QCVyAR1-17o1FOBkkiKTQxtLVBwopsjBHeVmRU2BZGk/w598-h220/1.png" width="598" /></span></a></div><span style="font-size: medium;"><br /><span></span></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">There’s atrial
flutter with controlled ventricular response, a non-specific intra-ventricular
conduction delay, borderline right axis, normal R wave progression and normal
voltages. The abnormal depolarization from the IVCD can produce secondary repolarization abnormalities, but here there appears to be superimposed primary ST depression V2-4 indicating posterior OMI. <span></span></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-family: "Times New Roman"; font-size: medium;"> </span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Here's the prior ECG: <span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0oqnDNYxBu969BhdjxMX5bPE9VMFlP3MRVNVjb33VNVvgWoJtbQXqd4C424vtfqdSPM_TNkvegBTqxPDAedHsysaPYBL2LIeqpd8D_Cgfvpy33bsJAroGRoTcPeb5d2kCnhP3hmICXpdKlJ8NG3h3B8MFt1Uy0JVVKIvFmtZ294LqYcffPVfNlL_de0o/s1657/2.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="463" data-original-width="1657" height="165" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0oqnDNYxBu969BhdjxMX5bPE9VMFlP3MRVNVjb33VNVvgWoJtbQXqd4C424vtfqdSPM_TNkvegBTqxPDAedHsysaPYBL2LIeqpd8D_Cgfvpy33bsJAroGRoTcPeb5d2kCnhP3hmICXpdKlJ8NG3h3B8MFt1Uy0JVVKIvFmtZ294LqYcffPVfNlL_de0o/w593-h165/2.png" width="593" /></span></a></div><span style="font-size: medium;"><br /><span><br /></span></span></div><div><span style="font-size: medium;"><span>This confirms thew anterior ST depression is new. <span style="font-family: "Times New Roman";">The first ECG was
labeled “anterior subendocardial ischemia”, but subendocardial ischemia does
not localize. If there were diffuse ischemic STD, with precordial STDmaxV5-6
and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from
ACS or supply-demand mismatch. <b>But here there is ischemic STDmaxV1-4, which is not
“anterior subendocardial ischemia” but rather reciprocal to posterior OMI.</b><span></span></span></span>
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">So a patient
with high pretest probability (prior CABG with new chest pain), had new ECG
changes showing posterior OMI. Do you need posterior leads? If so, how
will they change management?<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";"><span> </span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">Posterior leads are unnecessary if
anterior leads are diagnostic<span></span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">According to the
STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary
occlusion, and if there’s no ST elevation on anterior leads you can look for it
on posterior leads. But for decades we’ve known that you don’t have to have
posterior leads to diagnose posterior MI in the setting of typical LBBB: In both the Original Sgarbossa
criteria, and in the Smith Modified Sgarboss Criteria, <b>criterion 2 only requires concordant STD in <u>one</u> lead of V1-V3 to diagnose
posterior MI</b>, without the need for posterior leads. In this case there was not
typical LBBB, but the principles of concordant STD still apply. </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span></span></span></span></p><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span></span></span></span><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></div><div><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Smith and Meyers
have also shown that ischemic STDmaxV1-4 is 97% specific for posterior OMI,
without the need for posterior leads. </span></span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">In this case the IVCD complicates the ECG interpretation, but there was clearly new ischemic STDmaxV1-4, which is diagnostic of posterior OMI. <span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Here’s the first
ECG flipped upside down, which shows concordant ST elevation in V2-4.<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifrKVTeVLVMPbabUsY-83cmsuSa1QlF3YwzvR_Javoc2rxl-asjZssWNftexhccX-2fcdufe4Ost2_OwyLgfpGsHFkXI2NhVyNAbhE4cyvbb92HfGD5Loz-6GtxCsxxj90-TdA0Di7k-NEhDUSQC-qr8n-RAkFKq4A1h0hNNvY8gz7OB4F_OaIPmcZL-o/s1639/3.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="471" data-original-width="1639" height="172" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifrKVTeVLVMPbabUsY-83cmsuSa1QlF3YwzvR_Javoc2rxl-asjZssWNftexhccX-2fcdufe4Ost2_OwyLgfpGsHFkXI2NhVyNAbhE4cyvbb92HfGD5Loz-6GtxCsxxj90-TdA0Di7k-NEhDUSQC-qr8n-RAkFKq4A1h0hNNvY8gz7OB4F_OaIPmcZL-o/w598-h172/3.png" width="598" /></span></a></div><span style="font-size: medium;"><br /><span>Why not just get posterior leads anyway, to confirm?<br /></span></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">Posterior leads can be falsely negative <span></span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";"><span> </span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span><span style="font-family: "Times New Roman";">A 15 lead can be
helpful if the 12 lead is non-diagnostic. But if the 12 lead is already
diagnostic the 15 lead<span></span></span></span><span><span style="font-family: "Times New Roman";"> posterior leads
can be falsely negative. <span></span></span></span>
</span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span><span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The emergency
physician was worried about posterior MI, so recorded a 15 lead ECG:<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcndesZ5pzUx_E8kOIiOaBliaVCHc9RvQikOGmqY_tvb83N3suPUg420noS1jjpJmpSKa5P_3X6hsKgTBnp049zDuQad_2wV0BhVilDPVSE9R_mZhf3lFroKGQ6_GsNBOYk5TC-0iwugZ3JNQrmB9d8mh-qwCVsXN8Wwi42K7eO_v4qVukzLn10WaFc0w/s1644/4.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="480" data-original-width="1644" height="177" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcndesZ5pzUx_E8kOIiOaBliaVCHc9RvQikOGmqY_tvb83N3suPUg420noS1jjpJmpSKa5P_3X6hsKgTBnp049zDuQad_2wV0BhVilDPVSE9R_mZhf3lFroKGQ6_GsNBOYk5TC-0iwugZ3JNQrmB9d8mh-qwCVsXN8Wwi42K7eO_v4qVukzLn10WaFc0w/w610-h177/4.png" width="610" /></span></a></div><span style="font-size: medium;"><br /><span><br /></span></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">There’s still
ischemic STDmaxV1-4, but posterior leads are negative. So when the first
troponin returned at 2,200 ng/L (normal <26 in males and <16 in females)
the patient was referred to cardiology as a non-STEMI.<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">So a patient with
high pretest probability and now lab confirmation of MI, had an ECG with
ischemic STDmaxV1-4 that identified the MI as being occlusive (OMI) rather than
non-occlusive (NOMI). But because there was no ST elevation on either anterior or
posterior leads, they were diagnosed as ‘non-STEMI’<span> </span>– which can produce diagnostic momentum that
can be difficult to reverse.<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">‘Non-STEMI’ diagnostic momentum<span></span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";"><span> </span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Cardiology
repeated the ECG and troponin, and did a bedside echo.<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt4j7pCbgoStzVaoW7dwKhxS3SKuxAu5uPrYfT-cITzWrZvYJB6VzjvQmMnmED_l-KnBPlm-ykQv2JGRryCjM2layv9ndCEZaBFqzVAgFy8lnZcziGrGifoLUi97iBYOvceb8dLPjC5-_koIxpvwDel3plQ_bU5tlXCt0PC9C71rXlho8_zq48p5mWiaE/s1657/5.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="458" data-original-width="1657" height="166" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgt4j7pCbgoStzVaoW7dwKhxS3SKuxAu5uPrYfT-cITzWrZvYJB6VzjvQmMnmED_l-KnBPlm-ykQv2JGRryCjM2layv9ndCEZaBFqzVAgFy8lnZcziGrGifoLUi97iBYOvceb8dLPjC5-_koIxpvwDel3plQ_bU5tlXCt0PC9C71rXlho8_zq48p5mWiaE/w604-h166/5.png" width="604" /></span></a></div><span style="font-size: medium;"><br /><span><br /></span></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">There’s still
ischemic STDmaxV1-4, but now there’s subtle posterior STE (but still less
obvious than the anterior STD). Cardiology noted “transient concordant ST
elevation”, and echo showed posterior RWMA and CHF with MR. </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">So now there’s clinical, laboratory, ECG and echo findings of OMI.<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">But the pain had
improved on nitro infusion and the repeat troponin 2 hours after the first was
the same, so the patient was admitted as ‘non-STEMI’ with a focus on medical
management and dialysis for fluid overload.<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The next day
troponin rose to 20,000 and then 50,000, with ECG showing ongoing ischemic
STDmaxV1-4 – which was now interpreted as “anterior STD similar to prior ECGs”:<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNLPbHGaF1Yjy5mZMCaDmBTKktWRVPfwQlSiVjHp3ya2vVlHeL687a0Kn02lZ2u33VNuL1Sv6Dvy6mrvfEbEh9eK0wVhxEu3i3nCtnLif0R4vDczF0VgWaJJBdwm1nY9rL4l3ttY0khDgSI6Ke4RvT7ymqPF1BDgs2WroMW2tXQambS1KPRbEEn2iP92s/s1652/6.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="484" data-original-width="1652" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNLPbHGaF1Yjy5mZMCaDmBTKktWRVPfwQlSiVjHp3ya2vVlHeL687a0Kn02lZ2u33VNuL1Sv6Dvy6mrvfEbEh9eK0wVhxEu3i3nCtnLif0R4vDczF0VgWaJJBdwm1nY9rL4l3ttY0khDgSI6Ke4RvT7ymqPF1BDgs2WroMW2tXQambS1KPRbEEn2iP92s/w606-h178/6.png" width="606" /></span></a></div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The following
day the patient had non-urgent angiogram: 95% circumflex occlusion (not fully occluded due to some spontaneous reperfusion in those intervening 20 hours), with <b>peak
troponin >65,000 ng/L (this is a huge infarct).</b><span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";"><span> </span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Discharge
diagnosis was still “non-STEMI” based on the initial ECGs – despite the
diagnostic 12 lead, transient STE on posterior lead, echo findings and massive
troponin elevation. <span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Discharge ECG
showed normalization of anterior segments.<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkrKspyjYmxYjG0m23tmDR6RXpaPa3yjQ2C-b4eHsZ-6ZWk_Oqj2OnczPONH7kjU_PJpRO9Qbssp4Ms7sMphh8P3r9Kgwkh6Izvb5rvmN8Jf_o8puzKnnVGsITvRew7I_cfVs2k12eFX56f5MJSF361ls4wK3VGJE_Cgf3WwgHB3VJOAJCYZTup45Zh1Q/s1634/7.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="504" data-original-width="1634" height="184" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkrKspyjYmxYjG0m23tmDR6RXpaPa3yjQ2C-b4eHsZ-6ZWk_Oqj2OnczPONH7kjU_PJpRO9Qbssp4Ms7sMphh8P3r9Kgwkh6Izvb5rvmN8Jf_o8puzKnnVGsITvRew7I_cfVs2k12eFX56f5MJSF361ls4wK3VGJE_Cgf3WwgHB3VJOAJCYZTup45Zh1Q/w594-h184/7.png" width="594" /></span></a></div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>'Working diagnosis' vs 'final diagnosis'?<span></span></b></span><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The new ESC
guidelines has for the first time merged both STEMI and non-STEMI in the same
guideline because they are both on the spectrum of ACS. They have also
recommended differentiating between the initial “working diagnosis” of STEMI vs
non-STEMI vs the “final diagnosis” based on troponin, echo and angio. </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">This is a helpful starting point to separate the initial tests from the actual patient outcome. But as an <a data-saferedirecturl="https://www.google.com/url?q=https://www.powerfulmedical.com/blog/acs-guidelines-update-2023-esc-omi&source=gmail&ust=1707421721606000&usg=AOvVaw1Ygg_VkSuIHtrPX2_X45wJ" href="https://www.powerfulmedical.com/blog/acs-guidelines-update-2023-esc-omi" style="color: blue; text-decoration: underline;" target="_blank">analysis</a>
by Dr. Robert Herman explained, “Although coronary angiography and further
diagnostic testing establish the presence of an occlusive or flow-limiting
lesion as a culprit for the present symptoms, the guidelines continue to give a 'final diagnosis' based on inaccurate ECG terminology (ST-elevation and
Non-ST-Elevation Myocardial Infarction). This reinforces the logical fallacy of
the STEMI vs. NSTEMI paradigm called the 'No False Negative Paradox,' in which
no NSTEMI patient can ever be recognized as a false negative for OMI,
regardless of their underlying pathology or their benefit from emergent
reperfusion.”<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">In this case all
investigations – ECG, echo, peak trop, and angio – confirmed OMI, but the
‘working diagnosis’ never changed. But the very first test could have
identified OMI at triage, before the first troponin was back, and reduced
reperfusion delay by two days. </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><br /></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><b>I sent the first ECG to Smith and Meyers without any clinical information or comparison to prior ECG, and they both immediately identified posterior OMI.<br /></b></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><br /></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The Queen of Hearts had the same interpretation: <span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijamj6xZMJVEgVqsOrKzi115QgXTw8y2Lk0ghVScWIDZrtg6lNlC2WKFW2eKwzeZcCJNzhulzYtGC5PLZC1EUkDWIOhRxRn7hoKJDlvQurreCbiB2wjc7Amv57R5Ylm4zSojcJ9O4ZqmNmk-BZtr636LGZaqcPgAq3-rcLuYWRMEPF7jenmFolNN3dyVw/s560/8.jpeg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="337" data-original-width="560" height="386" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijamj6xZMJVEgVqsOrKzi115QgXTw8y2Lk0ghVScWIDZrtg6lNlC2WKFW2eKwzeZcCJNzhulzYtGC5PLZC1EUkDWIOhRxRn7hoKJDlvQurreCbiB2wjc7Amv57R5Ylm4zSojcJ9O4ZqmNmk-BZtr636LGZaqcPgAq3-rcLuYWRMEPF7jenmFolNN3dyVw/w640-h386/8.jpeg" width="640" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium; text-shadow: none;">This is for the version housed on Telegram:</span></span></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"></span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></a></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><b style="text-shadow: none;">You can get the full PM Cardio app here if you live in the UK or EU (or say you do upon registration):</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="font-size: medium; text-shadow: none;"><a href="https://qrco.de/bebW8d" style="color: #2066f5; text-decoration-line: none; text-shadow: none;">https://qrco.de/bebW8d</a></span></div></span></div><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b><br /></b></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: large;"><b>Take home<span></span></b></span></p><span style="font-size: large;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>1.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> I</span></span></span>schemic STDmaxV1-4 is highly specific for
posterior OMI, without the need for posterior leads.<span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>2.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> P</span></span></span>osterior leads can be falsely negative and lead to missing an OMI<span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>3.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>‘NSTEMI’ triaged for non-urgent angio should be reconsidered if
there is dynamic ST changes, refractory ischemic, large troponin elevation, or
echo findings of RWMA<span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>4.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> T</span></span></span>o differentiate between ‘working’ and ‘final
diagnosis’ of ACS we need to shift to OMI paradigm to acknowledge missed occlusions retrospectively and work to identify them prospectively<br /></span></p><span style="font-size: medium;">
<span><span>5.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>Queen of Hearts can identify STEMI(-)OMI
</span>Jesse McLarenhttp://www.blogger.com/profile/05809707984126529952noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-79520402971439094712024-02-06T11:30:00.003-06:002024-02-06T12:53:41.741-06:00A teenager involved in a motor vehicle collision with abnormal ECG<p><span style="font-size: medium;">Written by Pendell Meyers</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">A teenager was involved in a motor vehicle collision and presented to the Emergency Department via EMS altered and potentially critically ill. He was intubated for altered mental status. Chest trauma was suspected on initial exam. </span></p><p><span style="font-size: medium;">Here is his initial ECG around 1330:</span></p><div style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoqJcoVx4ctDAsrOCJR2ScZ16BN2M_LETffV6GXi1-hfhSVyg3wVd28kJ7UOdUt_44pUBvVNEwjq5zKizs5qptomJtMV6j_K7kJ6-r-KdvGbJgvH10caofSfvCdYC4OgBWRLCPPPQCcoZNcw34SKqX73CCvLyJrFemycY9gHjuCNOfHBStowLsZQffNtCW/s1559/ed1%201346.png" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="826" data-original-width="1559" height="340" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoqJcoVx4ctDAsrOCJR2ScZ16BN2M_LETffV6GXi1-hfhSVyg3wVd28kJ7UOdUt_44pUBvVNEwjq5zKizs5qptomJtMV6j_K7kJ6-r-KdvGbJgvH10caofSfvCdYC4OgBWRLCPPPQCcoZNcw34SKqX73CCvLyJrFemycY9gHjuCNOfHBStowLsZQffNtCW/w640-h340/ed1%201346.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">What do you think?</span></td></tr></tbody></table><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. It is very unlikely that a previously healthy teenager would have such disease of the conduction system, bringing up the possibility of blunt cardiac injury in this clinical setting.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Trauma CTs showed a "mildly displaced sternal fracture and a small retrosternal hematoma." There were no radiographic injuries noted in the head/spine/abdomen/pelvis CTs.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><span style="font-size: medium;">Initial high sensitivity troponin I: 3,830 ng/L (URL 20 ng/L for men)</span><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">1445:</span></div><div><div style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNoVENgxwFuBagW-AB8ipXNQ2RJY6qSVZ4qypTkIfw8Luqvts7rA9FN46mhq4_OBK5RLg_okZ5jqYFyBAu5cPZaXxr3MZSF76ljxdjNHYu0aITNEdq_BSeRmo4_AtAXTQ14zKOVOJa6TL2Zfx6-BZ3JuymIaQT8LCsWqc3qkLPCiDHU5xzr0UQcO8Al_b9/s2007/ed2%201443.png" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="964" data-original-width="2007" height="308" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNoVENgxwFuBagW-AB8ipXNQ2RJY6qSVZ4qypTkIfw8Luqvts7rA9FN46mhq4_OBK5RLg_okZ5jqYFyBAu5cPZaXxr3MZSF76ljxdjNHYu0aITNEdq_BSeRmo4_AtAXTQ14zKOVOJa6TL2Zfx6-BZ3JuymIaQT8LCsWqc3qkLPCiDHU5xzr0UQcO8Al_b9/w640-h308/ed2%201443.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">Similar to initial ECG.</span></td></tr></tbody></table><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">1520:</span></div><div style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWixtCOJTLRo4fbr1Bxr6uE32P6-lccn_1mz4m360cbzkLtmYIpUMPqgI6txq5CaF0yZCkqE5SbDfyexvOyk_4-7-rc8pMuPCR4Nu5FBcJyXBJ6lfI9HWCKeYF-OFTX9fy-eeb7i5PkrJMpT7DTbdz-bb6XlUxab39q2QkY_5EngATyVyF7hbB7SDXnEmS/s844/ed3%201521.png" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="345" data-original-width="844" height="262" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWixtCOJTLRo4fbr1Bxr6uE32P6-lccn_1mz4m360cbzkLtmYIpUMPqgI6txq5CaF0yZCkqE5SbDfyexvOyk_4-7-rc8pMuPCR4Nu5FBcJyXBJ6lfI9HWCKeYF-OFTX9fy-eeb7i5PkrJMpT7DTbdz-bb6XlUxab39q2QkY_5EngATyVyF7hbB7SDXnEmS/w640-h262/ed3%201521.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">The QRS has narrowed slightly, but the morphology is similar.</span></td></tr></tbody></table><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuRNS-w6U-ra1Qo-vlXMJW7ZYX45rbZEWsomm4JQ2y3AJN5fuu64NeOsBYPhruQqpNMfa9xzcO9YDeCPicZGTseIdJ3MOqyaweIjDnc5sgBhZIcBftEs7eTNwCYLj7o39Sg5q_gQImVt_7oWBCqDpuJ8E6B9xpKdDzZmUAqFeo8Mfzk2NaFQcXqLR7KvQE/s844/ed3%201521.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"></span></a></div></td></tr></tbody></table><br /><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Troponins:</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">3,830 ng/L</span></div><div><span style="font-size: medium;">4,098 ng/L</span></div><div><span style="font-size: medium;">1,343 ng/L</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Echo:</span></div><div><span style="font-size: medium;">LV: normal cavity size and thickness. Systolic function is mildly reduced by visual assessment. EF 45%, with mild global hypokinesis. </span></div><div><span style="font-size: medium;">RV: Cavity size normal. Systolic function normal by visual assessment only, unable to visualize well for further characterization.</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><span style="font-size: medium;">1900:<br /></span><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi20S4Xdc69BRlumxf1xio3LZQuFUPf5sosOM3jOhVqBkWks9gzefhNlZB2FLBxO1hbgvZd0tf3QJ-_qbTNcW-C9FSe1913wtwsGrH-gqONN6aItNOLsWqG7GIauAm8_1jpbV_Kf3X1u5VlYnqkYvFZdEarD4o85fG_g9jHaC2TiuNhrgtngPQS4OBm0hQC/s846/ed4%201905.png" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="348" data-original-width="846" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi20S4Xdc69BRlumxf1xio3LZQuFUPf5sosOM3jOhVqBkWks9gzefhNlZB2FLBxO1hbgvZd0tf3QJ-_qbTNcW-C9FSe1913wtwsGrH-gqONN6aItNOLsWqG7GIauAm8_1jpbV_Kf3X1u5VlYnqkYvFZdEarD4o85fG_g9jHaC2TiuNhrgtngPQS4OBm0hQC/w640-h264/ed4%201905.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">RBBB and LAFB are almost fully resolved.<br /><br /></span></td></tr></tbody></table></td></tr></tbody></table><br /><span style="font-size: medium;"><br /></span></div><span style="font-size: medium;">2300:<br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFrcSgkKIiIzDDYKbujse3uH-sEv5HxD-nOUASMry6gQc8_Z56CB5_RuTsgZY_zCqpSe9tLr0x1gQpYcB-ObK6cCNl4O9NDEn2Vqa5FpokZggXql-RxQH1h0WfjPwH_08YLl5iAry0qcbEgxPP7HZMp1tlZE3dzZkVbsdYfHl70wEoo65VCS7E053YSru9/s2005/ed5%20last.png" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="940" data-original-width="2005" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFrcSgkKIiIzDDYKbujse3uH-sEv5HxD-nOUASMry6gQc8_Z56CB5_RuTsgZY_zCqpSe9tLr0x1gQpYcB-ObK6cCNl4O9NDEn2Vqa5FpokZggXql-RxQH1h0WfjPwH_08YLl5iAry0qcbEgxPP7HZMp1tlZE3dzZkVbsdYfHl70wEoo65VCS7E053YSru9/w640-h300/ed5%20last.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">QRS now within normal limits.</span></td></tr></tbody></table><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXuR1BYCl26hXhqzWhzajJAl62QO4VQI1sd1h4EUeRwVIVsu4f4wV9S5olYfU1ym87sFutXXAA8GHsclJzwGemqfxloFBEBT-trY84oWapWMf-YGsFCOPHN65DwU9bINhW_Ifebtq9SyRFJU4MQQSDOHuvgYUIjd75xcIcWj99-DtakoXdDG2DFb74k0sG/s2005/ed5%20last.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"></span></a></div><span style="font-size: medium;"><br style="text-align: left;" /></span></td></tr></tbody></table><br /><div style="text-align: center;"><br /></div></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">No other significant injuries were found. The patient did well and was discharged. No cardiac MRI was done. Hopefully a repeat echocardiogram will be performed outpatient. </span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><div style="text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">See our other cases of myocardial contusion and related cases (some of which have an important diagnosis OTHER THAN myocardial contusion!):</span></span></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><p><span style="font-size: medium;"></span></p><div style="text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="font-size: medium;"><span style="background-color: #fcff01; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2012/07/right-bundle-branch-block-after-blunt.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">A Child with Blunt Trauma</a> -- See how the ECG can be definite for myocardial contusion, but subtle, and what happens if you miss it. </span><span style="background-color: white; text-shadow: none;"> </span></span></h3><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2020/07/massive-transfusion-for-motorcycle.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Massive Transfusion for Motorcycle Collision with Hemorrhage, Troponin Elevated.</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2015/12/ecg-of-pneumopericardium-and-probable.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">ECG of pneumopericardium and probable myocardial contusion shows typical pericarditis</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2014/04/male-in-30s-2-days-after-motor-vehicle.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Male in 30's, 2 days after Motor Vehicle Collsion, complains of Chest Pain and Dyspnea</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2014/07/head-on-motor-vehicle-collision-st.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Head On Motor Vehicle Collision. ST depression. Myocardial Contusion?</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2012/08/gunshot-wound-to-chest-with-st-elevation.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Gunshot wound to the chest with ST Elevation</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2022/01/would-your-radiologist-make-this.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Would your radiologist make this diagnosis, or should you record an ECG in trauma?</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2013/03/blunt-trauma-in-child.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Blunt Trauma in a Child</span></a></h3></div><div style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="text-shadow: none;"><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2019/10/40-something-male-in-head-on-motor.html" style="color: #29aae1; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">40-something male in a head-on Motor Vehicle Collision and Splenic Injury</span></a></h3></div></div><p><span style="font-size: medium;"></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2022/08/a-man-in-his-40s-with-multitrauma-from.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">A man in his 40s with multitrauma from motor vehicle collision</span></a></h3><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><p><span style="font-size: medium;">Here is some information on blunt cardiac injury from one of our prior posts:</span></p><p><span style="font-size: medium;"><br /></span></p><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">The EKG is not generally sensitive for cardiac contusion. The right ventricle comprises the majority of the anterior heart which is most susceptible to direct injury in blunt chest trauma. Cardiac contusion can manifest on the ECG in a number of ways, including: ST segment elevation or depression, prolonged QT, new Q waves, conduction disorders such as RBBB, fascicular block, atrioventricular (AV) nodal conduction disorders (1,2, and 3 degree AV block), and arrhythmias such as sinus tachycardia, atrial and ventricular extrasystoles, atrial fibrillation, ventricular tachycardia, ventricular fibrillation, sinus bradycardia, and atrial tachycardia (Sybrandy). RBBB in blunt chest trauma seems to be indicative of several RV injury. Atrial fibrillation is also a predictor of worse outcomes in this case (Alborzi).<br style="text-shadow: none;" /><br style="text-shadow: none;" />See <a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C50&q=bundle+branch+block+and+myocardial+contusion&btnG=" style="color: #2066f5; text-decoration-line: none; text-decoration: none; text-shadow: none;" target="_blank">these publications</a> for more information</span></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><span style="text-shadow: none;"><br style="text-shadow: none;" />Overall, management for cardiac contusion is mostly supportive unless surgical complications develop, involving appropriate treatment of dysrhythmias and hemodynamic instability. Ultimately, a normal ECG and normal troponin at 4-6 hours from initial traumatic incident is highly predictive of a lack of future cardiac complications in blunt chest trauma.</span> <span style="text-shadow: none;">Between 81-95% of life-threatening ventricular dysrhythmias and acute cardiac failure occur within 24-48 hours of hospitalization. Troponins and EKGs should be trended until normalization (Sybrandy). </span></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><p><span style="font-size: medium;"></span></p><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><span style="text-shadow: none;"><b style="text-shadow: none;">Delayed cardiac rupture</b> is a potential consequence, especially if there is any ST Elevation. See <a href="https://www.injuryjournal.com/article/S0020-1383(01)00105-X/abstract" style="color: #2066f5; text-decoration-line: none; text-decoration: none; text-shadow: none;">this case</a>, <a href="https://www.sciencedirect.com/science/article/pii/S1752928X11001624" style="color: #2066f5; text-decoration-line: none; text-decoration: none; text-shadow: none;">this case</a>, and <a href="http://hqmeded-ecg.blogspot.com/2012/07/right-bundle-branch-block-after-blunt.html" style="color: #2066f5; text-decoration-line: none; text-decoration: none; text-shadow: none;">this case</a>. In patient's at risk, physical activity should be limited for several months after the injury.<br style="text-shadow: none;" /></span><br style="text-shadow: none;" /><br style="text-shadow: none;" /><br style="text-shadow: none;" /><br style="text-shadow: none;" /><span style="text-shadow: none;"><b style="text-shadow: none;"><u style="text-shadow: none;">References<br style="text-shadow: none;" /></u></b><br style="text-shadow: none;" />Alborzi, Z., Zangouri, V., Paydar, S., Ghahramani, Z., Shafa, M., Ziaeian, B., Radpey, M. R., Amirian, A., & Khodaei, S. (2016, April 13). Diagnosing myocardial contusion after blunt chest trauma. The journal of Tehran Heart Center. Retrieved July 2, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027160/<br style="text-shadow: none;" /><br style="text-shadow: none;" />Moyé, D. M., Danielle M. Moyé From the Division of Cardiology, Dyer, A. K., Adrian K. Dyer From the Division of Cardiology, Thankavel, P. P., Poonam P. Thankavel From the Division of Cardiology, & The Data Supplement is available at http://circimaging.ahajournals.org/lookup/suppl/doi:10.1161/CIRCIMAGING.114.002857/-/DC1.Correspondence to Poonam Punjwani Thankavel. (2015, March 1). Myocardial contusion in an 8-year-old boy. Circulation: Cardiovascular Imaging. Retrieved July 2, 2022, from https://www.ahajournals.org/doi/10.1161/CIRCIMAGING.114.002857<br style="text-shadow: none;" /><br style="text-shadow: none;" />Sybrandy, K. C., Cramer, M. J. M., & Burgersdijk, C. (2003, May). Diagnosing cardiac contusion: Old Wisdom and new insights. Heart (British Cardiac Society). Retrieved July 2, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767619/ </span></span></div><p><span style="font-size: medium;"><br /></span></p><div style="text-align: justify;"><div style="background-color: white;"><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><div class="separator" style="caret-color: rgb(0, 0, 0); clear: both; color: black; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div><br /></div><div><br /></div></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>2/6</i></span><span style="color: #454545;"><i>/2024</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div><span style="font-family: arial; font-size: medium;">Today's case by Dr. Meyers provides insight with regard to sequential evolution of serial ECGs during the course of <b><i>cardiac</i></b> <b>contusion</b>.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">For clarity in <u style="font-weight: bold;">Figure-1</u> — I've reproduced and labeled a number of findings in the initial ECG from today's case.</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><u><span style="font-family: arial; font-size: medium;">The <i>Initial</i> ECG in <i>Today's</i> Case:</span></u></b></div><div><span style="font-family: arial; font-size: medium;">As per Dr. Meyers — the initial ECG in today's case shows <b><i>sinus</i></b> <b>tachycardia</b> with <b><i><u>bifascicular</u></i></b> <b>block ( </b>= <i>RBBB/LAHB</i><b>)</b>. Especially in view of Dr. Meyers point that a previously healthy teenager would be unlikely to manifest such significant ECG abnormalities — I thought there were a number of additional ECG indicators of injury severity. These include:</span></div><div><ul><li><span style="font-family: arial; font-size: medium;"><b><i>Marked</i></b> <b>fragmentation</b> of the QRS complex in <b>lead V1</b> — which rather than manifesting a clear triphasic rsR' complex expected when RBBB occurs in an otherwise healthy young adult — shows an all positive and slurred upright and <b><i>markedly</i></b> <b>widened (</b><i>to ≥0.16 second</i><b>)</b> complex in this lead <b>(</b><i>within the RED oval in </i><u>Figure-1</u><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><i>Small-but-present</i> <b><i>initial</i></b> <b>Q waves</b> are seen in 4/6 chest leads <b>(</b>ie, <i>in leads V2,V3,V4,V5 — as per the RED arrows in </i><u>Figure-1</u><b>)</b>. Q waves in association with RBBB are usually <u style="font-style: italic;">not</u> seen in anterior leads unless there is pulmonary hypertension or anterior infarction.</span></li><li><span style="font-size: medium;"><span style="font-family: arial;">Although ST-T wave appearance in <u>Figure-1</u> is unlikely to be the result of an acute OMI in today's previously healthy teenage trauma victim — I thought at least 4/12 leads in <u>ECG #1</u> manifested <b>potentially <i><u>hyperacute</u></i> changes</b>, i</span><span style="font-family: arial;">ncluding:</span><span style="font-family: arial;"> </span><b style="font-family: arial;">i<span style="color: red;">)</span></b><span style="font-family: arial;"> The ST-T wave in</span><span style="font-family: arial;"> </span><b style="font-family: arial;">lead V1</b><span style="font-family: arial;"> </span><span style="font-family: arial;">looks disproportionately deep, with depth of T wave inversion comparable to height of the R wave in this lead</span><span style="font-family: arial;"> </span><b style="font-family: arial;">(</b><i style="font-family: arial;">within the BLUE rectangle in Figure-1</i><b style="font-family: arial;">)</b><span style="font-family: arial;">;</span><span style="font-family: arial;"> </span><u style="font-family: arial;">and</u><span style="font-family: arial;">,</span><span style="font-family: arial;"> </span><b style="font-family: arial;">ii<span style="color: red;">)</span></b><span style="font-family: arial;"> The ST segment takeoff in</span><span style="font-family: arial;"> </span><b style="font-family: arial;">leads V4</b><span style="font-family: arial;">,</span><span style="font-family: arial;"> </span><b style="font-family: arial;">V5</b><span style="font-family: arial;">, and</span><span style="font-family: arial;"> </span><b style="font-family: arial;">V6</b><span style="font-family: arial;"> is straightened, having lost the normal slight, gentle upsloping of chest lead ST segments</span><span style="font-family: arial;"> </span><b style="font-family: arial;">(</b><i style="font-family: arial;">within the BLUE rectangles in these leads</i><b style="font-family: arial;">)</b><span style="font-family: arial;">. The ST-T wave in leads V5,V6 looks to be</span><span style="font-family: arial;"> </span><b style="font-family: arial;"><i>disproportionately</i> large (</b><span style="font-family: arial;">ie,</span><span style="font-family: arial;"> </span><i style="font-family: arial; font-weight: bold;">hyperacute</i><span style="font-family: arial;"><b>) </b>given QRS amplitude in these leads.</span></span></li></ul></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSZtxOwfojjZn_6y8CwetL7osLO1VxpOPruPETU4PJzSQJojeR4AcyMryO3tSrOwACa_dMe_ix-rQf66f-Ge2821l-ejhpZ9yJ9IVtfHUpYO6xggkO7SFaI5tPg6XO4qf9F1b4w20YVOBNLsleT6HZFPP4Y98rvuwH9WCQGYpkOJdv3eiABHNqfOpGiac/s3788/Figure-1%20%20ECG-1%20labeled%20%20(2-4.22-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1812" data-original-width="3788" height="306" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSZtxOwfojjZn_6y8CwetL7osLO1VxpOPruPETU4PJzSQJojeR4AcyMryO3tSrOwACa_dMe_ix-rQf66f-Ge2821l-ejhpZ9yJ9IVtfHUpYO6xggkO7SFaI5tPg6XO4qf9F1b4w20YVOBNLsleT6HZFPP4Y98rvuwH9WCQGYpkOJdv3eiABHNqfOpGiac/w640-h306/Figure-1%20%20ECG-1%20labeled%20%20(2-4.22-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><span><b style="text-align: justify;"><u>Figure-1:</u></b><span style="text-align: justify;"> </span></span><span>The <b><i><u>initial</u></i></b> <b>ECG</b> in today's case.</span></span></td></tr></tbody></table><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><div><span style="font-family: arial; font-size: medium;"><b><u>What are the ECG Findings of Cardiac Contusion?</u></b></span></div><div><span style="font-family: arial; font-size: medium;"><span>I've copied <i>KEY</i> points from <i>My Comment </i>in the <b><a href="https://hqmeded-ecg.blogspot.com/2022/08/a-man-in-his-40s-with-multitrauma-from.html" target="_blank">August 6, 2022</a> post</b> in Dr. Smith's ECG Blog — regarding the answer to this question.</span></span></div><div><ul><li><b>The ECG is <i><u>less</u></i> than optimally sensitive for detecting cardiac injury following blunt trauma</b><span style="font-family: arial;">. This is because the anterior anatomic position of the RV (</span><i><u>R</u>ight <u>V</u>entricle</i><span style="font-family: arial;">), and its immediate proximity to the sternum — </span><b>makes the RV much <i><u>more</u></i> susceptible to blunt trauma injury than the LV</b><span style="font-family: arial;">. </span></li><li><span style="font-family: arial;"><u style="font-weight: bold;">CAVEAT:</u> Although the RV is much more susceptible to blunt trauma injury than the LV — Because of the much greater electrical mass of the LV, electrical activity <b>(</b></span><i>and therefore ECG abnormalities</i><span style="font-family: arial;"><b>) </b>from the much smaller and thinner RV are more difficult to detect.</span></li></ul></div><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;"><br /></span></div><div><b>To REVIEW (</b><span style="font-family: arial;">Sybrandy et al: </span><b><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767619/pdf/hrt08900485.pdf" target="_blank">Heart 89:485-489, 2003</a></b><span style="font-family: arial;"> — Alborzi et al: </span><b><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027160/pdf/JTHC-11-49.pdf" target="_blank">J The Univ Heart Ctr 11:49-54, 2016</a></b><span style="font-family: arial;"> — and Valle-Alonso et al: </span><b><a href="https://www.sciencedirect.com/science/article/pii/S0185106316300646" target="_blank">Rev Med Hosp Gen Méx 81:41-46, 2018</a>)</b><span style="font-family: arial;"> — </span><b><i>ECG findings commonly reported</i></b><span style="font-family: arial;"> in association with </span><b><i><u>Cardiac</u></i></b><span style="font-family: arial;"> </span><b><u>Contusion</u></b><span style="font-family: arial;"> include the following:</span></div></span></div><div><span style="font-family: arial; font-size: medium;"><div><span style="font-family: arial; font-size: medium; text-align: left;"><div style="text-align: justify;"><ul><li><b><br /></b></li><li><b>None (</b>ie, <i>The ECG may be normal — such that not seeing any ECG abnormalities does <u>not</u> rule out the possibility of cardiac contusion</i><b>).</b></li><li><b>Sinus Tachycardia (</b><i>common in any trauma patient ...</i><b>)</b>.</li><li><b><i><u>Other</u></i></b> <b>Arrhythmias (</b><i>PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib</i><b>)</b>.</li><li><b>RBBB (</b><i>as by far the <u>most</u> <u>common</u> conduction defect — owing to the more vulnerable anatomic location of the RV</i><b>)</b>. Fascicular blocks and LBBB are less commonly seen.</li><li>Signs of <b><i>Myocardial</i></b> <b>Injury (</b>ie, <i>Q waves, ST elevation and/or depression — with these findings suggesting LV involvement</i><b>)</b>.</li><li><b>QTc prolongation</b>.</li><li><br /></li><li><b><u>NOTE:</u></b> Prediction of cardiac contusion "severity" on the basis of cardiac arrhythmias and ECG findings — is an <i><u>imperfect</u></i> science.</li></ul></div></span><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><b><u>Additional <i>KEY</i> Points:</u></b></span></div><div><span style="font-family: arial; font-size: medium;">Despite the predominance for RV (<i>rather than LV</i>) injury — <b>use of a <i>right-sided</i> V4R lead has <i><u>not</u></i> been shown to be helpful</b> compared to use of a standard 12-lead ECG for detecting ECG abnormalities.</span></div></div><div><ul><li><span style="font-family: arial;">In addition to ECG abnormalities related to the blunt trauma of cardiac contusion itself — Keep in mind the possibility of </span><b><i><u>other</u></i> forms of cardiac injury </b><span style="font-family: arial;">in these patients </span><b>(</b><span style="font-family: arial;">ie, </span><i>valvular injury, aortic dissection, septal rupture</i><b>)</b><span style="font-family: arial;"> — as well as the possibility of a </span><b><i>primary</i> cardiac event (</b><span style="font-family: arial;">ie, </span><i>acute MI may have been the <u>cause</u> of an accident that led up to the trauma</i><b>)</b><span style="font-family: arial;">.</span></li><li><b>ECG abnormalities may be <i><u>delayed</u></i></b><span style="font-family: arial;"> — so </span><i>repeating</i><span style="font-family: arial;"> the ECG if the 1st tracing is normal </span><u><i>is</i></u><span style="font-family: arial;"> appropriate when concerned about severe traumatic injury.</span></li><li><span style="font-family: arial;">That said </span><span style="font-family: arial;">— </span><b>IF troponin is normal at 4-6 hours </b><i><u>and</u></i><b> IF the ECG is normal — then the risk of cardiac complications is extremely low</b><span style="font-family: arial;">.</span></li></ul></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><b><u>Final COMMENT:</u></b> While the literature does not provide us with specific ECG criteria for assessing severity of cardiac contusion — <b>today's case <i><u>does</u></i> provide insight as to how clinical correlation with serial ECGs <i><u>can</u></i> confirm that the patient is recovering</b>.</span></div><div><ul><li>I've noted above the plethora of distinct ECG abnormalities associated with today's initial tracing. As per Dr. Meyers — <b><i>all ECG abnormalities normalized</i></b> over the course of 5 sequential tracings.</li><li>As abnormal as the initial ECG was in <u>Figure-1</u> — the final ECG in today's case was a normal tracing, which correlated with dramatic improvement in the patient's condition, resulting in ultimate discharge home from the hospital.</li></ul></div></span></div></div></div></div><p><span style="font-size: medium;"></span></p><div style="text-align: justify;"><div style="font-family: arial; text-align: left;"><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div style="text-align: center;"> </div><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div></div></div><p><br /></p></div>Pendellhttp://www.blogger.com/profile/06506068475871794508noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-35516955264545201422024-02-04T13:06:00.000-06:002024-02-04T13:06:58.667-06:00What will happen if you implement the Queen of Hearts in your Hospital?<p><span style="font-size: medium;">This case was sent by Dr. Jean-christophe Reiters, an interventionalist in Belgium. He has been following the blog for 4 years.</span></p><p><span style="font-size: large;"><b>He has now implemented the Queen of Hearts in his hospital. </b></span></p><p><span style="font-size: medium;">He wanted to share one of the first cases.</span></p><p><span style="font-size: medium;">A 55 year old with no previous cardiac history presented with 3 hours of chest pain. The pain was persistent and reportedly still present at the time of the ECG.</span></p><p><span style="font-size: large;">Here is the EKG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdIDtOZjHXWAzjIjXni9vPNpvQ5QDqLsjjCbpnoCP99rC5MPi8tg__luD5h7VPHL4r5YkoC6whKUkBmzK_jwirs_XpWDo9vsD9RVgTQYe9kEuEGnmUyphIB0sNPFevNFC9F0BZbUkGkqxAuC806VhrHXEVffDL-w5aZeFwpAMfFf_4z1vrq6qmef-T6b9W/s1504/First%20ECG.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1125" data-original-width="1504" height="478" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdIDtOZjHXWAzjIjXni9vPNpvQ5QDqLsjjCbpnoCP99rC5MPi8tg__luD5h7VPHL4r5YkoC6whKUkBmzK_jwirs_XpWDo9vsD9RVgTQYe9kEuEGnmUyphIB0sNPFevNFC9F0BZbUkGkqxAuC806VhrHXEVffDL-w5aZeFwpAMfFf_4z1vrq6qmef-T6b9W/w640-h478/First%20ECG.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><b>Smith</b>: It looks like a reperfused inferior lateral OMI. (Inverted T-waves in inferior and lateral leads, with reciprocally upright (pseudo-hyperacute) T-waves in I and aVL. But if the pain is persistent, as reported, then the patient must go to the cath lab even if the ECG suggests reperfusion.</span></p><p><span style="font-size: medium;">The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria.</span></p><p><span style="font-size: medium;">Dr. Reiters wrote: "I was worried about hyperacute T-waves in leads I, aVL and V2, and perhaps a reperfused infero-lateral OMI because of the Wellens'-like waves in inferolateral leads. I was not confident that it was OMI, but because of the persistent pain I used the PM Cardio app with Queen of Hearts interpretation:</span></p><p><br /></p><p><span style="font-size: medium;"><b>This is from the PM Cardio app (in contrast to the Queen of Hearts on Telegram). The app is fully approved for clinical use in Europe, and has both the Queen of Hearts and 38 other diagnoses, such as LVH, rhythm diagnoses, etc.</b></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkNQj71f04PIwwF_IDdyri53IiuOQsw6R1pJlkkNdYO2xDLGNIR2IKpiT92f7KQg3MF0CTDc_rzw7iZmUGFnMzh6KVx0PQlfFfE1rLHbxPipwy-FNWv-_triQjgYOt62EeR4exJdDM9y00WduZb99NDkrE1XlQb5S7NZONjih_QE1-HBDp-XmDcFqu0cAX/s1114/Queen%20diagnosis.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1114" data-original-width="1083" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkNQj71f04PIwwF_IDdyri53IiuOQsw6R1pJlkkNdYO2xDLGNIR2IKpiT92f7KQg3MF0CTDc_rzw7iZmUGFnMzh6KVx0PQlfFfE1rLHbxPipwy-FNWv-_triQjgYOt62EeR4exJdDM9y00WduZb99NDkrE1XlQb5S7NZONjih_QE1-HBDp-XmDcFqu0cAX/w622-h640/Queen%20diagnosis.png" width="622" /></span></a></div><span style="font-size: medium;"><br /></span><p><b><span style="font-size: medium;">Translation from French: Acute Occlusion Myocardial Infarction with High Confidence.</span></b></p><p><span style="font-size: medium;">(The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH)</span></p><p><span style="font-size: medium;"><b>Note on version 1 of the Queen: </b>she will diagnose "OMI" whether it is an active or reperfused OMI. This will be corrected in Version 2, coming soon.</span></p><p style="text-align: center;"><span style="font-size: medium;">So he activated the cath lab based on the Queen of Hearts, and here is the angiogram </span><span style="font-size: large;">video:
</span><iframe allow="autoplay; fullscreen; picture-in-picture" allowfullscreen="" frameborder="0" height="360" src="https://player.vimeo.com/video/909737211?h=91b63313de&autoplay=1&loop=1&title=0&byline=0&portrait=0" width="640"></iframe></p><div style="text-align: center;"><span style="font-size: medium;">Dr Reiter's angiographic diagnosis: This is total occlusion of the proximal circumflex.</span></div><span style="font-size: medium;"><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><br /></span><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Now opened up:</span></div><span style="font-size: medium;"><span style="font-size: medium;"><div style="text-align: center;"><span style="text-align: left;"> </span><iframe allow="autoplay; fullscreen; picture-in-picture" allowfullscreen="" frameborder="0" height="360" src="https://player.vimeo.com/video/909735362?h=f34624075d&autoplay=1&loop=1&title=0&byline=0&portrait=0" width="640"></iframe></div></span></span><p style="text-align: left;"><span style="font-size: medium;"><br /></span></p><p style="text-align: left;"><span style="font-size: medium;">First troponin T returned after cath lab activation and was 400 ng/L</span></p><p style="text-align: left;"><span style="font-size: medium;">Peak high sensitivity troponin T was 5244 ng/L after rapid reperfusion</span></p><p><span style="font-size: medium;">LV EF was 50-55% with infero-lateral hypokinesis</span></p><p><span style="font-size: medium;">Final diagnosis: NSTEMI</span></p><p><b><span style="font-size: medium;">Dr. Reiter's Learning Points:</span></b></p><p><span style="font-size: medium;">OMI (+) STEMI (-)</span></p><p><span style="font-size: medium;">Saved at least one hour compared with using first troponin</span></p><p><span style="font-size: medium;">Saved 2 hours compared with European Society of Cardiology Guidelines.</span></p><p><span style="font-size: medium;"><br /></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="color: red; text-shadow: none;"><b style="text-shadow: none;"><span style="font-size: medium;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</span></b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;"><br /></span></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><span style="font-size: medium;">This is for the version housed on Telegram:</span></span></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-size: medium;"><span style="text-shadow: none;"></span></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-size: medium;"><span style="text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</span></a></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-size: medium;"><br /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-size: medium;"><b>You can get the full PM Cardio app here:</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><span style="font-size: medium;"><br /></span></div><div style="background-color: white; text-shadow: none;"><span face="Arial, Tahoma, Helvetica, FreeSans, sans-serif" style="color: #333333; font-size: medium;"><a href="https://qrco.de/bebW8d">https://qrco.de/bebW8d</a></span></div><div style="text-align: justify;"><div style="background-color: white;"><div style="font-family: arial;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div style="font-family: arial; text-align: center;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="caret-color: rgb(0, 0, 238); color: #0000ee; text-align: center; text-decoration: underline;" width="320" /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>2/4</i></span><span style="color: #454545;"><i>/2024</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div><span style="font-family: arial; font-size: medium;">Our appreciation to Dr. Jean-Christophe Reiters from Belgium — for his contribution to Dr. Smith’s ECG Blog. I’d add the following points from my perspective:</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">I find it <b><i><u>reassuring</u></i></b> when interpretation by the <b>QOH (</b><i><u>Q</u>ueen <u>O</u>f <u>H</u>earts</i><b>) AI application</b> comes to the same conclusion that I come to. Hopefully for other clinicians — this facilitates confidence for taking action on cases about which “the Answer” may <i><u>not</u></i> be initially clear.</span></li><li><span style="font-family: arial; font-size: medium;">The <b><u>QOH</u></b> application is both <b>international </b>in scope<b> (</b><i>Today’s case from Beligum</i><b>) </b>— and <b><i>continually</i></b> <b>improving (</b><i>Drs. Smith and Meyers forever adding cases to QOH’s already amazingly huge data base of ECGs — with clinical follow-up on these cases for this AI application to learn from</i><b>)</b>. This is in stark contrast to computer-based algorithms previously (<i>and still presently</i>) in use — which continue to regularly <i><u>over</u></i>- and <i><u>under</u>-diagnose</i> acute OMI <u style="font-style: italic;">without</u> possibility of improving their performance.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-size: medium;"><span style="font-family: arial;">The above said — I feel the “approach” for optimal use of QOH shares one essential similarity with <i><u>any</u></i> computer-enhanced application: <b>The clinician should assess the ECG himself/herself <u style="font-style: italic;">before</u> looking at QOH’s interpretation</b>. This sequence for assessment serves 2 <i>KEY</i> purposes: <b>i<span style="color: red;">)</span> It ensures the clinician will not be <u style="font-style: italic;">biased</u> by what QOH says</b>. This <u style="font-style: italic;">adds</u> the power of a 2nd opinion <b>(</b>ie, <i>The unbiased clinician interpretation <u>and</u> the QOH interpretation — rather than acceptance by blind faith of the QOH alone</i><b>); </b>—<b> </b><u>and</u>,<b> ii<span style="color: red;">)</span></b> The <i>BEST</i> way to improve one's ability in clinical ECG interpretation — is to <i><u>force</u></i> yourself to come up with your <i><u>own</u></i> interpretation <i><u>before</u></i> you look at what QOH says! After all, the ultimate goal is <i><u>both</u></i> t</span><span style="font-family: arial;">o</span><span style="font-family: arial;"> </span><b style="font-family: arial;">optimize care of the patient (</b><i style="font-family: arial;">by incorporating the “experience and wisdom” of the QOH application from her expertise in assessing the likelihood of acute OMI</i><b style="font-family: arial;">)</b><span style="font-family: arial;"> </span><span style="font-family: arial;">—</span><span style="font-family: arial;"> </span><u style="font-family: arial;">and</u><span style="font-family: arial;"> —</span><span style="font-family: arial;"> </span><b style="font-family: arial;"><i>to improve the abilities of practicing clinicians</i></b><span style="font-family: arial;"> </span><span style="font-family: arial;">so that their future care of patients continues to improve.</span></span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><u><span style="font-family: arial; font-size: medium;"><i>Regarding</i> Today’s <i>Initial</i> ECG:</span></u></b></div><div><span style="font-family: arial; font-size: medium;">As was later confirmed by cardiac cath — today’s ECG is <i><u>diagnostic</u></i> of <b>acute <i>infero-postero-lateral</i> OMI</b>, with ECG findings of <b>diffuse <i>reperfusion</i> T waves</b> at the time today’s initial ECG was recorded.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">For clarity in <u style="font-weight: bold;">Figure-1</u> — I’ve reproduced today’s <b><i><u>initial</u></i></b> <b>ECG</b>. There are obvious reperfusion T waves in <i>no less</i> than 10/12 leads.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><b><u style="font-style: italic;">Inferior</u> OMI: </b>Q waves are present in leads III and aVF. Although the Q in lead aVF is small — in proportion to the small QRS complex in this lead, this Q in aVF is clearly significant. ST segment coving with deep T wave inversion in leads II,III,aVF is consistent with reperfusion ST-T waves following new inferior OMI <b>(</b><i>being impossible to determine if the Q waves in III and aVF are from the current ongoing event — vs from prior inferior MI with superimposed new OMI</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">The T waves in high-lateral leads I and aVL are disproportionately tall and peaked. I interpreted this mirror-image opposite ST-T wave appearance (<i>compared to the ST-T wave in lead III</i>) — as reciprocal changes to the inferior lead reperfusion T waves.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><b><u style="font-style: italic;">Lateral</u> OMI: </b>The disproportionately deep, symmetric T wave inversion in leads V5,V6 suggest lateral reperfusion T waves following lateral OMI.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><b><u style="font-style: italic;">Posterior</u> OMI:</b> We often emphasize that the <i><u>normal</u></i> appearance of the ST-T wave in anterior leads V2,V3 — is for there to be slight ST elevation with gentle upsloping of the ascending ST segment in these leads. As a result — the ST segment straightening <i><u>without</u></i> any ST elevation, culminating in much taller and <i>more-peaked-than-they-should-be</i> T waves in leads V2 and V3 in <u>Figure-1</u> presents the <i>mirror-image</i> of inverted reperfusion T waves in anterior leads — which indicates <b><u style="font-style: italic;">posterior</u> OMI</b>, now in the reperfusion stage.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><u style="font-weight: bold;">NOTE:</u> Lead V4 shows ST segment flattening, with a trace of ST depression. I interpreted this appearance as simply reflecting that <b>lead V4</b> is a “transition lead” located in between the disproportionately tall and peaked T waves of leads V2,V3 — and the deep, symmetric T wave inversion of leads V5,V6.</span></li></ul></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixVlzuh8e3sts3bwxRL9MN7IuGwvfH1Gv-x-LggupxDOKxK3N7Y8P8WQ251TugvwvmYIPluePMPna6jG72kK-EbzDDJlaAUdSzSXjR1RjBBkjc6v8X-0cQhQwDb_jK-QITzVtQ-wYCstvIn9xOxJbKBJzRkbU3n_YQRsbfZKqHoOl1n9f2sQQKXpt2EeQ/s3788/Figure-1%20ECG-1%20(1-2.32-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1342" data-original-width="3788" height="226" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixVlzuh8e3sts3bwxRL9MN7IuGwvfH1Gv-x-LggupxDOKxK3N7Y8P8WQ251TugvwvmYIPluePMPna6jG72kK-EbzDDJlaAUdSzSXjR1RjBBkjc6v8X-0cQhQwDb_jK-QITzVtQ-wYCstvIn9xOxJbKBJzRkbU3n_YQRsbfZKqHoOl1n9f2sQQKXpt2EeQ/w640-h226/Figure-1%20ECG-1%20(1-2.32-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b style="text-align: justify;"><u>Figure-1:</u></b><span style="text-align: justify;"> </span><span>The <b><i><u>initial</u></i></b> <b>ECG</b> in today's case. </span><b>(</b><i>To improve visualization — I've digitized the original ECG using</i><span> </span><b><a href="https://www.powerfulmedical.com/" target="_blank">PMcardio</a>)</b><span>. </span></span></td></tr></tbody></table><span style="font-family: arial; font-size: medium;"><br /></span></div></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;">Our THANKS to Dr. Jean Christophe Reiters for sharing his case! </span></div><div style="font-family: -webkit-standard;"><span style="font-family: arial;"><br /></span></div></div></div><div style="font-family: arial; text-align: justify;"><div style="text-align: left;"><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"></span></div></div></div></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-74341646767531050472024-02-02T07:08:00.005-06:002024-02-02T07:30:15.632-06:00What is this ECG finding? Do you understand it before you hear the clinical context?<p><span style="font-size: medium;">Written by Pendell Meyers</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">First try to interpret this ECG with no clinical context:</span></p><p><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhm1KKoUPdWGaBOZHQWGKS_ca9kvDJLf1Iopyz74wLf_jHxJEHEGwzqsbQXCer1lYiLtuSJhXA6gBKnJ9f0ENmZEBNj-LT1jq2Rw-25JbPzIeIgbolpKMy_HAhP123bEheBWgZ9wWmtayd7ZSrO0RMXO8HR-DkWS6Y8FrkVgcq0RAz8QhSvparEKl_HKdnL/s1561/osborn%202.png" style="margin-left: 1em; margin-right: 1em; text-align: center;"><span style="font-size: medium;"><img border="0" data-original-height="841" data-original-width="1561" height="344" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhm1KKoUPdWGaBOZHQWGKS_ca9kvDJLf1Iopyz74wLf_jHxJEHEGwzqsbQXCer1lYiLtuSJhXA6gBKnJ9f0ENmZEBNj-LT1jq2Rw-25JbPzIeIgbolpKMy_HAhP123bEheBWgZ9wWmtayd7ZSrO0RMXO8HR-DkWS6Y8FrkVgcq0RAz8QhSvparEKl_HKdnL/w640-h344/osborn%202.png" width="640" /></span></a></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The ECG shows an irregularly irregular rhythm, therefore almost certainly atrial fibrillation. After an initially narrow QRS, there is a very large abnormal extra wave at the end of the QRS complex. These are Osborn waves usually associated with hypothermia. There is also large T wave inversion and long QT.</span></p><p><span style="font-size: medium;"><b>Clinical context:</b></span></p><p><span style="font-size: medium;">A man in his 50s was found down outside in the cold, unresponsive but with intact vital signs. </span></p><p><span style="font-size: medium;">He was intubated on arrival at the ED for mental status and airway protection due to vomiting. </span></p><p><span style="font-size: medium;">Initial vitals included heart rate 109 bpm and BP 145/92 mmHg. They reported that the rectal thermometer simply reported "low".</span></p><p><span style="font-size: medium;">Here is the initial ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTHADMg2IB6TZR6JX44olTSkqnSf27gEvhvq5bPF8hK22zaAYq1_-ZET7biYYNavuFaUfx5FAHgnmm0nWkSnfWsYUgrN52hfs3hs5HKYbyYNtODiBAlwmjb9ZTGexuLRquuyOa-33mhBXghlMUU1MBUSJAXKLFxP5RNKvTIzWJWSpZ99PPbGbs43fhb2Yx/s1558/osborn%20ekg.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="796" data-original-width="1558" height="326" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTHADMg2IB6TZR6JX44olTSkqnSf27gEvhvq5bPF8hK22zaAYq1_-ZET7biYYNavuFaUfx5FAHgnmm0nWkSnfWsYUgrN52hfs3hs5HKYbyYNtODiBAlwmjb9ZTGexuLRquuyOa-33mhBXghlMUU1MBUSJAXKLFxP5RNKvTIzWJWSpZ99PPbGbs43fhb2Yx/w640-h326/osborn%20ekg.png" width="640" /></span></a></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">A temperature sensing Foley was inserted and reported a core temperature of 26.7 C (80 F).</span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">15 minutes after the first ECG, the patient was noted to become bradycardic and hypotensive. Norepinephrine was started, and another ECG was recorded:</span></div><p style="text-align: center;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhm1KKoUPdWGaBOZHQWGKS_ca9kvDJLf1Iopyz74wLf_jHxJEHEGwzqsbQXCer1lYiLtuSJhXA6gBKnJ9f0ENmZEBNj-LT1jq2Rw-25JbPzIeIgbolpKMy_HAhP123bEheBWgZ9wWmtayd7ZSrO0RMXO8HR-DkWS6Y8FrkVgcq0RAz8QhSvparEKl_HKdnL/s1561/osborn%202.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="841" data-original-width="1561" height="344" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhm1KKoUPdWGaBOZHQWGKS_ca9kvDJLf1Iopyz74wLf_jHxJEHEGwzqsbQXCer1lYiLtuSJhXA6gBKnJ9f0ENmZEBNj-LT1jq2Rw-25JbPzIeIgbolpKMy_HAhP123bEheBWgZ9wWmtayd7ZSrO0RMXO8HR-DkWS6Y8FrkVgcq0RAz8QhSvparEKl_HKdnL/w640-h344/osborn%202.png" width="640" /></span></a></div><p></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The patient was rewarmed with external rewarming, heated humidified air via ventilator circuit, warm IV fluid, and Arctic sun device. </span></p><p><span style="font-size: medium;">His temperature was brought back to normal over time in the ICU. He was extubated and had normal neurologic function. He did well and was discharged.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;"><u style="text-shadow: none;"><span style="font-size: medium;">See our other blog posts of hypothermia and Osborn waves</span></u></b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="font-size: medium;">--<a href="https://hqmeded-ecg.blogspot.com/2015/01/massive-osborn-waves-of-severe.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; font-weight: normal; text-shadow: none;">Massive Osborn Waves of Severe Hypothermia (23.6 C), with Cardiac Echo</span></a></span></h3><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="font-size: medium;">--<a href="https://hqmeded-ecg.blogspot.com/2015/03/a-pathognomonic-ecg-what-is-it.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; font-weight: normal; text-shadow: none;">A Pathognomonic ECG. What is it?</span></a></span></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="font-size: medium;">--<a href="https://hqmeded-ecg.blogspot.com/2015/02/this-patient-was-found-outside-in-cold.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; font-weight: normal; text-shadow: none;">Hypothermia and Right Bundle Branch Block, with ST Elevation?</span></a></span></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="font-size: medium;">--<a href="https://hqmeded-ecg.blogspot.com/2014/11/read-this-ecg.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; font-weight: normal; text-shadow: none;">Read this ECG</span></a></span></h3></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><span style="font-family: times; font-weight: normal; text-shadow: none;"><span style="font-size: medium;">--<a href="https://hqmeded-ecg.blogspot.com/2011/11/osborn-waves-and-hypothermia.html" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; font-weight: bold; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">Osborn Waves and Hypothermia</a> (this is the "Figure" above)</span></span></h3><div><span style="font-family: times; font-weight: normal; text-shadow: none;"><span style="font-size: medium;"><br /></span></span></div></div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2022/01/what-does-lbbb-look-like-in-severe.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">What does LBBB look like in severe hypothermia? Is there a long QT? Is the QT appropriate for the temperature?</span></a></h3><div><span style="font-size: medium;"><br /></span></div><div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2020/01/how-would-you-manage-this-patient.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">How would you manage this patient?</span></a></h3></div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2018/02/altered-mental-status-bradycardia.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Altered Mental Status, Bradycardia</span></a></h3><p><br /></p><div style="text-align: justify;"><div style="text-align: left;"><div style="text-align: justify;"><div style="background-color: white;"><div style="font-family: arial;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div style="font-family: arial; text-align: center;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="caret-color: rgb(0, 0, 238); color: #0000ee; text-align: center; text-decoration: underline;" width="320" /></span></span></div><div style="font-family: arial;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>2/2</i></span><span style="color: #454545;"><i>/2024</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div><span style="font-family: arial; font-size: medium;">Dr. Meyers began today’s case with the clinical challenge of asking you to identify the underlying cause of <b><u>ECG #2</u></b>. This first tracing that Dr. Meyers shows in his discussion — was actually the 2nd ECG recorded in today’s case <b>(</b><i>For clarity in </i><u style="font-weight: bold;">Figure-1</u><i> — I’ve labeled both of the ECGs that were done in today’s case</i><b>)</b>.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">As per Dr. Meyers — today’s case is a “study” on <b><u style="font-style: italic;">Osborn</u> Waves</b>. We periodically review this intriguing ECG finding that is best known for its association with hypothermia — but which may also be seen in association with a number of other entities, including acute infarction and cardiac arrest. </span></li><li><span style="font-family: arial; font-size: medium;"><i>My Comment</i> addresses a few additional aspects of this phenomenon.</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjc2WVEqUR3RM_R05eFa-uH_bGrLJwenyUN0EroleGsxs5JjGmEGInMHbvjcI6Q0tJEXRYIPWJz83DjmRDOGtQ6P-nMDRVmIUU5IBC_bVF2gVE-EvoeDhwU3oB1Xu3xAdNFDj7cPdfO0sNdOgUbkBd0nka7avgty52C8IrjA0PUBegTddLv7dVmdKBxnw/s3092/Figure-1%20%20ECGs-2,1%20(2-1.21-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2756" data-original-width="3092" height="570" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjc2WVEqUR3RM_R05eFa-uH_bGrLJwenyUN0EroleGsxs5JjGmEGInMHbvjcI6Q0tJEXRYIPWJz83DjmRDOGtQ6P-nMDRVmIUU5IBC_bVF2gVE-EvoeDhwU3oB1Xu3xAdNFDj7cPdfO0sNdOgUbkBd0nka7avgty52C8IrjA0PUBegTddLv7dVmdKBxnw/w640-h570/Figure-1%20%20ECGs-2,1%20(2-1.21-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b><u>Figure-1:</u></b> I’ve reproduced and labeled the 2 ECGs in today’s case.</span></td></tr></tbody></table><div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium;"><br /></span></div></div><div><span style="font-family: arial; font-size: medium;"><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><i><u><span face="Arial, sans-serif"><br /></span></u></i></b></span></p><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><i><u><span face="Arial, sans-serif">OSBORN </span></u></i></b><b><u><span face="Arial, sans-serif">Waves:</span></u></b><span face="Arial, sans-serif"> </span></span></p><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><span face="Arial, sans-serif">By way of review — the Osborn wave has been described as a deflection with a dome or hump that occurs at the point where the end of the QRS complex joins with the beginning of the ST segment. This is the <b>J-Point (</b>ie, <i>it <b><u>J</u></b>oins the end of the QR<b><u>S</u></b> with the beginning of the <b><u>S</u></b>T segment</i><b>)</b> — so Osborn waves are <i>exaggerated</i> “J waves” <u>or</u> J-point waves. They’ve also been called the <i>“camel-hump”</i> sign.</span></span></p><p style="margin: 0in;"></p><ul><li><span style="font-family: arial; font-size: medium;"><span face="Arial, sans-serif">First described in 1953 (</span><i>by Dr. John Osborn</i><span face="Arial, sans-serif">) — the finding of</span><span face="Arial, sans-serif"> </span><b><i>Osborn</i></b><span face="Arial, sans-serif"> </span><b>waves</b> is<span face="Arial, sans-serif"> most commonly associated with significant</span><span face="Arial, sans-serif"> </span><b><i><u>hypothermia</u></i></b><span face="Arial, sans-serif"> <b>(</b></span><i>usually not seen until core temperature drops <u>below</u> 90°F = 32°C</i><span face="Arial, sans-serif"><b>)</b>.</span></span></li><li><span style="font-size: medium;"><span style="font-family: arial;">It is important to appreciate that <i><u>other</u></i> conditions may <i>also</i> be associated with this prominent J-point deflection. <b><i>Osborn</i></b> <b>waves</b> have been reported with hypercalcemia, brain injury, subarachnoid hemorrhage, Brugada syndrome, <b><i>cardiac</i></b> <b>arrest</b> from <b>VFib</b> — <u>and</u> — severe, <i>acute</i> ischemia resulting in <i>acute</i> MI</span></span><span style="font-family: arial;"> <b>(</b><i>See My Comment in the</i></span><span style="font-family: arial;"> </span><b><a href="http://hqmeded-ecg.blogspot.com/2019/11/persistent-ventricular-fibrillation-ed.html" target="_blank">November 22, 2019</a> post</b><span style="font-family: arial;"> </span><i>on Dr. Smith’s Blog</i><span style="font-family: arial;"><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">Rituparna et al — as well as Chauhan and Brahma (<b><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4705575/" target="_blank">Int. J. Crit. Illn. Inj. Sci 5[4] 268-270, 2015</a></b>) both highlight a likely <b><i>association</i></b> between acute development of <b><i>ischemic</i> J waves</b> — and <b><i>high risk </i></b>of developing <b>malignant <i>ventricular</i> arrhythmias (</b><i>My Comment in the</i> <b><a href="https://hqmeded-ecg.blogspot.com/2020/09/a-woman-in-her-60s-with-chest-pain-and.html" target="_blank">September 23, 2020 post</a>)</b>.</span></li></ul><div><br /></div><div><b><u>ECG Findings with Hypothermia:</u></b></div><div><span face=""arial" , "helvetica" , sans-serif">In addition to <b><i>Osborn</i></b> <b>waves</b> — other commonly associated <b>ECG features</b> with <b><i>Hypothermia</i></b> include</span><span face=""arial" , "helvetica" , sans-serif">: </span><b>i<span style="color: red;">)</span></b><span face=""arial" , "helvetica" , sans-serif"> Bradycardia (</span><i>which may be marked</i><span face=""arial" , "helvetica" , sans-serif">); </span><b>ii<span style="color: red;">)</span></b><span face=""arial" , "helvetica" , sans-serif"> Atrial fibrillation or other arrhythmias (<i>including VFib</i>);</span><span face=""arial" , "helvetica" , sans-serif"> </span><b>iii<span style="color: red;">)</span></b><span face=""arial" , "helvetica" , sans-serif"> Artifact (</span><i>from baseline undulations resulting from associated shivering</i><span face=""arial" , "helvetica" , sans-serif">); <b>iv<span style="color: red;">)</span> </b>QTc prolongation (<i>which may be marked</i>); <b>v<span style="color: red;">)</span></b> ST elevation in multiple leads; <u>and</u>, <b>vi<span style="color: red;">)</span></b><span style="color: red;"> </span>Brugada phenocopy. </span></div><ul><li><b><u>NOTE:</u> </b><span style="font-family: arial;">Virtually </span><u><i>all</i></u><span style="font-family: arial;"> of the above ECG features are seen in the 2 tracings from today’s case </span><b>(</b><i>See </i><u>Figure-1</u><b>)</b><span style="font-family: arial;">. </span></li><li><br /></li><li><span style="font-family: arial;"><u style="font-weight: bold;">ECG #1</u> <b>(</b><i>Bottom tracing in </i><u>Figure-1</u><b>): </b>The most remarkable finding in this initial ECG is the <b><i>baseline</i></b> <b>artifact</b> that is seen in virtually all 12 leads! Presumably, this is the result of <b><i>body</i></b> <b><u>shivering</u></b>, that so often accompanies hypothermia once temperatures drop below 30-32°C <b>(</b> = <i>86-90°F</i><b>)</b>. The rhythm is <i>irregularly</i> irregular, and appears to be <b>AFib</b> with a <b>fairly</b> <b><u><i>slow</i></u> ventricular response</b> <b>(</b><i>overall rate <70/minute</i><b>) </b>— although marked baseline artifact renders the search for atrial activity futile.</span></li><li><span style="font-family: arial;"><b><i>Osborn</i></b> <b>waves</b> <u style="font-style: italic;">are</u> seen in multiple leads in <u>ECG #1</u> — although once again, the marked baseline artifact makes it difficult to identify these Osborn waves <b>(</b><i>See BLUE arrows in Figure-1</i><b>)</b>. Otherwise — QRS width and the QTc appear normal — and ST-T wave appearance manifests nonspecific changes without significant ST elevation or depression.</span></li><li><br /></li><li><span style="font-family: arial;"><b><u>ECG #2</u> (</b><i>Top tracing in </i><u>Figure-1</u><b><u>)</u>: </b>This ECG was obtained ~15 minutes after <u>ECG #1</u> — and was associated clinically with hypotension and <b>further <i>slowing</i> </b>of the already slow <b>AFib rhythm</b>. Baseline artifact is <u style="font-style: italic;">no</u> longer present. That said — the <b>QTc has markedly widened</b>, in association with <b><i>unusually</i></b> <b>round</b> and <b>deeply <i>inverted</i> T waves</b>.</span></li><li><span style="font-family: arial;">The <b><i><u>giant</u></i></b> <b>Osborn waves</b> seen in <u>ECG #2</u> are as large as you are likely to see <b>(</b><i>RED arrows</i><b>)</b> — and could easily be mistaken for ST elevation!</span></li><li><span style="font-family: arial;">An additional subtle finding is seen within the <i>RED rectangle</i><span><i> — </i>in that there now appears to be <b>ST elevation</b> in <b>lead V2</b> with a slowly downsloping shape consistent with a<b> Brugada-1 pattern (</b>ie, <i>suggestive of developing Brugada phenocopy from the marked hypothermia</i><b>)</b>.</span></span></li></ul><div><p style="margin: 0in;"><br /></p></div></span></div><div><span style="font-family: arial; font-size: medium;"><b><u><i>How Large </i>Can <i>Osborn</i> Waves Get?</u></b></span></div><div><span style="font-family: arial; font-size: medium;"><span>We've discussed </span><b><i>Osborn</i></b><span> </span><b>Waves (</b><i>both ischemic and hypothermic</i><b>)</b><span> — on a number of occasions in Dr. Smith's ECG Blog </span><b>(</b><i>Please check out My Comment at the bottom of the page in the</i><span> </span><b><a href="https://hqmeded-ecg.blogspot.com/2022/02/hypothermia-at-18-celsius-in-v-fib.html" target="_blank">February 8, 2022</a> post</b><b>)</b><span>.</span><span> When due to </span><b><i><u>hypothermia</u></i></b><span> — </span><b>there <i>may be </i></b><b>correlation </b><b>between <i>severity</i> of hypothermia</b><span> </span><u>and</u><span> the </span><i><b>size</b></i><span> of Osborn Waves <b>(</b></span><span><span face=""arial" , sans-serif" style="color: #454545;"><i>See My Comment at the bottom of the page in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2023/01/unconscious-stemi-criteria-activate.html" target="_blank">January 21, 2023</a> post </b><i>in Dr. Smith’s ECG Blog</i><b>)</b>.</span></span></span></div><div><span style="font-family: arial; font-size: medium;"><ul><li>Today’s case joins a number of others we have published regarding attainment of truly large Osborn Waves <b>(</b><i>See My Comment in the</i> <b><a href="https://hqmeded-ecg.blogspot.com/2022/02/hypothermia-at-18-celsius-in-v-fib.html" target="_blank">February 8, 2022</a></b> <b>post </b><i>and the </i><b><a href="https://hqmeded-ecg.blogspot.com/2015/03/a-pathognomonic-ecg-what-is-it.html" target="_blank">March 12, 2015</a> post</b><i>, to name just 2 cases</i><b>)</b>. </li><li>To note that after the appearance of Osborn Waves — there may sometimes be a "lag time" for these exaggerated J waves to resolve. That said — The point is to appreciate the potential variability in Osborn Wave size, with awareness of how large they can sometimes become! </li></ul></span></div><div style="font-family: -webkit-standard;"><span style="font-family: arial; font-size: medium;"><br /></span></div></div></div></div><div style="font-family: arial; text-align: justify;"><div style="text-align: left;"><div style="text-align: center;"><br /></div></div></div></div></div><div style="font-family: arial; text-align: justify;"><div style="text-align: left;"><span style="font-family: arial;"><div style="text-align: justify;"><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div style="text-align: center;"><br /></div><div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"></span></div></div></div></span></div></div>Pendellhttp://www.blogger.com/profile/06506068475871794508noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-167808896533066072024-01-31T11:14:00.003-06:002024-01-31T11:59:47.064-06:00Chest pain, ST Elevation, well-formed Q-waves, and infarction with peak hs troponin I over 1000 ng/L. Is it OMI?<p></p><p><span style="font-family: times; font-size: medium;">A 60-something male presented stating that he had had chest pain that morning which awoke him from sleep but then resolved after several minutes. He has had similar pain in the past which he attributed to acid reflux. He has a history of untreated hypertension.</span></p><p><span style="font-family: times; font-size: medium;">He is pain free now.</span></p><p><span style="font-family: times; font-size: medium;">His systolic BP was 200.</span></p><p><span style="font-family: times; font-size: medium;">The patient is pain free at the time of this ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6t-Mz3aOpksuI6SWgIAA7rha38aE3qInumFW8ZmkYzOuFLmDbdVEgxwSnZVarCdCWNWFiKZGf4-GvEvnu7YxHKfcleHyoZO_Rftp-IVVK5-hxEgbCTgrNo3eEwJvx5dvVfQldQbM4j58INuMEgZv2WOjF0wLU9ww3WoRcSRh6WYkpGX0wq11_bDJ8pGn2/s3380/LVA%20time%20zero%20with%20NOMI%20too.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1512" data-original-width="3380" height="286" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6t-Mz3aOpksuI6SWgIAA7rha38aE3qInumFW8ZmkYzOuFLmDbdVEgxwSnZVarCdCWNWFiKZGf4-GvEvnu7YxHKfcleHyoZO_Rftp-IVVK5-hxEgbCTgrNo3eEwJvx5dvVfQldQbM4j58INuMEgZv2WOjF0wLU9ww3WoRcSRh6WYkpGX0wq11_bDJ8pGn2/w640-h286/LVA%20time%20zero%20with%20NOMI%20too.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">What do you think?</div><div style="text-align: center;"><br /></div><div style="text-align: center;"><b>The conventional algorithm said:</b></div><div style="text-align: center;"><p class="p1" style="font-family: Arial; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; text-align: start;"></p><div style="text-align: center;">SINUS RHYTHM</div><div style="text-align: center;">ANTERIOR MYOCARDIAL INFARCTION , PROBABLY RECENT [40+ ms Q WAVE AND/OR ST/T ABNORMALITY IN V3/V4]</div><div style="text-align: center;">***ACUTE MI***<span class="Apple-converted-space"> </span></div><p></p></div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">There are well-formed Q-waves in precordial leads. The T-waves are inverted. Thus, this is either:</span></p><p><span style="font-family: times; font-size: medium;">1) a subacute MI with a significant (large amount) of completed infarction, or </span></p><p><span style="font-family: times; font-size: medium;">2) old MI with persistent ST Elevation (LV aneurysm).</span></p><p><span style="font-family: times; font-size: medium;">The patient is pain free now, so it is either a reperfused subacute MI or a Non-OMI superimposed on an old MI (aneurysm).</span></p><p><span style="font-family: times; font-size: medium;">If this is subacute MI, then the first troponin should be VERY high, unless the infarct occurred many days or weeks ago.</span></p><p><span style="font-size: medium;">The first troponin returned at 541 ng/L.</span></p><p><span style="font-size: medium;">This is not high enough to be subacute MI unless the infarct happened at least a week ago. </span></p><p><span style="font-size: medium;"><br /></span></p><p><b><span style="font-size: medium;">What did the Queen of Hearts say?</span></b></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5Tf0GaZ4zpsVBcG4keVeLCtkle8txoxSr7KUA_SZhI7hyphenhyphen9XgV869BLQ71mwC0X2EvozmRCzJfh2RaEgPXuZwgFq7oKMYKk3b2flFceMJOJDdjYdsi5AohN5gVeWK2hwUyFLHAIIB3NpMlgVBV1Bnn5h6j1JKGa5zFZ_KFHhvnlx_BZZrlpU2UFrYRK5_7/s2560/Queen%20explains%20on%20LV%20aneurysm%20ECG.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="767" data-original-width="2560" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5Tf0GaZ4zpsVBcG4keVeLCtkle8txoxSr7KUA_SZhI7hyphenhyphen9XgV869BLQ71mwC0X2EvozmRCzJfh2RaEgPXuZwgFq7oKMYKk3b2flFceMJOJDdjYdsi5AohN5gVeWK2hwUyFLHAIIB3NpMlgVBV1Bnn5h6j1JKGa5zFZ_KFHhvnlx_BZZrlpU2UFrYRK5_7/w640-h192/Queen%20explains%20on%20LV%20aneurysm%20ECG.jpg" width="640" /></span></a></div><span style="font-size: medium;"><div style="text-align: center;">Version 1 of the Queen states: <b>"OMI with high confidence"</b>. </div><div style="text-align: center;">Although she was taught "Active vs. Reperfused" and "Acute vs. Subacute," she does not report this in version 1.</div><div style="text-align: center;">So if it is a reperfused OMI, she will say "OMI"</div><div style="text-align: center;">If it is a subacute OMI, she will say "OMI"</div></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; font-size: medium; text-shadow: none;"><b style="text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br style="text-shadow: none;" /></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"></span></p><p><span style="font-size: medium;"></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</a></span></div><p><span style="font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">Recorded at 45 minutes after arrival</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy_xKTamxWr1xMswunnEW9W1oYfF88BUmAyuwjwH38xvIIQ2v5BOlIzGIzT-TgdR0nf8W2uFLs1sP3sjHYRbgPKbLna8GBjjhNRGhWH2-fEcHGMIYXlWB8UAIqNbyJRgfHKSgzo8qZJpYdBmw0qVKogOb8yG9FNPbXk_YdtA2m5ZU2XSjj9K2U9yujMQHS/s3400/LVA%20time%2045%20min%20with%20NOMI%20too.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1490" data-original-width="3400" height="280" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy_xKTamxWr1xMswunnEW9W1oYfF88BUmAyuwjwH38xvIIQ2v5BOlIzGIzT-TgdR0nf8W2uFLs1sP3sjHYRbgPKbLna8GBjjhNRGhWH2-fEcHGMIYXlWB8UAIqNbyJRgfHKSgzo8qZJpYdBmw0qVKogOb8yG9FNPbXk_YdtA2m5ZU2XSjj9K2U9yujMQHS/w640-h280/LVA%20time%2045%20min%20with%20NOMI%20too.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">No significant difference</div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">Time 6 hours</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDn6g50M2pno3mnBubK14bMsFGuZa4N8l9wmhwtCw2lg5DC2jHXft0uSam0Vk2zmFHnohriElzqRyvzVC3J1jaB0CHASgkQeJBHreL4ZIrFp5niCi_mC1e2aBe1PM1ZC6lk-Ce2x19yqplx97EADWCd4ji6H6XJEwu9xIyq2mDc0OltLBizn5W2KE-jM4o/s3398/LVA%20time%206%20hours%20with%20NOMI%20too.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1532" data-original-width="3398" height="288" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDn6g50M2pno3mnBubK14bMsFGuZa4N8l9wmhwtCw2lg5DC2jHXft0uSam0Vk2zmFHnohriElzqRyvzVC3J1jaB0CHASgkQeJBHreL4ZIrFp5niCi_mC1e2aBe1PM1ZC6lk-Ce2x19yqplx97EADWCd4ji6H6XJEwu9xIyq2mDc0OltLBizn5W2KE-jM4o/w640-h288/LVA%20time%206%20hours%20with%20NOMI%20too.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">21 hours</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj79gSQjqJFZe_UOueYr1XSenENVLXEmACzVIUjwuHEw46X_CULFCeHOouGFYfXU8CB-iYMD3sLMK0rFgEXfX7MfvQzcsPHw_Bm1OhyphenhyphenGEhB9Qj1CJpjJwS6us9_y3vV-N0-E-_oegSos3uICsmSrceNc7YEY2Ad2VKbOanG0wPwMvsUP7MuNcKM6DywjpzY/s3410/LVA%20time%2021%20hours%20with%20NOMI%20too.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1560" data-original-width="3410" height="292" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj79gSQjqJFZe_UOueYr1XSenENVLXEmACzVIUjwuHEw46X_CULFCeHOouGFYfXU8CB-iYMD3sLMK0rFgEXfX7MfvQzcsPHw_Bm1OhyphenhyphenGEhB9Qj1CJpjJwS6us9_y3vV-N0-E-_oegSos3uICsmSrceNc7YEY2Ad2VKbOanG0wPwMvsUP7MuNcKM6DywjpzY/w640-h292/LVA%20time%2021%20hours%20with%20NOMI%20too.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p><span style="font-family: times; font-size: medium;">Here is the troponin profile:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9ywgjD1Elq2DhkeocAI993NS8wqlHur-6P-51DICvnAUkt2lpS7QJQ04CrsF7UvQ00fcYkTzyZfD7a097uibPgIog3j32n7XwV4H2Srd989rwjJetVyjIMyeEFVR5AwQtUolP3dBjW68vjJzQ95wSJaE_biuuDmkol15ITv4MGzPBHztLYA6IPpJgTxY5/s810/troponin%20trend%20LVA.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="366" data-original-width="810" height="290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9ywgjD1Elq2DhkeocAI993NS8wqlHur-6P-51DICvnAUkt2lpS7QJQ04CrsF7UvQ00fcYkTzyZfD7a097uibPgIog3j32n7XwV4H2Srd989rwjJetVyjIMyeEFVR5AwQtUolP3dBjW68vjJzQ95wSJaE_biuuDmkol15ITv4MGzPBHztLYA6IPpJgTxY5/w640-h290/troponin%20trend%20LVA.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p><span style="font-size: medium;">This confirms that the patient has an acute MI. The fact that the patient is pain free tells us that this is either a NOMI or a reperfused OMI. But the ECG tells us that that there is also old or subacute MI.</span></p><p><b><span style="font-size: medium;">Therefore, this is a NOMI or reperfused OMI <u>SUPERIMPOSED</u> on an old (LV aneurysm) or subacute MI.</span></b></p><p><span style="font-size: medium;"><br /></span></p><p><b><span style="font-size: medium;">How could we tell the difference between subacute MI that is many days old and LV aneurysm?</span></b></p><p><b><span style="font-family: times; font-size: medium;"></span></b></p><p><span style="font-size: medium;">A high quality echo should show <b>dyskinesis</b> and wall thinning if this is aneurysm. If it is subacute MI, then it will show akinesis and no wall thinning.</span></p><p><span style="font-family: times; font-size: medium;"></span></p><div><span style="font-size: medium;"><br /></span></div><p><span style="font-family: times; font-size: medium;"><b>High Quality Contrast Echo</b></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span style="font-family: times;">--Normal left ventricular cavity size, mildly increased wall thickness and </span><span style="font-family: times;">mild LV systolic dysfunction.</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">--The estimated left ventricular ejection fraction is 45-50 %.</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><span style="font-family: times;">--Regional wall motion abnormality-distal mid and apical anterior, apical </span><span style="font-family: times;">inferior, apical lateral, apical septum and apex, <b>aneurysmal</b>.</span></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-size: medium;"><br /></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"> </span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">ADDITIONAL REMARKS</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"> </span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><b><span style="font-size: medium;"><span style="font-family: times;">Prior infarct with aneurysm in the distal LAD vascular territory. No </span><span style="font-family: times;">convincing evidence for LV thrombus.</span></span></b></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"> </span></p><p><span style="font-family: times; font-size: medium;">The patient refused angiogram.</span></p><p><span style="font-family: times; font-size: medium;">He was supposed to get a stress test and/or angiogram later but never showed up</span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><div style="text-align: justify;"><div style="margin: 0in 0in 0.0001pt;"><div style="margin: 0in 0in 0.0001pt;"><div style="text-align: left;"><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><div style="text-align: left;"><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;"><div style="caret-color: rgb(0, 0, 0); color: black;"><span style="font-family: arial; font-size: medium;"><div class="separator" style="clear: both; font-family: -webkit-standard; text-align: center;"><span style="font-family: arial; font-size: medium; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div style="font-family: -webkit-standard;"><br /></div><div><br /></div></span></div></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;">==================================</span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-family: arial; font-size: medium;"><span><b><span face=""arial" , sans-serif" style="color: #454545;"><i>My Comment</i> by </span></b><b><span face=""arial" , sans-serif" style="color: red;">K</span></b><b><span face=""arial" , sans-serif" style="color: #454545;">EN </span></b><b><span face=""arial" , sans-serif" style="color: red;">G</span></b><b><span face=""arial" , sans-serif" style="color: #454545;">RAUER, MD (</span></b><span face=""arial" , sans-serif" style="color: #454545;"><i>1/31</i></span></span><span style="color: #454545;"><i>/2024</i></span><b style="color: #454545;">):</b></span></div><div style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;">==================================</span></div></div><div><span style="font-family: arial; font-size: medium;">Insightful commentary by Dr. Smith on how to interpret today's ECG — with the <i>PEARL</i> on how high quality Echo may assist in differentiation between LV aneurysm <u style="font-style: italic;">vs</u> subacute MI.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">I offer a few additional thoughts on today's <b><i><u>initial</u></i></b> <b>ECG</b> — which I've reproduced in <u style="font-weight: bold;">Figure-1</u>.</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4GI_nNt36_vYKGceSPMzb2yGQjGZUXLW5UZ6-hur0csIql8Lwhtj1iZnClg8NfvPbeiim_4zn5TZ-EgoS0pctJ1rrNfK0Yf9wzH8Da_pW-VFEXBC7ymJlmtWi4Ba2GyU6zMbZJEHRK0bZup5uNR4x-Nm9XWwsDuZzyQUqlKJFEi6TSPkl9ZF03INf_wU/s2512/Figure-1%20%20ECG-1%20%20(1-28.1-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1056" data-original-width="2512" height="270" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4GI_nNt36_vYKGceSPMzb2yGQjGZUXLW5UZ6-hur0csIql8Lwhtj1iZnClg8NfvPbeiim_4zn5TZ-EgoS0pctJ1rrNfK0Yf9wzH8Da_pW-VFEXBC7ymJlmtWi4Ba2GyU6zMbZJEHRK0bZup5uNR4x-Nm9XWwsDuZzyQUqlKJFEi6TSPkl9ZF03INf_wU/w640-h270/Figure-1%20%20ECG-1%20%20(1-28.1-2024)-USE.png" style="cursor: move;" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><span><b style="text-align: justify;"><u>Figure-1:</u></b><span style="text-align: justify;"> </span></span><span>The <b><i><u>initial</u></i></b> <b>ECG</b> in today's case.</span></span></td></tr></tbody></table><span style="font-family: arial; font-size: medium;"><br /></span><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><u><span style="font-family: arial; font-size: medium;"><i>Regarding</i> Today's <i>Initial</i> ECG:</span></u></b></div><div><span style="font-family: arial; font-size: medium;">Today's patient is a 60-something man who presented to the ED with <b>CP (</b><i><u>C</u>hest <u>P</u>ain</i><b>)</b> that awakened him from sleep — but which quickly resolved, and was no longer present at the time <u style="font-weight: bold;">ECG #1</u> was recorded.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">As per Dr. Smith — the principal concerns regarding this initial ECG relate to distinction as to what is "new" (<i>or at least recent</i>) — <u style="font-style: italic;">vs</u> "old" — <u style="font-style: italic;">vs</u> "new or recent <i><u>superimposed</u></i> on old". <b><i>Finding a prior baseline </i>ECG</b> on this patient could be extremely helpful for distinguishing between these entities <b>(</b><i>although prior tracings are not always available at the time we'd like to have them ... </i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">What <u style="font-style: italic;">can</u> be said about <u>ECG #1</u> — is that <b><i>anterior</i> MI</b> <u style="font-style: italic;">has</u> definitely occurred at some point in the past. There is <b><i><u>loss</u></i> of r wave</b> from <b>lead V1</b> <b>(</b><i>which manifests a small-but-definitely-present initial r wave</i><b>)</b> — to <b>lead V2</b> <b>(</b><i>which manifests an entirely negative QS complex</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">This is followed by an exceeding <b><u style="font-style: italic;">wide</u> Q wave </b>in <b>lead V3</b> — in association with ST segment straightening and fairly deep terminal T wave inversion in this lead. <b>(</b><i>I like to look for fragmentation with such wide Q waves as a sign in support of previous "scar" — but baseline artifact rendered my search for fragmentation useless</i><b>).</b></span></li><li><span style="font-family: arial; font-size: medium;"><b><i>Narrow</i></b> <b>q waves</b> continue in <b>leads V4</b>,<b>V5</b>,<b>V6</b>. That said — the finding of a q wave that is <i><u>deeper</u></i> in lead V4 than in lead V6 <u>is</u> consistent with <i>definite</i> anterior MI having occurred at some point in time <b>(</b><i>whereas isolated narrow q waves of similar size to that seen in leads V5,V6 of ECG #1 — might simply reflect normal septal q waves and <u>not</u> prior infarction</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">Finally — <b>I see <i>nothing acute</i> in the limb leads</b> of <u>ECG #1</u>. Reciprocal ST depression in inferior leads would be helpful in support of a recent event if present — but given that many acute anterior OMIs do <i>not</i> manifest reciprocal limb lead changes, their absence does <i><u>not</u></i> rule out a recent event.</span></li></ul><span style="font-family: arial; font-size: medium;"><b><i><u><div><b><i><u><br /></u></i></b></div>Putting It All Together:</u></i> </b><br /></span><ul><li><span style="font-family: arial; font-size: medium;">My impression on seeing today's <b><i><u>initial</u></i></b> <b>ECG</b> — was that extensive anterior infarction <u style="font-style: italic;">had</u> occurred at some point in time. </span></li><li><span style="font-family: arial; font-size: medium;"><b><i>Looking at leads V1,V2</i></b> — the ST segment coving with minimal ST elevation and no more than a hint of terminal T wave inversion is clearly consistent with LV aneurysm.</span></li><li><span style="font-family: arial; font-size: medium;"><b>Lead V3</b> <i>confirmed</i> the likelihood of prior infarction <b>(</b><i>given how large and wide the Q wave in this lead is</i><b>) </b>— but the <u style="font-style: italic;">shape</u> of the elevated ST segment in lead V3 potentially looks recent <b>(</b>ie, <i>ST straightening with steep descent into terminal T wave inversion</i><b>)</b>. Persistent T wave inversion in <b>leads V4</b> and <b>V5</b> — which only by <b>lead V6 </b>are resolving <b>(</b><i>the T wave still being positive-negative biphasic in this most lateral chest lead</i><b>)</b> — could clearly be consistent with <b><i>reperfusion</i></b> <b>T waves</b> from <i>recent</i> anterior infarction, perhaps <i>superimposed</i> on chronic LV aneurysm.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><u style="font-weight: bold;">BOTTOM Line:</u> I thought it impossible to know for certain from this single ECG what was "old" <u style="font-style: italic;">vs</u> "new" (<i>or recent</i>) — <i><u>vs</u> </i>"new or recent <i>superimposed</i> on old".</span></li></ul></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div></div><div style="text-align: left;"><div style="text-align: justify;"><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div></div></div></div></div><p><span style="font-size: medium;"><span style="font-family: arial; font-size: medium;"></span></span></p><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><div class="separator" style="clear: both; text-align: center;"></div></span></div><p><br /></p><p><br /></p>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-42424964435422413812024-01-29T08:13:00.008-06:002024-01-29T10:58:30.408-06:00A 40-something with chest pain<p><span style="font-family: times; font-size: medium;">This was sent by Sam Ghali @EM_RESUS</span></p><div class="gmail_default"><span style="font-family: times; font-size: medium;">A 44 year old man presented with chest pain</span></div><div class="gmail_default"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="gmail_default"><span style="font-family: times; font-size: medium;">The tech came running with the ECG as the computer called "STEMI!"</span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX0tcbqE56w-xzL-Tr8bawP4B2PcMw9QaG7aAqzxiVlXIiB2L0oHLW7aXQbbkSUwlOBHwQRx5vBDMQK2HphAEEwH38f_UpICEc2Sdxl7s7D38Y2hopZtZLnO83iPLPQuYxd3W8yXEE_vRpUVEBeJeM6YMdj28e60ih5OGB1YeSfp_ULCb5wxEOcaG-nsXV/s8192/PSEUDO%20LAD%20OCCLUSION%20.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="3271" data-original-width="8192" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX0tcbqE56w-xzL-Tr8bawP4B2PcMw9QaG7aAqzxiVlXIiB2L0oHLW7aXQbbkSUwlOBHwQRx5vBDMQK2HphAEEwH38f_UpICEc2Sdxl7s7D38Y2hopZtZLnO83iPLPQuYxd3W8yXEE_vRpUVEBeJeM6YMdj28e60ih5OGB1YeSfp_ULCb5wxEOcaG-nsXV/w640-h256/PSEUDO%20LAD%20OCCLUSION%20.jpg" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">The conventional computer algorithm read: ***STEMI***</div><div style="text-align: center;">The cardiologist overread was: "ST Elevation. Consider Anterolateral Injury or Acute Infarct"</div><div style="text-align: center;"><br /></div><div style="text-align: center;">What do you think?</div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">Sam sent this to me and asked: "What do you think, Steve?"</span></p><p><span style="font-family: times; font-size: medium;"><b>My answer:</b></span></p><div><span style="font-family: times; font-size: medium;">--Tough one!</span></div><div><span style="font-family: times; font-size: medium;">--But I'm going to stick my neck out and say "Not OMI"</span></div><div><span style="font-family: times; font-size: medium;">--STE in V2 has a near "saddleback" configuration, and that is a sign of false positive STE.</span></div><div><span style="font-family: times; font-size: medium;">--Tell me the outcome!</span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><b>He responded:</b></span></div><div><div class="gmail_default"><span style="font-family: times; font-size: medium;">--You nailed it!</span></div><div class="gmail_default"><span style="font-family: times; font-size: large;">--The Saddleback in V2 is </span><i style="font-family: times; font-size: large;">exactly</i><span style="font-family: times; font-size: large;"> what made me doubt it. (I learned that from you!)</span></div><div class="gmail_default"><span style="font-family: times; font-size: medium;">--I also had the benefit of old ECGs on this guy, which at baseline he has very concerning "Hyperacute" T waves!</span></div></div><p><span style="font-size: medium;"><span style="font-family: times;">"</span><span style="font-family: times;">I was skeptical because of the saddleback. Then I l</span><span style="font-family: times;">ooked at priors and was pretty much totally reassured. So signed it NO STEMI and triaged him OK to not be in RESUS."</span></span></p><p><span style="font-size: medium;"><b>What does the Queen of Hearts say?</b></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1_AMABRR8BKyNSNPM5QTkI6HNJo91Ut7n6sXKm9tq4km1EMzWTuvj9LOJnO_tLyMw86HMM0VH43H4iDCxbDaDDmte4qVBzmziPmv1XMpFuQQ_-3H3Jqya8kpa3a-gL1vKCj3iNPyHAP_rwGlgSXrVtIWpfnoKS2KPT1HkqyUFbhvhTfZwzEpJGgqT456x/s782/Queen%20sees%20the%20mimic.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="462" data-original-width="782" height="378" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1_AMABRR8BKyNSNPM5QTkI6HNJo91Ut7n6sXKm9tq4km1EMzWTuvj9LOJnO_tLyMw86HMM0VH43H4iDCxbDaDDmte4qVBzmziPmv1XMpFuQQ_-3H3Jqya8kpa3a-gL1vKCj3iNPyHAP_rwGlgSXrVtIWpfnoKS2KPT1HkqyUFbhvhTfZwzEpJGgqT456x/w640-h378/Queen%20sees%20the%20mimic.png" width="640" /></span></a></div><div><span style="font-size: medium;"><br /></span></div><span style="font-size: medium;"><b>And here she explains why:</b></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEill_yBngJFdDjC9IiGFxrvXfvKbToBF7lvEGMyo2AO8MTsS5DK-yUTJCpbcwnJeGMEC-dm7xJZdGgKDJOJRaGz65GV0JnIZimvgNloW7mjsACbZRnFR5eJK2XebXfBRBEFDQykB0oxzp2_ryS-kOI3JROqKTKuYV77md4i_HROzCvQc0qYGr_MSUdIkk65/s2510/Queen%20sees%20the%20mimic%20--%20explained.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1036" data-original-width="2510" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEill_yBngJFdDjC9IiGFxrvXfvKbToBF7lvEGMyo2AO8MTsS5DK-yUTJCpbcwnJeGMEC-dm7xJZdGgKDJOJRaGz65GV0JnIZimvgNloW7mjsACbZRnFR5eJK2XebXfBRBEFDQykB0oxzp2_ryS-kOI3JROqKTKuYV77md4i_HROzCvQc0qYGr_MSUdIkk65/w640-h264/Queen%20sees%20the%20mimic%20--%20explained.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div><span style="font-size: medium;">Notice that she highlights the relatively high voltage QRS in many leads. The Queen knows that OMI is not just diagnosed by ST Elevation, but that the ST and T must be assessed in the context of QRS voltage.</span></div><div><span style="font-size: medium;"><br /></span></div><div><div style="text-shadow: none;"><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; font-size: medium; text-shadow: none;"><b style="text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br style="text-shadow: none;" /></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</a></span></div></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br style="text-shadow: none;" /></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br /></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><div></div></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br /></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br /></div><p><b><span style="font-size: medium;">Case continued</span></b></p><p><span style="font-family: times; font-size: medium;">Previous ECG on file:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg49asqKwgDu_bXVJaEhpDW9fTpq9y2QTj2rGmJebVw-EUcWb5YDSLKQGI5MtRcmUjiQWJCxgUxeA61eYgw_GJqQOZZwexEoLoHjEg9oqiY6lgzh0kI5Ta2D48tAznXnDsMG6wTmV5ouvehMlQ8p112ie-ITqojnohmOBvNz6K1ROZUnTKLnDXI8yiuM_Qm/s8192/PSEUDO-LAD-OCCLUSION-OLD%20.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="3256" data-original-width="8192" height="254" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg49asqKwgDu_bXVJaEhpDW9fTpq9y2QTj2rGmJebVw-EUcWb5YDSLKQGI5MtRcmUjiQWJCxgUxeA61eYgw_GJqQOZZwexEoLoHjEg9oqiY6lgzh0kI5Ta2D48tAznXnDsMG6wTmV5ouvehMlQ8p112ie-ITqojnohmOBvNz6K1ROZUnTKLnDXI8yiuM_Qm/w640-h254/PSEUDO-LAD-OCCLUSION-OLD%20.jpg" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">This ECG is different in V2, but supports that the ECG above is a mimic.</div></span></div><div style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><div class="gmail_default" style="font-family: Times; font-size: medium;"><span style="font-family: times; font-size: medium;"><b>Sam confirms his impression, which was supported by this old ECG:</b></span></div><div class="gmail_default" style="font-family: Times; font-size: medium;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="gmail_default" style="font-family: Times; font-size: medium;"><span style="font-family: times; font-size: medium;">"A quick bedside Echo showed no wall motion abnormality and that sealed the deal."</span></div><div class="gmail_default" style="font-family: Times; font-size: medium;"><span style="font-family: times; font-size: medium;"><br /></span></div><div class="gmail_default" style="font-family: Times; font-size: medium;"><span style="font-size: medium;"><span style="font-family: times;">"Then the Hs Trop T at 0 hr + 1 hr: both normal [</span><span style="font-family: times;">19 ng/L then 21 ng/L, (ref range <22)]"</span></span></div></span><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><b>More Saddleback cases:</b></span></p><p><span style="font-family: times; font-size: medium;"></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2020/10/is-this-septal-stemiomi-many-examples.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">Is this Septal STEMI/OMI? Many examples of Septal STEMI/OMI</span></a></h3><div><span style="font-size: medium;"><br /></span></div><h3 class="post-title entry-title" style="color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2022/04/what-is-this-st-elevation.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">What is this ST Elevation?</span></a></h3><p><span style="font-family: times; font-size: medium;"></span></p><div style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif;"><h3 class="post-title entry-title" style="color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2021/09/a-man-in-his-50s-with-anterior-st.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-size: medium;">A man in his 50s with anterior ST elevation and a "tall T wave in V1"</span></a></h3><div><div style="background-color: white; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2013/09/epigastric-pain-syncope-and-saddleback.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;"><br class="Apple-interchange-newline" />Epigastric pain, Syncope, and Saddleback ST Elevation</span></span></a></h3></div><div style="background-color: white; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2016/07/a-65-year-old-man-with-chest-pain-and.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;">A 65 Year Old Man with Chest pain and Precordial ST Elevation</span></span></a></h3></div><div style="background-color: white; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2016/09/non-vagal-syncope-and-saddleback.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;">Non-Vagal Syncope and Saddleback Morphology in V2</span></span></a></h3></div><div style="background-color: white; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="background-color: white; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2015/10/is-this-stemi-pattern-recognition-is-key.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;">Is this STEMI? Pattern Recognition is Key</span></span></a></h3><div style="font-family: "Open Sans"; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2016/10/rsr-with-st-elevation-is-this-right.html" style="color: #29aae1; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;">RSR' with ST elevation: is this Right Bundle Branch Block with STEMI? Type 2 Brugada?</span></span></a></h3></div><div style="font-family: "Open Sans"; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;"><br style="text-shadow: none;" /></span></span></div><div style="font-family: "Open Sans"; text-shadow: none;"><h3 class="post-title entry-title" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="http://hqmeded-ecg.blogspot.com/2021/05/why-is-there-st-elevation-in-lead-v2.html" style="color: #0090ff; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;"><span style="font-family: times; text-shadow: none;"><span style="font-size: medium;">Why is there ST Elevation in lead V2? Think Lead Placement.</span></span></a></h3><div><span style="font-size: medium;"><br /></span></div></div></div></div></div><p><span style="font-family: times; font-size: medium;"><b>Saddleback in V2 is rarely LAD OMI, but can be! </b></span></p><p><span style="font-family: times; font-size: medium;"><a href="https://hqmeded-ecg.blogspot.com/search/label/Saddleback%20STEMI">2 cases of Saddleback that was indeed OMI</a></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><div style="text-align: justify;"><div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><div style="caret-color: rgb(0, 0, 0); color: black;"><div class="separator" style="clear: both; font-family: -webkit-standard; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div style="font-family: -webkit-standard;"><br /></div><div><br /></div></div></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>1/29</i></span><span style="color: #454545;"><i>/2024</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div><span style="font-family: arial; font-size: medium;">Today's case by Drs. Ghali and Smith illustrates the dilemma of assessing <b><i>Saddleback</i></b> <b>ST elevation</b> in one or more anterior leads. </span></div><div><ul><li><span style="font-size: medium;"><span style="font-family: arial;">The "good news" — is that most of the time, a saddleback pattern of ST elevation with <b><i>upward</i></b> <b>concavity </b></span><b style="font-family: arial;">(</b><span style="font-family: arial;">ie,</span><span style="font-family: arial;"> </span><i style="font-family: arial;">"smiley"-configuration — as shown in</i><span style="font-family: arial;"> </span><b style="font-family: arial;"><u>Figure-1</u>) </b><span style="font-family: arial;">— will be benign, and</span><span style="font-family: arial;"> </span><u style="font-family: arial; font-style: italic;">not</u><span style="font-family: arial;"> the result of acute anterior OMI.</span></span></li></ul><div><span style="font-family: arial;"><p style="text-align: left;"><span style="font-family: arial; font-size: medium;"></span></p><p style="text-align: left;"><span style="font-size: medium;"></span></p><div style="text-align: left;"><span style="font-family: arial; font-size: medium;"><div style="text-align: justify;"><p style="margin: 0in;"><br /></p><p style="margin: 0in;">As per <i>My Comment</i> in the <b><a href="http://hqmeded-ecg.blogspot.com/2023/07/a-man-in-his-70s-with-weakness-and.html" target="_blank">July 22, 2023</a> post</b> in Dr. Smith's ECG Blog — <i>No matter how many times</i> I have seen Brugada-1 <u>and</u> Brugada-2 ECG patterns — <i>I still find myself referring back to the images</i> I include in <u>Figure-1</u>:</p><p style="margin: 0in;"></p><ul><li>I therefore thought that it may be helpful to explore today's <b><i><u>initial</u></i></b> <b>ECG</b> a bit further.</li></ul><p></p><p style="margin: 0in;"><br /></p></div></span></div></span></div></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirAU0SfJC7NZU23KaBehvNsSoFZ4uLE-W9D6iR-kVr_OYhq16F_KPfmbMeOCBBAsodoeop2yJRO8rqrCSekV4PUpCQGFtYpyXOaKo0tXIloBhfJQuUXv25x6JtoDm8dy8q0_0DdWOJU9DhaNFVIYljJv8DLWTJj0j6WgwBPU48miWg36HraWGiWinHQNo/s3306/Figure-1%20%20ECG-1,%20Brugada%20(1-28.23-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2786" data-original-width="3306" height="540" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirAU0SfJC7NZU23KaBehvNsSoFZ4uLE-W9D6iR-kVr_OYhq16F_KPfmbMeOCBBAsodoeop2yJRO8rqrCSekV4PUpCQGFtYpyXOaKo0tXIloBhfJQuUXv25x6JtoDm8dy8q0_0DdWOJU9DhaNFVIYljJv8DLWTJj0j6WgwBPU48miWg36HraWGiWinHQNo/w640-h540/Figure-1%20%20ECG-1,%20Brugada%20(1-28.23-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b style="text-align: justify;"><u><span face="Arial, sans-serif">Figure-1:</span></u></b><b style="text-align: justify;"> </b><span style="text-align: justify;">I've combined today's <b><i><u>initial</u></i></b> <b>ECG</b> with </span><span style="text-align: justify;">the <b>ECG Patterns in Brugada Syndrome (</b><i>adapted from Brugada et al in </i><b><a href="https://www.onlinejacc.org/content/72/9/1046?_ga=2.247224589.869150275.1567990447-155531933.1567990447" target="_blank">JACC: </a></b></span><b style="text-align: justify;"><span face="Arial, sans-serif"><a href="https://www.onlinejacc.org/content/72/9/1046?_ga=2.247224589.869150275.1567990447-155531933.1567990447" target="_blank">Vol. 72; Issue 9; 2018</a></span></b><b style="text-align: justify;">) — A<span style="color: red;">)</span></b><span style="text-align: justify;"> <b><u>Brugada-1</u></b> ECG pattern, showing coved ST-segment elevation ≥2 mm in ≥1 right precordial lead, followed by a negative T-wave. <br /><b>—</b> <b>B<span style="color: red;">)</span></b> <b><u>Brugada-2</u></b> ECG pattern (<i>the <b>“Saddleback”</b> pattern</i>) — showing concave-up ST-segment elevation ≥0.5 mm (<i>generally ≥2 mm</i>) in ≥1 right precordial lead, followed by a positive T-wave. <br /><b>—</b> <b>C<span style="color: red;">)</span></b> <i>Additional</i> criteria for diagnosis of <b><u>Brugada-2</u></b> <b>(</b><u>TOP</u>: <i>the</i> <b>ß-angle</b>; <u><i>LOWER RIGHT</i></u>: <i>A Brugada-2 pattern is present if 5 mm down from the maximum r’ rise point — the base of the triangle formed is ≥4</i><b>)</b>.</span></span></td></tr></tbody></table><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><u><span style="font-family: arial; font-size: medium;"><i>MY Thoughts</i> on ECG #1</span></u></b></div><div><span style="font-family: arial; font-size: medium;">In a patient with new <b>CP (</b><i><u>C</u>hest <u>P</u>ain</i><b>)</b> — the >3 mm of <b>ST elevation</b> seen in <b>lead V2</b> of <u>ECG #1</u> is of obvious concern. That said, as per Drs. Ghali and Smith — the <i><b>saddleback</b></i> <b>shape</b> of this elevated ST segment is very often a benign finding.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">As suggested in <u>Figure-1</u> — a saddleback shape of ST elevation in one or more anterior leads suggests a <b>Brugada-2 pattern</b>. As illustrated in <u>Panel C</u> of Figure-1 — distinction between benign concave-up ST elevation <u style="font-style: italic;">vs</u> a Brugada-2 pattern is determined by width of the ß-angle. Unfortunately, lack of a descending segment from the point of ST elevation in <u>ECG #1</u> precludes calculation of the ß-angle. </span></li><li><span style="font-family: arial; font-size: medium;">That said — <i><u>regardless</u></i> of whether or not ST-T wave morphology in lead V2 of ECG #1 represents a Brugada-2 pattern — the <u style="font-style: italic;"><b>shape</b></u> of the <b>ST elevation</b> in lead V2 <u>is</u> <b><i>concave</i></b> <b>up (</b><i>"smiley"-configuration</i><b>)</b> — which is often benign.</span></li><li><span style="font-family: arial; font-size: medium;">That said — complicating assessment of potential significance (<i>or lack thereof</i>) of the elevated ST-T wave in lead V2 — is the <u style="font-style: italic;"><b>shape</b></u> of the <b>ST-T wave</b> in <b>lead V1</b> in <u>ECG #1</u>. There is in fact slight ST elevation in V1 — with gradual descent to modest T wave inversion. This picture is <u style="font-style: italic;">not</u> unlike the picture of a Brugada-1 pattern, with exception that it <i>lacks</i> sufficient ST elevation to qualify for Brugada-1. I therefore could <i><u>not</u></i> rule out the possibility of <b><i>Brugada</i></b> <b>Phenocopy</b> on the sole basis of this single ECG. As we've discussed on mutiple posts in Dr. Smith's ECG Blog — Brugada Phenocopy is <i>not</i> uncommon in association with other underlying conditions, including infarction <b>(</b><i>See My Comment at the bottom of the page in the </i><b><a href="http://hqmeded-ecg.blogspot.com/2023/07/a-man-in-his-70s-with-weakness-and.html" target="_blank">July 22, 2023</a> post</b><i>, among many other posts</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">The above said — I suspected that <u>ECG #1</u> may be benign because: <b>i<span style="color: red;">)</span> </b>None of the other chest leads looked abnormal <b>(</b><i>The 1-2 mm of upward sloping ST elevation that we see in lead V3 is a common normal finding</i><b>)</b>; <b>ii<span style="color: red;">)</span></b> There is excellent R wave progression <b>(</b><i>vs common loss of R wave in leads V2,V3 when there is anterior OMI</i><b>)</b>; <u>and</u>, <b>iii<span style="color: red;">)</span></b> Nothing acute is seen in the limb leads. While true that reciprocal inferior lead ST depression is not always seen in association with acute anterior OMI — reciprocal limb lead changes <u style="font-style: italic;">are</u> more likely to be seen when the site of LAD OMI is proximal, as could be suggested by leads V1 and V2 being the 2 remarkable chest leads.</span></li></ul></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><b><u>To Emphasize:</u></b> My interpretation above of <u>ECG #1</u> in today's case is based <i>solely</i> on ECG features of this tracing, knowing only that this patient presented with <i>new</i> CP. </span></div><div><ul><li><span style="font-family: arial; font-size: medium;"><b>Subsequent investigation (</b><i>which clearly <u>was</u> indicated given the amount of ST elevation in today's initial ECG in this patient with new CP</i><b>) — went on to <i>confirm</i></b> that <b><u>ECG #1</u> was benign</b>, and <u style="font-style: italic;">not</u> indicative of acute OMI.</span></li></ul></div><div style="font-family: arial;"><br /></div></div><div style="font-family: arial;"><br /></div></div><div style="font-family: arial; text-align: justify;"><br /></div><p><br /></p></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-65648230273574227422024-01-27T08:27:00.004-06:002024-01-27T08:39:23.522-06:00 Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span>Written by Jesse McLaren, comments by Smith</span></span><br /><span style="font-size: medium;"><span></span></span><span style="font-size: medium;">
</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">A 55 year old with a history of
NSTEMI presented with two hours of exertional chest pain, with normal vitals. Below
is the triage ECG, with a computer interpretation (Marquette 12 SL) of “normal” <b>which was
confirmed by the over-reading cardiologist</b>.</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">What do you think? </span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Should this patient continue to stay in the waiting room, without interruption of the physician to interpret the ECG, because the computer interpretation is normal?<span></span></span></p><span style="font-size: medium;">
</span><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEge8uraig8PT0iT3JlZs6WJPRmuP-AF-JYMoLNLU3PrEVReda8TnbDjacwXCKV8IWQeEjshty1lb4f5zDBdy3LL4QaTniN365afhKnLD2IcZJzKfDmnMLS59LxeEYwH9o0slfhzmyl2jb9Q9uM-wC3DKTJNg-IedGU0pmuJkuZT00XPX7CayxlV-WBTjuU/s1634/1.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="600" data-original-width="1634" height="235" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEge8uraig8PT0iT3JlZs6WJPRmuP-AF-JYMoLNLU3PrEVReda8TnbDjacwXCKV8IWQeEjshty1lb4f5zDBdy3LL4QaTniN365afhKnLD2IcZJzKfDmnMLS59LxeEYwH9o0slfhzmyl2jb9Q9uM-wC3DKTJNg-IedGU0pmuJkuZT00XPX7CayxlV-WBTjuU/w640-h235/1.png" width="640" /></a></div><br /><span style="font-size: medium;"></span></div><div style="text-align: center;"><span style="font-size: medium;">Interpretation by the GE/Marquette 12 SL conventional algorithm</span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Smith</b>: This article, <b>published this month (!)</b>, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal:</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"></span></p><div class="half_rhythm" style="-webkit-text-stroke-width: 0px; background-color: white; box-sizing: inherit; color: #212121; font-family: "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; letter-spacing: normal; margin-bottom: 10pt; margin-top: 10pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; text-decoration-thickness: initial; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px;"></div><p></p><h1 class="content-title" style="-webkit-text-stroke-width: 0px; background-color: white; box-sizing: inherit; clear: initial; color: black; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; letter-spacing: -0.01em; line-height: 22.5pt; margin: 20pt 0px 10pt; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; text-decoration-thickness: initial; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10777178/"><span style="font-family: times; font-size: medium;">Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients</span></a></h1><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">I reviewed this article for a different journal and recommended rejection and it was rejected. There were zero patients in this study with a "normal" ECG who had any kind of ACS! This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value. So this study is actually worthless. </span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">On the other hand, <b>if the physician is unable to recognize subtle OMI</b>, as is the case with the overreading cardiologist, then the conclusion would be correct.</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: large;">_____________</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>ECG analysis</b></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">There’s normal sinus rhythm,
normal conduction, normal axis, normal R wave and normal voltages. What sticks
out is the ST depression in aVL, which is reciprocal to subtle inferior ST
elevation and bulky T waves. There is also a down-up T-wave in aVL, which makes aVL even more diagnostic. <span> </span><b>This is
diagnostic is inferior OMI</b>, accompanied by inferior Q waves, and with a flat ST
segment in V2 that could indicate posterior extension.</span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Old ‘NSTEMI’<span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">A history of coronary artery
disease and a stent to the same territory further increases pre-test likelihood
of acute coronary occlusion, including in-stent thrombosis. It’s also possible
that the old inferior MI left residual ST elevation and reciprocal ST
depression, which can difficult to differentiate from acute OMI.<span></span></span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"></span></p><p class="MsoNormal" style="-webkit-text-stroke-width: 0px; color: black; font-family: Cambria; font-size: medium; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-decoration-color: initial; text-decoration-style: initial; text-decoration-thickness: initial; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px;"><span style="font-size: medium;"><span style="font-size: medium;"></span></span></p><p></p><p class="MsoNormal" style="-webkit-text-stroke-width: 0px; color: black; font-family: Cambria; font-size: medium; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-decoration-color: initial; text-decoration-style: initial; text-decoration-thickness: initial; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px;"><span style="font-size: medium;">The patient had a history of ‘NSTEMI’ a decade prior, with an RCA stent. Does this change your interpretation?<span></span></span><span style="font-size: medium;"> </span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">_________</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Smith</b>: Old inferior MI with persistent ST Elevation ("inferior aneurysm") has well-formed Q-waves. In inferior aneurysm, we usually see QR-waves, whereas for anterior aneurysm, we see QS-waves (no R- or r-wave at all!). This ECG has Q-waves, but they are not very wide nor very deep, and so I doubt that the inferior STE is due to old MI.</span></p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>See these posts: </b></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2015/11/chest-pain-st-elevation-and-elevated.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?</a></h3><div><br /></div><div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2010/10/tachycardia-must-make-you-doubt-acs-or.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context</a></h3></div><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"></span></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;"><a href="https://hqmeded-ecg.blogspot.com/2013/04/pulmonary-edema-hypertension-and-st.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI</a></h3><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: large;">_________________</span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">There’s limited information from
the NSTEMI decade ago, except that the cath report describes a critical RCA
stenosis treated with a stent, and the following discharge ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8FOea-lBkD2jXgYJK1uWBfPBS6eskvWcmIuOH5JIMf2ECIFx_CijNhXd9fuXz8H3BL8eNxt-vEMEDWN8OyggfGyNQ9PWah2Hk5qIchgWMz1aC0K4t1iboH9ZHgR_fAkFBdEDTPDUGSwOGYSlCNh4Zmo7h0JQIdrZTIbzrdrFzZuN9yL-DyvAQF8FcD1g/s1372/2.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="389" data-original-width="1372" height="171" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8FOea-lBkD2jXgYJK1uWBfPBS6eskvWcmIuOH5JIMf2ECIFx_CijNhXd9fuXz8H3BL8eNxt-vEMEDWN8OyggfGyNQ9PWah2Hk5qIchgWMz1aC0K4t1iboH9ZHgR_fAkFBdEDTPDUGSwOGYSlCNh4Zmo7h0JQIdrZTIbzrdrFzZuN9yL-DyvAQF8FcD1g/w602-h171/2.png" width="602" /></a></span></div><span style="font-size: medium;"><br /></span><p></p>
</div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">This shows inferior Q and
inferoposterior reperfusion, corresponding to RCA territory. So this NSTEMI was
likely a STEMI(-)OMI with delayed reperfusion. A couple of years later these
ECG changes resolved, except for small inferior Q waves, leaving an almost
normal baseline ECG. Below are the baseline and new ECG from the current
patient presentation:<span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoEsWGOdaryx5wzhOL17k2h-A019mdhL2cc28Xd0A3QVs3a8dFP4nctwNFAQCr9jIGrQj2pvGmwIqkI4mxicuw17W4eXSJo7Eqbp34KhdfZPI4CxQOmNlORotugjb6Bvng6evxsjxbhYHeAIwZTZ8niFcdwFl2qrtAroWaaPZh621VuAEhBfawpVE4jmM/s1380/3.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="919" data-original-width="1380" height="379" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoEsWGOdaryx5wzhOL17k2h-A019mdhL2cc28Xd0A3QVs3a8dFP4nctwNFAQCr9jIGrQj2pvGmwIqkI4mxicuw17W4eXSJo7Eqbp34KhdfZPI4CxQOmNlORotugjb6Bvng6evxsjxbhYHeAIwZTZ8niFcdwFl2qrtAroWaaPZh621VuAEhBfawpVE4jmM/w569-h379/3.png" width="569" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">This confirms that the new ECG
represented acute inferoposterior OMI: the inferior ST segments have straightened,
increase the area under the curve of the T waves, there is new ST depression in
aVL which is highly sensitive for inferior OMI, and there’s flattening of the
ST segment in V2.<span> </span><span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">But the ECG was labeled 'normal', and the
patient waited to be seen.<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span> </span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>New ‘NSTEMI’<span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Two hours later the first
troponin I returned at 450 ng/L (normal <26 in males and <16 in females),
which flagged the patient to be seen. By this time their pain had spontaneously
resolved, and another ECG was done which was also interpreted as normal. What
do you think?<span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEibNr5Ua4LbaIjug4xo8f-z3EO2z72VdY42VV5MpmX80UsPTI2Oq1YR0smRZYvftBn7QZYkLZuY2nbmGYQRa_OF0yTbdD6OaYlMqcnOR2Jk2oRtvfBRLEIAfGu90CrZUJa0pm2fjyRXY3CNnp-ookILnMlaiDwre9lyAUBg2mxvBBFIwhvyeJx_7UfUbAE/s1639/4.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="484" data-original-width="1639" height="175" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEibNr5Ua4LbaIjug4xo8f-z3EO2z72VdY42VV5MpmX80UsPTI2Oq1YR0smRZYvftBn7QZYkLZuY2nbmGYQRa_OF0yTbdD6OaYlMqcnOR2Jk2oRtvfBRLEIAfGu90CrZUJa0pm2fjyRXY3CNnp-ookILnMlaiDwre9lyAUBg2mxvBBFIwhvyeJx_7UfUbAE/w597-h175/4.png" width="597" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p style="font-family: Cambria;"><span style="font-size: medium;">On its own this ECG is nonspecific, with in isolated T wave inversion in
III. But compared to the previous ECG the inferior T waves have deflated, the
ST depression in aVL has resolved, and the ST segment in V2 is no longer flat and
has a taller T wave. This confirms that the previous ECG with pain represented
inferoposterior OMI, and that the current ECG with resolved pain represents
reperfusion. <span></span></span></p>
<p style="font-family: Cambria;"><span style="font-size: medium;">So
the patient had a transient acute coronary occlusion that spontaneously reperfused
but is at risk for reocclusion. The patient was admitted as ‘NSTEMI’ which is
supposed to represent a non-occlusive MI, but the underlying pathophysiology is
analogous to a transient STEMI. Fortunately the patient did not reocclude while
awaiting the angiogram. Next day ECG showed ongoing reperfusion:<span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEia5B0KZqQ-ScsJgXqVOB5tZBWyW0FxTDkVVnGhpPg5xAnI69cgtL0hPjwlYIJ8XlVH4ZsZxLgKAgLnOe7rtq9tzlPH0TbaCWShN5Mt8lYlJfYkx3qy5wLjsKknGkT-YNrOg2kkiBDZ2ZTg8rKJ38GnjL9H92jEJubaQVjV3n8Yb4Y5qPjfIFsxwq7T_ZQ/s1375/5.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="414" data-original-width="1375" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEia5B0KZqQ-ScsJgXqVOB5tZBWyW0FxTDkVVnGhpPg5xAnI69cgtL0hPjwlYIJ8XlVH4ZsZxLgKAgLnOe7rtq9tzlPH0TbaCWShN5Mt8lYlJfYkx3qy5wLjsKknGkT-YNrOg2kkiBDZ2ZTg8rKJ38GnjL9H92jEJubaQVjV3n8Yb4Y5qPjfIFsxwq7T_ZQ/w593-h178/5.png" width="593" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Angiogram found 90% RCA in-stent
thrombus corresponding to the ECG, peak troponin was 12,000 ng/L which is a
sizable infarct, and echo showed new inferior wall hypokinesis. This
retrospectively confirms the diagnosis of OMI, yet the patient had a discharge
diagnosis of ‘NSTEMI’.<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Discharge ECGs showed inferior Q
waves, and now very obvious inferoposterior reperfusion T wave inversion (the
same pattern as after their prior ‘NSTEMI’): TWI in III/aVF with reciprocal
tall T waves in aVL, and tall T wave in V2 reciprocal to posterior TWI:<span></span></span></p>
</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbnkMyfplF_8q1Rq2cyLMiMTKspA84VEHoptUASDn0sDXDG-PaXMggPEaN5-djAtWYQNo3Y6dTD1tBWhqKcZSwfbka1n4Nx8ME_KRR97B2_yQ5Vl6mZUVtwn6H8J97TX52c47ZQ5cJDKDT7-myS_PjVfDnkwyCCC0guv8fGDJGTjQ28ai9S5wVu95h_Ls/s1630/6.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="501" data-original-width="1630" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbnkMyfplF_8q1Rq2cyLMiMTKspA84VEHoptUASDn0sDXDG-PaXMggPEaN5-djAtWYQNo3Y6dTD1tBWhqKcZSwfbka1n4Nx8ME_KRR97B2_yQ5Vl6mZUVtwn6H8J97TX52c47ZQ5cJDKDT7-myS_PjVfDnkwyCCC0guv8fGDJGTjQ28ai9S5wVu95h_Ls/w595-h182/6.png" width="595" /></a></div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">Below are the baseline ECG(#1),
ECG with occlusion (#2), and follow up ECGs with progressive reperfusion – from
initial normalization (#3)to progressive reperfusion TWI (#4-5): <br /></span><p class="MsoNormal" style="font-family: Cambria;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjME1IvDfn54J4zNNecOZqcrL0UfAVro3Jw_2L_Vyjl-1vNlMBRkfVb9IgiZJNnXGYT_DPD0YYzUlX6lJebWKAA0MUK3efvhX-Lb3ZKMS-0Ivm1MbtAGUOpYWfLj0PZMklUW2tiEp2aL5KGA6dSBBr0KYvUlWqEv_2YmPgWLqPim2xvP3caih66sUYiffc/s792/7.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="601" data-original-width="792" height="418" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjME1IvDfn54J4zNNecOZqcrL0UfAVro3Jw_2L_Vyjl-1vNlMBRkfVb9IgiZJNnXGYT_DPD0YYzUlX6lJebWKAA0MUK3efvhX-Lb3ZKMS-0Ivm1MbtAGUOpYWfLj0PZMklUW2tiEp2aL5KGA6dSBBr0KYvUlWqEv_2YmPgWLqPim2xvP3caih66sUYiffc/w549-h418/7.png" width="549" /></a></div><br /><span style="font-size: medium;"><br /></span><p></p><p class="MsoNormal" style="font-family: Cambria;">
</p><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>STEMI vs OMI<span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Another study has claimed that
computer interpreted ‘normal’ ECGs can “safely wait for physician
interpretation until the time of patient evaluation without delaying an acute
STEMI diagnosis.” (Deutch et al. <a data-saferedirecturl="https://www.google.com/url?q=https://escholarship.org/uc/item/06c239bc&source=gmail&ust=1706301895483000&usg=AOvVaw2CTDQxjQHUxpNn2wNgmm2K" href="https://escholarship.org/uc/item/06c239bc" style="color: blue; text-decoration: underline;" target="_blank">Validity of
computer-interpreted ‘normal’ or ‘otherwise normal’ ECG in emergency department
triage pateints</a>. West J Emerg Med 2024). They compared computer
interpretations with cardiologist interpretations and final diagnosis of STEMI, and found a Marquettte 12 12SL had 100% negative predictive value of STEMI. But in this case, the ECG did not meet STEMI
criteria and therefore the patient did not get emergent reperfusion and did not
have a diagnosis of STEMI, so their ‘normal’ ECG (also by Marquette 12 SL) would be considered valid
despite the patient having an acute coronary occlusion that was visible on ECG.
Fortunately they spontaneously reperfused, or else they could have had a worse
outcome, but deferring all ‘normal’ ECGs will perpetuate delayed diagnosis and
reperfusion for STEMI(-)OMI.</span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">As Deutch et al note in the limitations
section, their study “does not directly address other outcomes of interest to
an emergency physician such as acute coronary occlusion MI (OMI) which may
benefit from timely reperfusion therapy…Moreover, there is a growing body of
literature supporting a paradigm shift from evaluating ECGs for STEMI vs no
STEMI as an indicator of OMI that may benefit from emergent reperfusion to
evaluating ECGs for signs acute total OMI (inclusive of STEMI negative OMI) vs
non-OMI.” <span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">This same body of literature has
highlighted the hazards of computer-interpreted ‘normal’ ECGs – including <a data-saferedirecturl="https://www.google.com/url?q=http://hqmeded-ecg.blogspot.com/search/label/Normal%2520ECG%2520by%2520computer%2520algorithm&source=gmail&ust=1706301895483000&usg=AOvVaw3EUAzegJxVtCUyX2jOPvLn" href="http://hqmeded-ecg.blogspot.com/search/label/Normal%20ECG%20by%20computer%20algorithm" style="color: blue; text-decoration: underline;" target="_blank">dozens
of cases on this blog</a> and a <a data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14795&source=gmail&ust=1706301895483000&usg=AOvVaw1TP4kwc_TYvwueog3mk6BP" href="https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14795" style="color: blue; text-decoration: underline;" target="_blank">7-year
retrospective review</a> that found 4% of true positive Code STEMIs presented
with an ECG labeled ‘normal’ by computer interpretation—many of which were
identified in real time despite the false reassurance of the computer
interpretation and had rapid reperfusion. This 4% is underestimation because it only included patients admitted as STEMI not those admitted as NSTEMI like the case above.<br /></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;">Rather that comparing conventional
computer interpretations with STEMI criteria, the real goal standard should be
patient outcome of OMI, and then AI can be trained to look for subtle signs of
occlusion. I sent the first three ECGs to the Queen of Hearts: even without
comparison to baseline the first ECG was identified as OMI, the second was
called Not OMI because it had normalized, and the third was called ‘OMI’
because the Queen is currently trained to apply this label to reperfused OMI as
well. Future versions will be able to integrate serial ECGs, and differentiate
between OMI and reperfused OMI.<span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><span></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkm0hX87jCJCFcgalyzCsYeKQoHWw7a_74Frrd3BWHOwmPH1IPXCSDxTHIVT4725O-HlzkNBHDAWCK5oh3co4SImjSParhK4cKBGEHZ2uFKZ2rvmEibfMC0L5OLlqk4fV_yTQVqk3qRnbPk2Zv7LlYG47ucmiCDB5Pnunaa_tu8FgTfK_AdYWzv9qhXlo/s1039/12.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="200" data-original-width="1039" height="124" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkm0hX87jCJCFcgalyzCsYeKQoHWw7a_74Frrd3BWHOwmPH1IPXCSDxTHIVT4725O-HlzkNBHDAWCK5oh3co4SImjSParhK4cKBGEHZ2uFKZ2rvmEibfMC0L5OLlqk4fV_yTQVqk3qRnbPk2Zv7LlYG47ucmiCDB5Pnunaa_tu8FgTfK_AdYWzv9qhXlo/w640-h124/12.png" width="640" /></a></span></div><span style="font-size: medium;"><br />Let's look at explainability for that first ECG:</span></div><div><span style="font-size: medium;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLBKhKHUj-ggq6O5xL2l6f3_ZF6ycl5S6vUGeHHnLBPX301uIDoctS8Tczex0-NmcEylewHp0H1rpyq-L7m_G-tKnR5F_Ejxg_KtFsJmH0PS27Wik7WLytABiKFcz1ArYqUmyXah9gM6hkPUuWQaLzz1jSqjZ8WNP_Tf4cI7YGRXqlQ9ES7VUqM7gP67FL/s2764/Screen%20Shot%202024-01-27%20at%208.23.12%20AM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="988" data-original-width="2764" height="228" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLBKhKHUj-ggq6O5xL2l6f3_ZF6ycl5S6vUGeHHnLBPX301uIDoctS8Tczex0-NmcEylewHp0H1rpyq-L7m_G-tKnR5F_Ejxg_KtFsJmH0PS27Wik7WLytABiKFcz1ArYqUmyXah9gM6hkPUuWQaLzz1jSqjZ8WNP_Tf4cI7YGRXqlQ9ES7VUqM7gP67FL/w640-h228/Screen%20Shot%202024-01-27%20at%208.23.12%20AM.png" width="640" /></a></div><div style="text-align: center;">You can see that it is aVL which the Queen is most concerned about.</div><div style="text-align: center;"> She diagnoses OMI with <b>high confidence.</b></div><div style="text-align: center;">She was correct</div><div style="text-align: center;"><b>And this is in an EKG that the conventional algorithm diagnosed as completely normal!! </b></div><div style="text-align: center;">That algorithm could at least have given a diagnosis of <b>"Nonspecific ST-T abnormalities"</b>, but it could not even do that!!</div></span></div><div><b style="background-color: white; color: red; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><br /></b></div><div><b style="background-color: white; color: red; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;"><br /></b></div><div><b style="background-color: #fcff01; color: red; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</b><p></p>
</div><div style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="background-color: #fcff01; font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="background-color: #fcff01; font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></div><div style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="background-color: #fcff01;"><br style="text-shadow: none;" /></span></div><p style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="background-color: #fcff01;"><span style="font-size: medium; text-shadow: none;"></span></span></p><div style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="background-color: #fcff01; color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;"><b>https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</b></a></span></div><span style="font-size: medium;"><b>
</b></span><p class="MsoNormal" style="font-family: Cambria;"><span style="font-size: medium;"><b>Take away<span></span></b></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>1.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>Computer interpretations of ‘normal’ are based on
STEMI criteria, which will miss STEMI(-)OMI<span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria;"><span style="font-size: medium;"><span><span>2.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>‘NSTEMI’ does not differentiate between
occlusion, reperfusion at risk of reocclusion, and non-occlusive MI<span></span></span></p><span style="font-size: medium;">
<span><span>3.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span>Patterns of occlusion and reperfusion can be
learned and taught, including to AI</span><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><b>4. The Queen of Hearts not only recognizes this "normal" ECG as not normal, but correctly diagnoses OMI with High Confidence<br /></b></span><div><span style="font-size: medium;"><br /></span></div><div style="text-align: center;"><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><div style="text-align: justify;"><div style="font-family: -webkit-standard; text-align: center;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div style="font-family: -webkit-standard; text-align: center;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="caret-color: rgb(0, 0, 238); color: #0000ee; text-align: center; text-decoration: underline;" width="320" /></span></span></div><div style="font-family: -webkit-standard;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div style="font-family: -webkit-standard;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>1/27</i></span><span style="color: #454545;"><i>/2023</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div><span style="font-family: arial;">Superbly illustrated case by Dr. Jesse McLaren — showing that serial ECGs called "normal" and "NSTEMI" were in reality <i>diagnostic</i> of <i style="font-weight: bold;">prior</i> and <b><i>current</i></b> <b>OMIs</b>, including evolving patterns of reperfusion.</span></div><div><ul><li><span style="font-family: arial;"><u>To Emphasize:</u> In a patient with <b><i>new</i></b> <b>CP (</b><i><u>C</u>hest <u>P</u>ain</i><b>)</b> — the oversight of calling the <b><i><u>initial</u></i></b> <b>ECG</b> in today's case <b><i>"normal"</i></b> — <i>is a mistake that should <u>not</u> be made</i>.</span></li><li><span style="font-family: arial;"><br /></span></li><li><span style="font-family: arial;">For clarity — I've labeled this initial ECG in <u style="font-weight: bold;">Figure-1</u>.</span></li></ul><div><span style="font-family: arial;"><br /></span></div></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCHFnImmzLccSe6X8rSBc3S-FHNPTy-ZaOlW3IL7S9fWvieOkbp1OK2rZ8G81vngJ0a1LWuXJhwc_RD2JH09t6WTQ5svmPhoJ9Q0LdIBZI72WSPMf9mIT-LisHKtzboe1GVphNpIMFF4Hrt69gdhyphenhyphenCVB8dhII1a9k2Jp0pF1PINv7nDystPTwFBcj8rKE/s3766/Figure-1%20%20ECG-1%20labeled%20(1-25.23-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="1344" data-original-width="3766" height="228" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCHFnImmzLccSe6X8rSBc3S-FHNPTy-ZaOlW3IL7S9fWvieOkbp1OK2rZ8G81vngJ0a1LWuXJhwc_RD2JH09t6WTQ5svmPhoJ9Q0LdIBZI72WSPMf9mIT-LisHKtzboe1GVphNpIMFF4Hrt69gdhyphenhyphenCVB8dhII1a9k2Jp0pF1PINv7nDystPTwFBcj8rKE/w640-h228/Figure-1%20%20ECG-1%20labeled%20(1-25.23-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;"><span style="font-family: arial;"><b style="text-align: justify;"><u>Figure-1:</u></b></span><span style="font-family: arial;"> I've labeled the <b><i><u>initial</u></i></b> <b>ECG</b> in the ED.</span></span></td></tr></tbody></table><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;"><br /></span></div><div><b><u><span style="font-family: arial;"><i>KEY</i> Findings in the History:</span></u></b></div><div><span style="font-family: arial;">As per Dr. McLaren, <i><u>despite</u></i> a past history of <b><i>prior</i></b> <b>MI</b> — and a presenting history of <b>2 hours of <i><u>new</u></i> CP</b> — ECG #1 in <u>Figure-1</u> was interpreted as "normal" by the cardiologist overreading the computer interpretation — <u>and</u> — this patient was left in the waiting room <i><u>without</u></i> his/her ECG being immediately interpreted by the ED physician.</span></div><div><ul><li><span style="font-family: arial;"><b><u><i>KEY</i> Point:</u></b> All patients who present to the ED for <i>new</i> CP should <i><u>promptly</u></i> have a triage ECG recorded, <b>that is then <i><u>immediately</u></i> interpreted by the ED physician</b>. Today's case illustrates what happens when this procedure isn't followed. <i>It literally should take an experienced ED phsyician minimal seconds to interpret the initial ECG of a patient with new CP.</i></span></li><li><span style="font-family: arial;">Cardiologists assigned to overreading the initial ECG of a patient with <i>new</i> CP should: <b>i<span style="color: red;">)</span></b><i> </i>Not allow themselves to be biased by what the computer says <u><i>until</i></u> they have <i>independently</i> interpreted the ECG; <u>and</u>, <b>ii<span style="color: red;">)</span> </b>Account for the clinical reality that a patient who presents to the ED for <i>new</i> CP is <i><u>by</u></i> <u>definition</u> in a <b><i>"<u>high</u>-prevalence"</i></b> <b>group</b> with <b>significantly</b> <b><i>increased</i></b> <b>likelihood of having an acute event</b> — <i><u>especially</u></i> if this patient has a history of a <b><i>prior</i></b> <b>MI (</b><i>as in today's case</i><b>)</b>. As a result — even subtle ECG abnormalities <i><b>have to be assumed acute</b> — </i><u><i>until</i></u> proven otherwise <b>(</b><i>which was obviously <u>not</u> done in today's case</i><b>)</b>.</span></li></ul></div><div><span style="font-family: arial;"><br /></span></div><div><div><b><u><span style="font-family: arial;"><i>KEY</i> Findings in the <i>Initial</i> ECG:</span></u></b></div><div><span style="font-family: arial;">In a patient with <b><i>new</i></b> <b>CP</b> — emergency providers should pick up on the following ECG findings <i><u>within</u></i> seconds:</span></div><div><ul><li><span style="font-family: arial;"><i><b>The <u>shape</u> of the ST-T wave in</b></i> <b>lead V2 (</b><i>within the RED rectangle in this lead</i><b>)</b>. As we often emphasize — there normally should be gentle upsloping with slight elevation of the ST segment in leads V2 and V3. When this normal feature is lost in one or both of these anterior leads in a patient with <i>new</i> CP — <u>and</u> is replaced by an isoelectric or slightly depressed ST segment — <b><i><u>posterior</u></i></b> <b>OMI</b> should be strongly considered <u><i>until</i></u> proven otherwise. </span></li><li><span style="font-family: arial;">Not only is the ST segment in lead V2 of <u>Figure-1</u> isoelectric and straightened — but there is <b><i>abnormal</i></b> <b>angulation</b> between this straightened ST segment and the <i>taller-than-expected</i> T wave in this lead V2. <b>The shape of the ST-T wave in this lead V2 is a "face" that should be <i><u>instantly</u></i> recognized as <i>abnormal</i> in a patient</b> with new CP.</span></li><li><span style="font-family: arial;">Confirmation that the ST-T wave in lead V2 is abnormal — is forthcoming by the obviously <b><i>"<u>hypervoluminous</u>"</i></b> <b>T wave</b> in <b><i>neighboring</i></b> <b>lead V3</b> <b>(</b><i>within the BLUE rectangle in this lead — with the dotted BLUE line showing that this T wave in V3 is even <u>taller</u> than the R wave in this lead</i><b>)</b>.</span></li></ul><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;"><b><i>Abnormal</i></b> <b>Findings</b> in the <b><i><u>Limb</u></i></b> <b>Leads</b> of <u>Figure-1</u>:</span></div></div></div><div><ul><li><span style="font-family: arial;">I've enclosed within the <i>RED rectangle</i> in <b>lead aVL</b> the <i>KEY</i> limb lead change that should <i><u>immediately</u></i> catch your attention. In a patient with <b><i>new</i></b> <b>CP</b> — there is <b><u><i>no</i></u> way that the downsloping ST depression with terminal biphasic (</b><i>down-up</i><b>) T waves in this lead can be normal (</b><i>RED arrows in lead aVL</i><b>)</b>.</span></li><li><span style="font-family: arial;">The fact that the ST-T wave in lead aVL is <i><u>definitely</u></i> abnormal — should <b><i>heighten</i> your attention to ST-T wave appearance in the <i>inferior</i> leads</b>, since there is so often that <b>"magical" reciprocal</b> <b>(</b><i>mirror-image opposite</i><b>)</b> <b>relationship</b> between the ST-T wave deviation in <b>lead aVL</b> <u><i>vs</i></u> <b>lead III (</b><i>as well as in the other 2 inferior leads = leads II and aVF</i><b>)</b>.</span></li><li><span style="font-family: arial;">In this context — the <i>subtle-but-real</i> <b><i>"fattening"</i></b> of the <b><i>peak</i></b> of the <b>T wave</b> in each of the <b><i><u>inferior</u></i></b> <b>leads (</b><i>upright BLUE arrows in these leads</i><b>) </b>— with subtle straightening of the ST segment takeoff and a hint of J-point ST elevation in leads II,III,aVF <b><u style="font-style: italic;">is</u> abnormal <i><u>until</u></i> proven otherwise</b>.</span></li></ul></div><div><b><i><span style="font-family: arial; font-size: medium;"><br /></span></i></b></div><div><div><span style="font-family: arial;"><i>Are the </i><b>Q waves</b><i> in the </i><b><u style="font-style: italic;">inferior</u> leads </b>of Figure-1 <b><i>"<u>significant</u>"</i>?</b></span></div><div><ul><li><span style="font-family: arial;">Over the years — various definitions have been proposed for what should constitute a <b><i>"<u>significant</u>"</i> Q wave</b>, based on width <i>and/or </i>depth of the Q wave. The obvious implication of such definitions — is that IF a given Q wave is deemed "significant" because it satisfies a certain <i>millimeter-based</i> definition — that this then indicates infarction <i>has</i> occurred at <i>some</i> point in time.</span></li><li><span style="font-family: arial;">I feel <b><i>such definitions are misleading</i></b> because: <b>i<span style="color: red;">)</span> </b>Rather than some <i>millimeter-based</i> global definition for Q wave "significance" — <b><i>other</i> factors defy such generalization</b> <b>(</b>ie, <i>Relative size of the QRS in the lead being looked at in context with the presence or absence of Q waves in neighboring leads</i><b>)</b>; <b>ii<span style="color: red;">)</span></b> Q waves are <u><i>not</i></u> necessarily a permanent finding following infarction — in that what used to be a very large Q wave may with time decrease in size (<i>and even disappear</i>); <b>iii<span style="color: red;">)</span> </b>Axis shift <i>and/or</i> inconsistant chest electrode lead placement may influence both the presence and dimensions of any Q waves seen; <u>and</u>, <b>iv<span style="color: red;">)</span></b> The <i><u>angle</u></i> of the bed at the time the ECG was recorded may also a influence whether or not Q waves are seen.</span></li><li><span style="font-family: arial;"><u style="font-weight: bold;">BOTTOM Line:</u> In my opinion — <b>there is <u style="font-style: italic;">no</u> perfect definition</b> for what constitutes a <b><i>"significant"</i></b> <b>Q wave (</b>ie, <i>a Q wave that indicates infarction has occurred at some point in time</i><b>)</b>. Instead — this is a qualitative judgment to be made by the experienced clinician on the basis of a series of factors. My initial impression regarding the <b><i><u>inferior</u></i></b> <b>Q waves</b> in <u>Figure-1</u> <b>(</b><i>which I arrived at <u>before</u> having seen prior tracings on today's patient</i><b>)</b> — was that these Q waves are <u style="font-style: italic;">not</u> "deep" (<i>considering the relatively tall R waves in leads II,III,aVF</i>) — but that these Q waves are <i><u>wider</u>-than-I-would-normally-expect </i>— and therefore, provide yet one additional ECG feature <i>consistent with</i> <b><i>inferior</i></b> <b>infarction</b> at <i>some</i> point in time. </span></li></ul></div></div><div style="font-family: arial;"><br /></div></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"></span></div></div></span></div></div>Jesse McLarenhttp://www.blogger.com/profile/05809707984126529952noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-9355701096283767662024-01-25T05:30:00.001-06:002024-01-25T07:23:17.523-06:00Acute chest pain in a patient with LVH and known coronary disease. What does the ECG show?<p><span style="font-family: times; font-size: medium;">A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain.</span></p><p><span style="font-family: times; font-size: medium;">Here is his ED ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijQqYpOYpPiizTMxfparQSUChgHAdBzJ1ADMW7yLfXSs81gi75Guue3AQ9sA38K76gShyGcXaYO8nrJd-u0oXq25_l-JoBZnDVQfbRHU3FqSviIIHBUmXGdU0OtL4DNlAmWDYoTZHwnJw2KyrUPDqvPGc4NArS5aaQFftk5HRteNKtFEmoYsicFkpzJC15/s2908/Presenting%20with%20relative%20STD.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1346" data-original-width="2908" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijQqYpOYpPiizTMxfparQSUChgHAdBzJ1ADMW7yLfXSs81gi75Guue3AQ9sA38K76gShyGcXaYO8nrJd-u0oXq25_l-JoBZnDVQfbRHU3FqSviIIHBUmXGdU0OtL4DNlAmWDYoTZHwnJw2KyrUPDqvPGc4NArS5aaQFftk5HRteNKtFEmoYsicFkpzJC15/w640-h296/Presenting%20with%20relative%20STD.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;">What do you think?</div></span><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;">There is a flat and downsloping ST segment in V2 and V3. This could be due to posterior OMI. </span></p><p style="text-align: center;"><span style="font-family: times; font-size: medium;"><b>Is there an old ECG for comparison?</b></span></p><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">Here is the most recent previous ECG:</span></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbW1u9psp_Ua7DHif3VH6Pu22J5Ykm-nsirwji38_6egZtQTG480mvGKIlQIfMFiaOkj7u7hkUYyPg-rEITevuQImcSSkRRGIk0M1p29vKw-w5eARWe7qZx3IyqMoQFov1sLaKq6NH65Y7JqmMTMr00WEwfUzOcLlihF4SyHqt8On9eeUMGAwak0QO9W6j/s3410/most%20recent%20with%20normal%20LVH%20STE%20V1-V3.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1550" data-original-width="3410" height="290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbW1u9psp_Ua7DHif3VH6Pu22J5Ykm-nsirwji38_6egZtQTG480mvGKIlQIfMFiaOkj7u7hkUYyPg-rEITevuQImcSSkRRGIk0M1p29vKw-w5eARWe7qZx3IyqMoQFov1sLaKq6NH65Y7JqmMTMr00WEwfUzOcLlihF4SyHqt8On9eeUMGAwak0QO9W6j/w640-h290/most%20recent%20with%20normal%20LVH%20STE%20V1-V3.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><div style="text-align: center;"><b>Indeed, there was some normal ST elevation in V2 and V3</b>, discordant to a relatively deep S-wave which could be due to some LVH.</div></span><p><span style="font-family: times; font-size: medium;"><br /></span></p><p><span style="font-family: times; font-size: medium;">Here is another previous ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiG93-_vjjsIQmLsos_rrbbMnG2OmWk76DwqLcr3dTzYCBj-rJVxtU9pRvdhB2dQxxEa8A4759MjGRAUDF-_VjFg43Ti3yjhvlLtm9imRaTLZqxCKcvhGhYZhS9ZdGqdtcBRWrodFgbwiIr66DTaxi9uXjsoZMPCAYwHotUTyIad2tVOfzonkS2P8G4wJOZ/s3400/Next%20most%20recent%20LVH%20STE%20V1-V3.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1560" data-original-width="3400" height="294" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiG93-_vjjsIQmLsos_rrbbMnG2OmWk76DwqLcr3dTzYCBj-rJVxtU9pRvdhB2dQxxEa8A4759MjGRAUDF-_VjFg43Ti3yjhvlLtm9imRaTLZqxCKcvhGhYZhS9ZdGqdtcBRWrodFgbwiIr66DTaxi9uXjsoZMPCAYwHotUTyIad2tVOfzonkS2P8G4wJOZ/w640-h294/Next%20most%20recent%20LVH%20STE%20V1-V3.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p><span style="font-size: medium;"><span style="font-family: times;">So it looks like a posterior OMI. <b>2 years prior he had an angiogram which showed </b></span><span style="font-family: times;"><b>90% proximal stenosis of the circumflex.</b> It seems that this was probably the infarct vessel.</span></span></p><div><br /></div><p><span style="font-family: times; font-size: medium;">At this point, I was quite certain that this was a posterior OMI. We initiated "Pathway B", (pathway A is cath lab activation; pathway B is to consult cardiology about possible cath lab activation). </span></p><p><span style="font-family: times; font-size: medium;">Appropriately, they recommended IV NTG and cath lab if that was not successful.</span></p><p><span style="font-family: times; font-size: medium;">Here is the Queen's interpretation as submitted to the telegram bot; she does not have the benefit of comparing with an old one:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZOdefV7eyr-0ybtOlycMDtjPYewV3lP_-TEA7TnSx-l5-Fi4P3MNxNKGUhbM3mDVAwjfZh_i42tvOZXdNcVCNPYV8QlekrKdZPOmQ01iz2x2LBnkB3YARgV37DBOx5vy_i0LMZGWoBj0oPTPGcCxwSV-br7y3RnHsNmz98BCoQeMNlG-iVNaLuzWMDvLG/s894/Presenting%20with%20relative%20STD%20Queen%20Not%20OMI%20low%20confidence.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="550" data-original-width="894" height="394" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZOdefV7eyr-0ybtOlycMDtjPYewV3lP_-TEA7TnSx-l5-Fi4P3MNxNKGUhbM3mDVAwjfZh_i42tvOZXdNcVCNPYV8QlekrKdZPOmQ01iz2x2LBnkB3YARgV37DBOx5vy_i0LMZGWoBj0oPTPGcCxwSV-br7y3RnHsNmz98BCoQeMNlG-iVNaLuzWMDvLG/w640-h394/Presenting%20with%20relative%20STD%20Queen%20Not%20OMI%20low%20confidence.png" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p><span style="font-family: times; font-size: medium;">But when I put it through the PM Cardio app, which is now available in Europe, she says OMI with low confidence.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhvfMePs2Fow2c5uGgt5TENjBWVCWiNbdvHQFGXbXUAgwWWdYTcv1uVHBa3iDGQ09hRX8TFiB3w9CuJo7LXSuHrMaSyrGBUfUWJZMB7GrDy3tb5LjSD4WpL5RUD2SOYf5py3Xg1lIi_qCaLsZLLFEvoRjO59JT_RSp9-MB03Il5f59ldcHo8CuOg4FrZFTS/s1718/PM%20Cardio%20app%20interpretation.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1718" data-original-width="1696" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhvfMePs2Fow2c5uGgt5TENjBWVCWiNbdvHQFGXbXUAgwWWdYTcv1uVHBa3iDGQ09hRX8TFiB3w9CuJo7LXSuHrMaSyrGBUfUWJZMB7GrDy3tb5LjSD4WpL5RUD2SOYf5py3Xg1lIi_qCaLsZLLFEvoRjO59JT_RSp9-MB03Il5f59ldcHo8CuOg4FrZFTS/w632-h640/PM%20Cardio%20app%20interpretation.png" width="632" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"><br /></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"><b>The pain did not resolve with NTG, and so he went to emergent angiography:</b></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"><br /></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">1. Left main: no obvious stenosis.</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">2. LAD: severe in-stent restenosis in the mid (80%) and distal (90%)</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">segment and diffuse disease distally.</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">3. D1: severe (90%) de-novo stenosis in the mid to distal segment.</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">4. Ramus intermedius: large, severe in-stent restenosis at the distal</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">stent edge (90%) and severe de-novo stenosis at the ostial segment (90%).</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"><b>5. LCX: non-dominant. Occluded (it was small and did not supply much prior</b></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;"><b>angiography).</b></span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">6. RCA: Dominant: severe (80%) de-novo proximal stenosis. It supplies a</span></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><span style="font-family: times; font-size: medium;">large RPDA and RPLA.</span></p><p><span style="font-family: times; font-size: medium;"><b>This angiogra is consistent with acute posterior OMI</b></span></p><p><span style="font-family: times; font-size: medium;">Cath showed multiple vessel disease and following discussion with CV surgery, patient was deemed poor surgical candidate for CABG given his multiple comorbidities and poor rehab potential, thus, MPI was done for further evaluation which showed no significant reversible ischemia, so decision was made for <b>medical management</b> as patient has been symptom free for almost two days and has been clinically stable.</span></p><p><span style="font-family: times; font-size: medium;">- Dual Anti Platelet Therapy: continue ASA 81 mg and Plavix 75 mg daily</span></p><p><span style="font-family: times; font-size: medium;">- Continue atorvastatin 40 mg daily</span></p><span style="font-family: times; font-size: medium;"><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="color: red; font-size: medium; text-shadow: none;"><b style="text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</b></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></div><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><br style="text-shadow: none;" /></div><p style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"></span></p><div style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</a></span></div></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><p style="font-family: Times; font-size: medium;"><b style="font-family: times; font-size: large;">See these related posts:</b></p><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;">--<a href="https://hqmeded-ecg.blogspot.com/2018/09/a-dialysis-patient-with-nonspecific.html" style="color: #2066f5; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments</a> (patient has LVH and baseline ECG has non-ischemic STE in V2, V3)</h3><div style="font-family: Times; font-size: medium;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEglAYbWLAqX1OorkSV12tEH3ovuIupXJHwqQU5mS7znMeQkcyt2PWv4xYCpTu0CwYWmk6h1iwBwaBSM4no5NP86Sij1lo7rUwtsDWYi56x0H4Kl3f8s7cOY6z4sulO7vjsM55TxapaWHQjjwEQN1tCESAbasUgIeUuevpWYcWrjCU24t6FAvvBM9VIBfLnE" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="659" data-original-width="1434" height="294" src="https://blogger.googleusercontent.com/img/a/AVvXsEglAYbWLAqX1OorkSV12tEH3ovuIupXJHwqQU5mS7znMeQkcyt2PWv4xYCpTu0CwYWmk6h1iwBwaBSM4no5NP86Sij1lo7rUwtsDWYi56x0H4Kl3f8s7cOY6z4sulO7vjsM55TxapaWHQjjwEQN1tCESAbasUgIeUuevpWYcWrjCU24t6FAvvBM9VIBfLnE=w640-h294" width="640" /></a></div><br /><br /></div><div style="font-family: Times; font-size: medium;"><b><br /></b></div><div style="font-family: Times; font-size: medium;"><b><span style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-size: 18px;">--</span><a href="https://hqmeded-ecg.blogspot.com/2018/04/omi-can-be-diagnosed-by.html" style="color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; text-decoration-line: none; text-decoration: none; text-shadow: none;">OMI Can be Diagnosed by "Pseudonormalization of ST Segments"</a> </b></div><h3 class="post-title entry-title" style="background-color: white; color: #2066f5; font-family: "Open Sans"; font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size: 18px; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; position: relative; text-shadow: none;">(The patient has LVH and baseline LVH ECG has non-ischemic STE in V2, V3)</h3><p style="font-family: Times; font-size: medium;"><span style="font-family: times; font-size: medium;"></span></p><div class="separator" style="clear: both; font-family: Times; font-size: medium; text-align: center;"><span style="font-family: times; font-size: medium;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiO5oaDt2rHZSrh6qYIP65IYAD0BK88i81wnHoxM8fJ8LwJ3M_LxeoqilPtecTvGSDhF9E2OR1MHz8BjLkLLb_wiIuGgjsUavWgHJ0MW8wUXuTpPhveJYNY63EEEq_K8dV5k1EjNsTm4r15vAUhpmzU1jDubmFfVQCovnnmlklXovhYGj7agxQrjQZCLzFF" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="741" data-original-width="1600" height="298" src="https://blogger.googleusercontent.com/img/a/AVvXsEiO5oaDt2rHZSrh6qYIP65IYAD0BK88i81wnHoxM8fJ8LwJ3M_LxeoqilPtecTvGSDhF9E2OR1MHz8BjLkLLb_wiIuGgjsUavWgHJ0MW8wUXuTpPhveJYNY63EEEq_K8dV5k1EjNsTm4r15vAUhpmzU1jDubmFfVQCovnnmlklXovhYGj7agxQrjQZCLzFF=w640-h298" width="640" /></a></span></div><span style="font-family: times; font-size: medium;"><br /></span></span></div></span><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><br /></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><br /></p><p class="p1" style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px;"><br /></p><div style="text-align: justify;"><div style="font-family: -webkit-standard;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><div class="separator" style="caret-color: rgb(0, 0, 0); clear: both; color: black; font-family: -webkit-standard; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div style="font-family: -webkit-standard;"><br /></div><div><br /></div></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>1/25</i></span><span style="color: #454545;"><i>/2023</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div><span style="font-family: arial; font-size: medium;">Today’s interesting case by Dr. Smith offers the unique perspective of assessing the <b><i><u>initial</u></i></b> <b>ECG</b> of a patient who has had <b><i>prior</i></b> <b>events</b> — and, who now presents with <b><span><i>new</i></span> symptoms</b>.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">As per Dr. Smith — today's patient is a 40-something year old patient with severe diabetes, renal failure and known coronary disease — who presents with “acute <i>crushing</i> CP”.</span></li><li><span style="font-family: arial; font-size: medium;">For clarity and ease of comparison in <span style="text-decoration: underline;"><b>Figure-1</b></span> — I’ve reproduced today’s <b><i>initial</i> ECG</b>, together with the patient’s <b><i>most recent prior </i>ECG</b>.</span></li><li><span style="font-family: arial; font-size: medium;">In his discussion — Dr. Smith highlights the flat and downsloping ST segment in leads V2,V3. As a result, his concern is great about <b>acute <i><u>posterior</u></i> OMI</b>.</span></li></ul></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><i>Take Another LOOK</i> at <b>ECG #1</b> — <span style="text-decoration: underline;"><i>before</i></span> you take another look at the most recent prior tracing. </span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><u><span style="font-family: arial; font-size: medium;">QUESTION:</span></u></b></div><div><ul><li><span style="font-family: arial; font-size: medium;">In view of today’s <span style="text-decoration: underline;"><i>presenting</i></span> history — <b><i>What ELSE do you see in ECG #1?</i></b></span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div><span style="font-family: arial; font-size: medium;">To facilitate comparison in <span style="text-decoration: underline;">Figure-1</span> between today’s initial ECG and the most recent prior ECG — I’ve enclosed the <i>KEY</i> leads within <i>RED</i> and <i>BLUE</i> rectangles, respectively. <br /></span><ul><li><span style="font-family: arial; font-size: medium;">As you now <i>Take Another LOOK </i>at <u>ECG #1</u> in comparison to <u>ECG #2</u> — <b><i>How do these 2 tracings differ?</i></b></span></li><li><b><i><span style="font-family: arial; font-size: medium;"><br /></span></i></b></li><li><span style="font-family: arial; font-size: medium;">If told only that <u>ECG #2</u> is the "most recent previous ECG" — <b><i>What might this mean <u>clinically</u>?</i></b></span></li></ul></div><div><b><i><span style="font-family: arial; font-size: medium;"><br /></span></i></b></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSAfIiFnhk8iYDGBAPHDd5MqkMSrQ3iTsrRVZDkrYAh3NZP0Sn_Y6_W-d1c-5l4awCRUwkVaL0u-16UQ48jCvsQmXkDPAAan7IehkuECpCvD2hgX397KL2iufyWg6_aVH4mkdVqwDwLybx8JxV3vGu7PpWVqqshxW97RnJF5WHrIiCjjs2Qev1TTb-t6A/s3280/Figure-1%20%20ECGs-1,2%20(1-23.21-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2792" data-original-width="3280" height="544" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSAfIiFnhk8iYDGBAPHDd5MqkMSrQ3iTsrRVZDkrYAh3NZP0Sn_Y6_W-d1c-5l4awCRUwkVaL0u-16UQ48jCvsQmXkDPAAan7IehkuECpCvD2hgX397KL2iufyWg6_aVH4mkdVqwDwLybx8JxV3vGu7PpWVqqshxW97RnJF5WHrIiCjjs2Qev1TTb-t6A/w640-h544/Figure-1%20%20ECGs-1,2%20(1-23.21-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;"><span style="font-family: arial;"><b style="text-align: justify;"><u>Figure-1:</u></b></span><span style="font-family: arial;"> I've reproduced and have labeled today's <b><i><u>initial</u></i></b> <b>ECG</b> — with the <b><i>most recent <u>prior</u> </i>ECG</b> placed below it to facilitate comparison.</span></span></td></tr></tbody></table><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b style="text-decoration: underline;"><span style="font-family: arial; font-size: medium;">A <i>“Deep Dive”</i> Dissecting the <i>First</i> 2 ECGs in <i>Today’s</i> CASE:</span></b></div><div><span style="font-size: medium;"><span style="font-family: arial;">Dr. Smith correctly concluded that for today’s patient, who presents with <i>"crushing new CP"</i> — the <b><i><u>initial</u></i></b> <b>ECG</b>, interpreted in context with the 2 <i>prior</i> ECGs that were found — essentially <i>confirms</i> <b>acute <i>posterior</i> OMI</b>. </span><span style="font-family: arial;">I nevertheless thought it may be insightful to “retrace” my sequential thoughts as I viewed this case:</span></span></div><div><ul><li><span style="font-family: arial; font-size: medium;">I initially <span style="text-decoration: underline;"><i>only</i></span> saw only <b>ECG #1</b> in <u>Figure-1</u> — without knowing specifics about the history <b>(</b><i>beyond that this patient presented to the ED, presumably for chest pain</i><b>)</b>.</span></li></ul></div><div><p style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variation-settings: normal; line-height: normal; margin: 0px; min-height: 15px;"><span style="font-family: arial; font-size: medium;"><br /></span></p><div><span style="font-family: arial; font-size: medium;"><span style="text-decoration: underline;"><b><i>Looking Closer</i> at the <i>Initial</i> ECG</b></span><span style="color: #2e2d33; text-decoration: underline;"><b>:</b></span> </span></div><div><span style="font-family: arial; font-size: medium;">The rhythm in <u>ECG #1</u> is sinus at ~70/minute. All intervals are normal (<i>PR, QRS, QTc</i>). </span></div><ul><li><span style="font-family: arial; font-size: medium;">The frontal plane axis is leftward enough to qualify as <b><u>LAHB</u> (</b>ie, <i>the QRS being predominantly negative in lead II — therefore defining a leftward axis clearly more negative than -30 degrees</i><b>)</b>. </span></li><li><span style="font-family: arial; font-size: medium;"><b><u>LVH</u></b> is present — with voltage satisfied in <b>lead aVL</b> <b>(</b><i>R in aVL ≥12 mm</i><b>)</b> — and especially by the very deep S wave in <b>lead V2</b> <b>(</b><i>which measures more than 25 mm</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">A fairly large <b><u>Q</u> wave</b> is seen in <b>lead aVL</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><b><u>R</u> wave progression</b> is <b><i><u>poor</u></i></b> — in that <b>transition (</b><i>where the R wave becomes taller than the S wave is deep</i><b>) <u>never</u> occurs!</b> Although LAHB may delay transition (<i>because of loss of some anterior forces</i>) — it usually does <u style="font-style: italic;">not</u> result in such tiny R waves as we see in <u>ECG #1</u>, in which the R wave in leads V5,V6 does <i><u>not</u></i> exceed 2 mm in amplitude.</span></li><li><span style="font-family: arial; font-size: medium;">There is also <b><i>marked</i></b> <b><u>fragmentation</u></b> of the terminal ascending S wave in lateral chest leads V4,V5,V6, which display marked notching <b>(</b><i>within the YELLOW ovals in these lateral chest leads</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><i>Regarding</i> <b><u>S</u>T-<u>T</u> waves</b> — There is <b>ST segment flattening</b> in <i>multiple</i> leads <b>(</b><i>RED lines in leads II,III,aVF; and in V2,V3,V4,V5</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">The ST segment is coved but isoelectric in <b>lead aVL</b> — with fairly deep, symmetric T wave inversion in this lead <b>(</b><i>BLUE arrow in aVL</i><b>)</b>. The T wave is also inverted in <b>leads I</b> and <b>V6</b> <b>(</b><i>BLUE arrow in V6</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">Finally — There is ST elevation in <b>lead aVR (</b><i>RED arrow in this lead</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><i style="font-weight: bold;"><u>Putting It All Together:</u> </i>Before learning about the history — I suspected from <u>ECG #1</u> that this patient had <b>significant <i><u>multivessel</u></i> disease </b>because: <b>i<span style="color: red;">)</span></b> Abnormal ST segment flattening is present in <b>7/12 leads</b> <b>(</b><i>Leads II,III,aVF; and in V2,V3,V4,V5</i><b>) </b>— with abnormal T wave inversion in 3 of the remaining leads <b>(</b><i>leads I,aVL,V6</i><b>)</b>; <b>ii<span style="color: red;">) </span></b>There is ST segment elevation in <b>lead aVR</b>; <u>and</u>, <b>iii<span style="color: red;">)</span></b> There is marked <b>fragmentation</b> — which is a common indicator of "scar" <b>(</b><i>within the YELLOW ovals in leads V4,V5,V6</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><u style="font-weight: bold;"><i>KEY</i> Point:</u> In addition to the above findings suggesting <i>underlying</i> multivessel disease — the ST segment straightening, with abrupt angulation at the junction of the ST segment with ensuing upright T waves in <b>leads V2</b> and <b>V3 (</b><i>within the RED rectangle in ECG #1</i><b>)</b> — is clearly abnormal, because there typically should be slight ST <i>elevation</i> with gentle <i>upsloping</i> of the ST segment in these leads. As per Dr. Smith, in a patient with new chest pain — these flattened ST segments in leads V2,V3 suggest <b>acute <i>posterior</i> OMI</b> <i><u>until</u></i> proven otherwise.</span></li><li><span style="font-family: arial; font-size: medium;">I thought the lateral lead T wave inversion, in association with <i>more-peaked-than-expected</i> T waves in the inferior leads and in leads V2,V3 — might reflect <i>infero-postero-lateral </i><b><i>reperfusion</i></b> <b>T waves</b>.</span></li></ul><p></p></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><u><span style="font-family: arial; font-size: medium;"><i>YOUR Thoughts</i> on Comparing ECG #1 with ECG #2?</span></u></b></div><div><span style="font-family: arial; font-size: medium;">To emphasize — Comparison between ECG #1 and ECG #2 is made difficult by the fact that we are <u style="font-style: italic;">only</u> told that <b>ECG #2</b> is the <i>"most recent previous ECG"</i> on today's patient.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;"><u><b>ECG #2</b></u> is clearly abnormal. There is ST segment flattening in multiple leads — in association with abnormal ST segment coving, with <i>deeper</i> T wave inversion in high-lateral leads I and aVL than is seen in <u>ECG #1</u>. <b><i>It would be important to know the clinical circumstances at the time ECG #2 was obtained </i>(</b>ie, <i>Was ECG #2 associated with recent infarction? — OR — Is this tracing reflective of this patient's true "baseline" ECG?</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">That said — Note the appearance of the ST-T wave in <b>leads V2</b>,<b>V3</b> <b>(</b>ie, <i>within the light BLUE rectangle in ECG #2</i><b>)</b>. This is how a "normal" ST-T wave should look in these leads — being slightly elevated, with gentle upsloping of the ascending ST segment.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><b><u>BOTTOM Line:</u> </b>Although we do not know the clinical circumstances at time <u>ECG #2</u> was obtained <b>(</b><i>and many of the same leads show similar ST segment flattening as is seen in</i> <u>ECG #1</u><b>) </b>— there is <u style="font-style: italic;">no</u> doubt that the ST-T wave appearance in <b>leads V2</b> and <b>V3</b> becomes clearly abnormal in association with "acute <i>crushing</i> CP" at the time <u style="font-weight: bold;">ECG #1</u> is obtained. As per Dr. Smith, in this patient with underlying multivessel disease — today's <b><i><u>initial</u></i></b> <b>ECG</b> is diagnostic of <b><i><u>new</u></i> acute <i>posterior</i> OMI</b> <i><u>until</u></i> proven otherwise. </span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div></div></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><br /></div><div></div>Steve Smithhttp://www.blogger.com/profile/08027289511840815536noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-37422341503638881112024-01-23T10:50:00.001-06:002024-01-23T19:38:46.431-06:00What kind of AV block is this? And why does she develop Ventricular Tachycardia?<p style="text-align: justify;"><span style="font-size: medium;"><b>This was written by Magnus Nossen</b></span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">The patient is a female in her 50s. She presented with a one week hx of «dizziness» and weakness. She was feeling fine prior to the last seven days. There was no chest pain. She did admit to shortness of breath on exertion. She had no known heart condition. Other than being overweight and having an elevated cholesterol she was healthy. She was taking a single perscription drug, a statin.</span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Below is her presentation ECG. How will you interpret the ECG? </span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikHtrX0T9d5f8RhC4LFLzxBYCXy_b-oSX7ue2l5PF0wJPgXVCZGKBB9dZRiTDB0wtxVbnbcNs5qjc8-95v6vGCPOIfYV9rguwqtz1bXwTK6eHdZuYS0i-ENNxE0-L9HUKimTbYjo2B_lBhaODfIabpiWRbFzt97i12lsN211RqSKXyOfELLXR3-RlKPalH/s2560/IMG_4862.JPG" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1216" data-original-width="2560" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikHtrX0T9d5f8RhC4LFLzxBYCXy_b-oSX7ue2l5PF0wJPgXVCZGKBB9dZRiTDB0wtxVbnbcNs5qjc8-95v6vGCPOIfYV9rguwqtz1bXwTK6eHdZuYS0i-ENNxE0-L9HUKimTbYjo2B_lBhaODfIabpiWRbFzt97i12lsN211RqSKXyOfELLXR3-RlKPalH/w640-h304/IMG_4862.JPG" width="640" /></span></a></div><p><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">The ECG above is highly pathological. There are sinus P-waves throughout the tracing. It is immediately apparent that there are more P waves than QRS complexes. Thus some form of AV block must be present. For the majority of the tracing there are two P waves for each QRS. There is a LBBB. </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Whenever there is a fixed 2:1 AV block, it is difficult to determine if the AV block is due AV nodal disease (second degree AV block type I, Wenckebach) or if there is infra-Hisian AV block. Whenever there is a narrow complex 2:1 AV block, you can feel pretty safe that the AV block is second degree type I and therefore the likelihood of progression to complete AV block without stable escape rhythm is quite low. </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">However. If there is a 2:1 AV block with a wide QRS complex —<span style="color: red;"><b> </b></span>it is more likely that the AV block is second degree AV block type II. <i><b>Why is this an important distinction?</b></i> </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Mobitz type I AV block is caused by AV nodal disease. The PR interval gradually prolongs until a QRS is dropped and the pattern repeats itself. If there is no BBB the QRS will be narrow.</span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Mobitz type II AV block usually has a different pathophysiology. In most cases, there is an underlying complete BBB (left or right) and an intermittent block in the other bundle branch. This leads to periods of complete heart block below the His-Purkinje system. If any escape rhythm is present it will be ventricular and very slow.</span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">The ECG above shows LBBB. The P waves that conduct do so with normal PR interval (hinting at normal AV conduction). There is for the most part 2:1 AV block. There is for a short while 3:2 AV conduction. The PR interval seems to be the same, or at least not obviously prolonging. Unfortunately a longer rhythm strip is not available. </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Mobitz type II AV block was suspected. In this case (above ECG) </span><span style="font-family: times; font-size: medium;">ventricular activation depends on the RBB conducting impulses as there is a permanent LBBB. Intermittent RBBB is causing non-conduction leading to dropped QRS complexes. If the RBBB worsens and becomes persistent — ventricular escape rhythm is all that is left.</span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Biochemistry was unremarkable except for a mildy elevated NT-proBNP. Troponins were negative. The patient was admitted with telemetry. During the next 24 hours, she experienced periods of complete AV block with a ventricular escape rhythm in the 20s. She was started on <b>isoprenalin (isoproterenol)</b>. </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Shortly after isoprenalin infusion was initiated, there were short runs of ventricular tachycardia. The following ECG was recorded during one of these episodes of VT.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhco30Q_kC8KG4bBy8veTxOHUA76Tlf4EKnnrTz9pyDrGD0WGeP1pyjK8E1-D52JtWPYO-VZGcvKRODZJLOsz5Iuk3lDEa19QGCXL-T4hReHD0ftWvm9iBTbQFVXo8Ulczkp76_ZNYS7SM8x7z24I8LY_ANj71jcJPtUbbg7EagS4YhyphenhyphenD3bFGv1PDU3q4h-/s2560/IMG_4863.JPG" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1476" data-original-width="2560" height="370" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhco30Q_kC8KG4bBy8veTxOHUA76Tlf4EKnnrTz9pyDrGD0WGeP1pyjK8E1-D52JtWPYO-VZGcvKRODZJLOsz5Iuk3lDEa19QGCXL-T4hReHD0ftWvm9iBTbQFVXo8Ulczkp76_ZNYS7SM8x7z24I8LY_ANj71jcJPtUbbg7EagS4YhyphenhyphenD3bFGv1PDU3q4h-/w640-h370/IMG_4863.JPG" width="640" /></span></a></div><span style="font-family: times; font-size: medium;"><br /></span><p style="text-align: left;"><span style="font-family: times; font-size: medium;">The above ECG initially shows AV block. A run of very fast, irregular polymorphic VT ensues. Isoprenalin was discontinued, and a temporary transveous pacemaker was implanted. The patient stabilized following pacemaker placement.</span></p><p style="text-align: left;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;"><b>Discussion</b>: The initial ECG in today's case is pathological for any patient, especially for a 50-year old previously heathy female. Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc). Usually the medical history will provide clues to the cause. </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. When assessing patients with early onset high grade conduction disorders and ventricular tachydysrhythmia in the absence of coronary disease — <b>cardiac sarcoid</b> should be on the list of differential<b style="caret-color: rgb(255, 0, 0); color: red;"><i> </i></b>diagnoses. </span></p><p style="text-align: justify;"><span style="font-family: times; font-size: medium;">The patient underwent an MRI and cardiac PET scan. Below are videos of the PET scan showing areas of high metabolism/uptake in the myocardium, consistent with cardiac sarcoid.</span></p><p><span style="font-family: times; font-size: medium;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: times; font-size: medium;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwx53ozVMLqvtigYbcrc1BgzAWZV4Lg3cpkOR7u1v16Nj855kOSyMdlXujM2RFEK2z-ZlMUs73LoKVjw7p8bg' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: times; font-size: medium;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dz9l07J1G7eyx1XuQqagSI7Uj8r96X5LRDv-WUbzbZnlipLFUf9DLKWMKsGE9iO1vvUQOZ6_UvnnPtSEl4Z4A' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div><div><br /></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div style="text-align: justify;"><span style="font-family: times; font-size: medium;">The patient was transferred to a facility for cardiac biopsy. The biopsy was consistent with cardiac sarcoidosis. Medical treatment with oral steroids and methotrexate was started. She was given CRT-D (Cardiac Resynchronization Therapy-Defibrillator). The ECG below was recorded after her device was implanted. The ECG shows atrial sensing and biventricular paced rhythm. QRS complexes are quite narrow due to both ventricles being paced in a synchronized fasion. </span></div><span style="font-family: times; font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgC4Y9UZJ5AL0DYUth3Szl1l9AN8nShgl_7-R70KushASowHSLU4Spb5C4n3vf-h99vmHy7szlakGXWjqcQMY15l3lx-N1tuznw0KwmL8tSpBnN_88dqMpgE7UJKGfKAQ_yVumWfM8-gOPjZ1q-Cp9bwrHpRjeBxRn7QHxOFEUvbyvcZYuvnVGQdE1FHvkH/s2560/IMG_4861.JPG" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: times; font-size: medium;"><img border="0" data-original-height="1726" data-original-width="2560" height="432" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgC4Y9UZJ5AL0DYUth3Szl1l9AN8nShgl_7-R70KushASowHSLU4Spb5C4n3vf-h99vmHy7szlakGXWjqcQMY15l3lx-N1tuznw0KwmL8tSpBnN_88dqMpgE7UJKGfKAQ_yVumWfM8-gOPjZ1q-Cp9bwrHpRjeBxRn7QHxOFEUvbyvcZYuvnVGQdE1FHvkH/w640-h432/IMG_4861.JPG" width="640" /></span></a></div><div><span style="font-family: times; font-size: medium;"><br /></span></div><div><p style="-webkit-text-size-adjust: 100%; margin: 0.6923em 0px; text-align: justify; text-size-adjust: 100%;"><span style="font-family: times; font-size: medium;"><br /></span></p><p style="-webkit-text-size-adjust: 100%; margin: 0.6923em 0px; text-align: left; text-size-adjust: 100%;"><span style="font-family: times; font-size: medium;"><b>About sarcoidosis</b>: Sarcoidosis is a multisystem granulomatous disorder. Lung involvement is the typical presentation. Cardiac sarcoidosis (CS) is seen in ~10% of patients with sarcoidosis. The granulomatous inflammation affects the heart, causing an infiltrative cardiomyopathy</span></p><p style="-webkit-text-size-adjust: 100%; margin: 0.6923em 0px; text-align: left; text-size-adjust: 100%;"><span style="font-family: times; font-size: medium;">The most common manifestations of cardiac sarcoidosis are atrioventricular (AV) block and ventricular tachyarrhythmias (VT). AV block is the first manifestation of CS in more than 30% of patients. VT is the second most common presenting arrhythmia. SCD (sudden cardiac death) from sarcoid heart disease is thought to be caused by either from high-grade AV block or VT.</span></p></div><p style="text-align: justify;"><span style="font-family: times; font-size: medium;"><br /></span></p><ul><li><span style="font-family: times; font-size: medium;">Cardiac sarcoidosis is usually associated with lungs sarcoidosis, but can be an isolated finding without other organ involvement. Think of this possibility when you encounter a conduction disorder in a «younger» patient</span></li></ul><ul><li><span style="font-family: times; font-size: medium;">2:1 AV block may pose a diagnostic challenge. In general a wide complex AV block is more dangerous than a narrow complex AV block, which is more likely to have a stable escape rhythm.</span></li></ul><ul><li><span style="font-family: times; font-size: medium;">Vaso or inotropic medications are not harmless, and can precipitate life threatening arrhythmias.</span></li></ul><p></p><p style="text-align: justify;"><b><span style="font-family: times; font-size: medium;">Learning points:</span></b></p><p></p><p></p><p></p><p></p><p><br /></p><div><div style="text-align: justify;"><div style="text-align: left;"><div style="text-align: justify;"><div style="font-family: -webkit-standard;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div style="font-family: -webkit-standard;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><div style="caret-color: rgb(0, 0, 0); color: black;"> </div><div style="caret-color: rgb(0, 0, 0); color: black;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div></div></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><div style="text-align: left;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>1/23</i></span><span style="color: #454545;"><i>/2024</i><b>):</b></span></span></div><div><span style="color: red; font-family: arial; font-size: medium;">=================================== </span></div><div></div><div><span style="font-family: arial; font-size: medium;"><div>Today's case by Dr. Nossen differs from other cases of AV block we have published over the years in Dr. Smith's ECG Blog — in that the <b><i><u>cause</u></i></b> of <b>AV block</b> turned out to be <b>CS (</b><i><u>C</u>ardiac <u>S</u>arcoidosis</i><b>)</b>.</div><div><ul><li>Most of the cases of AV block that we see in practice, are the result of underlying heart disease. That said — it is important to be aware of <i><u><b>other</b></u></i> <b>potential etiologies</b> that emergency providers will periodically encounter <b>(</b><i>See </i><u style="font-weight: bold;">Figure-3</u><i> in the <b>ADDENDUM</b> below for a LIST of potential etiologies of AV Block</i><b>)</b>.</li></ul></div><div><br /></div><div>The 2nd reason I found today's case especially interesting — is the challenge posed by the <b><i><u>initial</u></i></b> <b>ECG</b>. For clarity in <u style="font-weight: bold;">Figure-1</u> — I have reproduced this initial tracing.</div><div><ul><li>The <i>KEY</i> decision to make regarding the interpretation of <u style="font-weight: bold;">ECG #1</u> — is to determine the <i><u><b>type</b></u></i> of <b>2nd-degree AV block</b> that is present<b>?</b></li></ul></div><div><br /></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmODVu1-Hv3slTb4hpHU1l4FhaiDw0s6efwFp9oyyMXJ8W4w8WGyTSFHXY6VHdumj2o7jHaJAdBGK_E-n4gQsI7tvQEqRKGl7-T6EQ46mymZODcduTR5VAr1kVWY3waZ4odNTMSDkKnlyHJFC9AJmHeHMJ75YeMyBUy5Gc-zD03CBYpAMfHguAvg2LYrQ/s3764/Figure-1%20%20ECG-1%20%20Final-%20P%20waves%20(1-15.22-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="2028" data-original-width="3764" height="344" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmODVu1-Hv3slTb4hpHU1l4FhaiDw0s6efwFp9oyyMXJ8W4w8WGyTSFHXY6VHdumj2o7jHaJAdBGK_E-n4gQsI7tvQEqRKGl7-T6EQ46mymZODcduTR5VAr1kVWY3waZ4odNTMSDkKnlyHJFC9AJmHeHMJ75YeMyBUy5Gc-zD03CBYpAMfHguAvg2LYrQ/w640-h344/Figure-1%20%20ECG-1%20%20Final-%20P%20waves%20(1-15.22-2024)-USE.png" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;"><b><u>Figure-1:</u></b> The <b><i><u>initial</u></i></b> <b>ECG</b> in today's case. <i>What type of AV block is present?</i></span></td></tr></tbody></table><div><span style="font-family: arial;"><br /></span></div><div><span style="font-family: arial;"><br /></span></div><b><u><i>MY Thoughts</i> on the ECG in Figure-1:</u></b></span></div><div><span style="font-family: arial; font-size: medium;">Today's <b><i><u>initial</u></i></b> <b>ECG</b> is highly instructive. I'll highlight the following points:</span></div><div style="font-family: arial;"><ul><li><span style="font-size: medium;"><b>There is <u style="font-style: italic;">no</u> long lead rhythm strip</b>. Instead, we are only provided with a 5.5 second rhythm strip that only shows <b>5 beats!</b> It is important to appreciate that <b>we see the <u style="font-style: italic;">same</u> 5 beats in <i>both</i> limb <i>and</i> chest leads</b> <b>(</b>ie, <i>Beats 1,2,3,4,5 in the limb leads are the <u>same</u> as beats 1c,2c,3c,4c,5c in the <u>c</u>hest leads</i><b>)</b>.</span></li><li><span style="font-size: medium;"><br /></span></li><li><span style="font-size: medium;"><b><u>To Emphasize:</u></b> It's impossible to determine with certainty the type of AV block from an abbreviated rhythm strip <i>less</i> than 6 seconds in duration, which contains a total of only 5 beats. That said (<i>as per Dr. Nossen</i>) — We <u style="font-style: italic;">can</u> assess the brief rhythm strip that we have, and predict clinical likelihood of what the rhythm etiology is.</span></li><li><span style="font-size: medium;">In doing so — I have labeled sinus P waves with <i>RED</i> arrows. As per Dr. Nossen — there are more P waves than QRS complexes, which defines this rhythm as some form of <b>2nd-degree AV block</b>.</span></li><li><span style="font-size: medium;">Even without calipers — it should be obvious that the atrial rhythm is <u style="font-style: italic;">not</u> regular! It is common with 2nd- and 3rd-degree AV block to see a <b><i>"<u>ventriculophasic</u>" </i>sinus arrhythmia</b>. Usually with <i>ventriculophasic</i> sinus arrhythmia — the P-P intervals that "sandwich" QRS complexes tend to have <i><u>shorter</u></i> P-P intervals than those P-P intervals that do not contain a QRS between them. The physiologic reason for this — is thought to be the result of momentarily increased circulation from mechanical contraction arising from the "sandwiched in" QRS complex.</span></li><li><span style="font-size: medium;">The QRS complex in <u>ECG #1</u> is wide. QRS morphology is consistent with <b>LBBB (</b><i><u>L</u>eft <u>B</u>undle <u>B</u>ranch <u>B</u>lock</i><b>)</b> — in that there are all upright QRS complexes in lateral leads I,aVL,V6 — and predominantly negative QRS complexes in chest leads until lateral lead V6.</span></li><li><span style="font-size: medium;"><b>There <u style="font-style: italic;">is</u> some conduction of these LBBB complexes</b> — because the PR interval preceding beats #2,3,4 is constant, as well as normal (ie, <i>not more than 0.20 second in duration</i>).</span></li><li><span style="font-size: medium;"><b>ST-T waves</b> in association with LBBB conduction do <u style="font-style: italic;">not</u> suggest acute OMI. That said — there are <i>at the least,</i> some nonspecific ST-T wave abnormalities in the form of ST segment straightening <i>beyond</i> that expected for simple LBBB conduction <b>(</b>ie, <i>in leads II,III,aVF; and in leads V5,V6</i><b>)</b>.</span></li><li><span style="font-size: medium;"><b>The ventricular rhythm is fairly (</b><i>but <u>not</u> completely</i><b>) regular for the first 4 beats</b>. The reason for this slight irregularity is simply a result of the underlying ventriculophasic sinus arrhythmia.</span></li><li><span style="font-size: medium;"><b>Beat #5</b> occurs <i>earlier-than-expected</i> — and <u style="font-style: italic;">is</u> preceded by a P wave. Determination of the PR interval before beat #5 is <i>KEY</i> for distinguishing between Mobitz I <i><u>vs</u></i> Mobitz II forms of AV block — because IF the PR interval before beat #5 is increasing compared to the PR interval before beat #4 — this would suggest <b>Mobitz I (</b> = <i>AV Wenckebach</i><b>)</b> as the type of AV block.</span></li></ul><span style="font-size: medium;"><u style="font-weight: bold;"><div><u><br /></u></div>CAVEATS <i>and</i> PEARLS:</u> Unfortunately, the P wave before beat #5 in occurs <i>before</i> the end of the preceding T wave. As a result — <b>we do <u style="font-style: italic;">not</u> clearly see the onset of this P wave</b>. This makes it difficult to determine whether or not the PR interval before beat #5 is a little bit longer than the PR interval before beat #4.<br /></span><ul><li><span style="font-size: medium;"><u style="font-weight: bold;">PEARL #1:</u> There are <b>3 types</b> of <b>2nd-degree AV block</b>. These are: <b>i<span style="color: red;">)</span></b> <b>Mobitz I (</b> = <i>AV Wenckebach</i><b>)</b> — in which the PR interval progressively increases until a beat is dropped; <b>ii<span style="color: red;">)</span></b> <b>Mobitz II </b>— in which the PR interval is constant, until one or more beats in a row are non-conducted; — <u>and</u>, <b>iii<span style="color: red;">)</span> 2:1 AV block</b> — with which it is impossible to be certain whether or not the type of 2nd-degree block is Mobitz I or Mobitz II, because <b>we <u style="font-style: italic;">never</u> see 2 QRS complexes in a row that are conducted with the same PR interval</b>. <i>It is for this reason that accurate determination of the PR interval before beat #5 is so important for clinical implications of today's case</i>.</span></li><li><span style="font-size: medium;"><br /></span></li><li><span style="font-size: medium;"><b><u>PEARL #2:</u></b> It is highly unusual for the type of AV block to alternate between Mobitz I and Mobitz II. Therefore, when the predominant rhythm is 2nd-degree AV block with 2:1 AV conduction — <b><u>IF</u> <i>elsewhere</i></b> during cardiac monitoring of your patient <b>you see occasional indication of clear Mobitz I (</b>ie, <i>progressive PR interval lengthening before the dropped beat</i><b>)</b> — then it becomes highly likely that those periods of 2:1 block reflect <b>Mobitz I</b> and <u style="font-style: italic;">not</u> Mobitz II.</span></li><li><span style="font-size: medium;"><br /></span></li><li><span style="font-size: medium;"><u style="font-weight: bold;">PEARL #3:</u> As per Dr. Nossen — the reason distinction between Mobitz I <u style="font-style: italic;">vs</u> Mobitz II is important — is because <b>IF the rhythm is Mobitz II — then pacing is needed (</b><i>because of a much higher incidence of progression to complete AV block than is seen with Mobitz I — with onset of complete AV block with Mobitz II often being <u>very</u> sudden!</i><b>)</b>. The physiologic reason why pacing is much more likely to be needed with <b>Mobitz II</b> — is that this conduction defect occurs at a <b><u style="font-style: italic;">lower</u> level in the conduction system</b> <b>(</b>ie, <i><u>below</u> the AV node</i><b>)</b> — therefore implying a slower and much less reliable intrinsic rhythm.</span></li><li><span style="font-size: medium;"><br /></span></li><li><span style="font-size: medium;"><u style="font-weight: bold;">PEARL #4:</u> While impossible to know for certain the type of 2nd-degree AV block in today's case from the brief 5-beat tracing we are provided with — certain <b><i>clinical</i></b> <b>features</b> <u style="font-style: italic;">can</u> help to predict the clinical likelihood of Mobitz I <u style="font-style: italic;">vs</u> Mobitz II when there is <b>2:1 AV block</b>. These clinical features include: <b>i<span style="color: red;">)</span></b> <b>QRS width (</b><i>As noted — Mobitz II occurs <u>lower</u> in the conduction system — therefore it is usually associated with QRS widening and a ventricular conduction defect</i><b>)</b>; <b>ii<span style="color: red;">)</span> <u>Statistics</u> (</b><i>In my experience of seeking out every AV block I have been able to locate over the past 40+ years of my career — well <b>over 95% of all 2nd-degree AV blocks I have encountered are Mobitz I</b>, such that my "collection" of Mobitz II tracings remains limited, compared to many hundreds of Mobitz I tracings</i><b>)</b>; <b>iii<span style="color: red;">)</span> PR interval (</b><i>The finding of a prolonged PR interval for conducted beats is <u>much</u> more commonly seen with Mobitz I AV block</i><b>)</b>; — <u>and</u>, <b>iv<span style="color: red;">)</span> Association with <i>acute</i> <u>or</u> <i>recent</i> MI (</b><i>Mobitz I is a common accompaniment of <u>inferior</u> MI — whereas Mobitz II is more likely to be seen with <u>anterior</u> MI</i><b>)</b>.</span></li><li><span style="font-size: medium;"><b><u><i>CAVEAT</i> to PEARL #4:</u></b> Although the QRS complex is most often narrow with Mobitz I 2nd-degree AV block — it may be wide if there is <i>preexisting</i> BBB. And, although the QRS is most often wide with Mobitz II — it can occasionally be narrow.</span></li></ul><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><b><u><span style="font-size: medium;"><span style="color: red;">L</span>ADDERGRAM of Today's Rhythm:</span></u></b></div><div><span style="font-size: medium;">For clarity in <b><u>Figure-2</u></b> — I've drawn a <b><i><u>laddergram</u></i></b> for the 5-beat rhythm in today's initial ECG.</span></div><div><ul><li><span style="font-size: medium;">As described above — there is 2:1 block for the first 3 beats.</span></li><li><span style="font-size: medium;"><b>Beat #4</b> occurs <i>earlier-than-expected</i>.<i> </i>As best I can tell —<i> the PR interval before beat #5 is <u>not</u> increasing compared to the PR interval before beat #4. </i>That said — IF I was "at the bedside" — I would reserve judgment about the type of 2nd-degree AV block present <u style="font-style: italic;">until</u> I saw a longer period of monitoring <b>(</b><i>this being the reason for the question mark I placed in the AV Nodal Tier after beat #5</i><b>)</b>.</span></li></ul></div><span style="font-family: arial; font-size: medium;"><div><br /></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiL7_zxNJ4O4mZRmSr5RejfbFxGuVNLTBG3MfMNKchqMmQfPsRQGD8qmlVYZ6dv4tO3tN8xCZPxuK2FDECjN401ivdyPUNOPl24ZVUHILAANf1Caew5eOhGlv99OeCWuaX5hehvFkiGvdLRsYtEecaQ_ztEL6bwT0FmUonxtuprzg-w-joZsYNTG9ZhPr8/s3694/Figure-1%20%20ECG-1%20Ladder%20(1-15.21-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-size: medium;"><img border="0" data-original-height="1636" data-original-width="3694" height="284" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiL7_zxNJ4O4mZRmSr5RejfbFxGuVNLTBG3MfMNKchqMmQfPsRQGD8qmlVYZ6dv4tO3tN8xCZPxuK2FDECjN401ivdyPUNOPl24ZVUHILAANf1Caew5eOhGlv99OeCWuaX5hehvFkiGvdLRsYtEecaQ_ztEL6bwT0FmUonxtuprzg-w-joZsYNTG9ZhPr8/w640-h284/Figure-1%20%20ECG-1%20Ladder%20(1-15.21-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b><u>Figure-2:</u></b> Laddergram of the rhythm in today's initial ECG.</span></td></tr></tbody></table><br /><div><br /></div><div><b><i><u><span style="color: red;">P</span>utting <span style="color: red;">I</span>t <span style="color: red;">A</span>ll <span style="color: red;">T</span>ogether:</u></i></b></div><div>As noted above — there is a ventriculophasic sinus arrhythmia in today's <b><i><u>initial</u></i></b> <b>ECG</b>, in which there is some form of 2nd-degree AV block.</div><div><ul><li>While fully acknowledging that there is need for a longer period of monitoring — I agree with Dr. Nossen that <b><i>the AV block is most likely </i>Mobitz II</b> because: <b>i<span style="color: red;">)</span></b><span style="color: red;"> </span>The QRS is wide <b>(</b>ie, <i>there is LBBB</i><b>)</b>; <b>ii<span style="color: red;">)</span> </b>As best I can tell in <u>Figure-2</u> — the PR interval is <i><u>not</u></i> increasing with consecutively conducted beats <b>(</b><i>albeit the T wave of beat #4 "blocks" our view of the true onset of the P wave before beat #5</i><b>)</b>; — <u>and</u>, <b>iii<span style="color: red;">)</span> </b>The <b><i>clinical</i></b> <b>course</b> of today's case is most consistent with <b>Mobitz II</b> AV block — because the patient went on to develop <b><i>complete</i></b> <b>AV block</b>, as well as a run of <b>VT</b> <b>(</b><i>with both of these rhythm disorders being common complications of cardiac sarcoidosis </i>[<i>Hussain and Shetty — </i><b><a href="https://www.ncbi.nlm.nih.gov/books/NBK578192/" target="_blank">StatPearls, 2023</a></b> — <u>and</u> — <i>Sink et al — </i><b><a href="https://www.ahajournals.org/doi/10.1161/JAHA.122.028342" target="_blank">JAHA 12:e028342, 2023</a></b>]<b style="font-style: italic;"> </b><b>)</b>.</li></ul></div><div><br /></div><div>=======================================</div><div><br /></div><div><b><u><span style="color: red;">A</span>DDENDUM:</u></b></div><div><div><div>There are many potential causes of AV block. Although most commonly seen in adults in association with ischemic heart disease (ie,<i> as the result of recent infarction</i>) — or in older adults as the result of fibrosis or calcification of the atrioventricular conduction system — there are a variety of <i><u><b>other</b></u></i> <b><i>Potenial</i></b> <b>Causes</b> of <b>AV Block</b> in adults, as well as in the pediatric age group (<u style="font-weight: bold;">Figure-3</u>).</div><div><ul><li><b><u><i>KEY</i> Point:</u></b> As some of the causes of AV block in <u>Figure-3</u> may be treatable <i>and/or</i> resolve with time — <b><i>a search for the cause is essential</i></b>. For example — bradycardia and AV conduction disturbances are not uncommon with <b><i>Hyperkalemia</i></b>, with these conduction disturbances most often resolving once serum K+ is corrected. </li><li>While today's case is the first we have published on cardiac sarcoidosis — we have featured <b><i>infiltrative</i></b> <b>cardiomyopathy</b> <b>(</b>ie,<i> with amyloidosis — in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2020/11/a-covid-patient-with-cough-and-fever.html" target="_blank">November 15, 2020</a> post</b> <i>in Dr. Smith's ECG Blog</i><b>)</b>.</li><li><u style="font-weight: bold;">NOTE:</u> The indications for permanent pacing are <i><u>different</u></i> in younger patients! Some patients function surprisingly well for long periods of time <i><u>despite</u></i> some degree of AV block. As a result — an <i>"optimal balance"</i> is sought between the immediate need for pacing <u>vs</u> the likelihood of pacer malfunction over time (<i>with eventual need for pacer replacement</i>).</li><li><br /></li><li><u style="font-weight: bold;">P.S.:</u> For those interested in additional examples of AV block <b>(</b><i>including laddergram illustration</i><b>) </b>— Please check out <i>My Comment</i> at the bottom of the page in the <b><a href="https://hqmeded-ecg.blogspot.com/2020/05/syncope-and-chest-pressure-then-unusual.html" target="_blank">May 16, 2020</a> post</b> — the <b><a href="https://hqmeded-ecg.blogspot.com/2021/10/acute-pulmonary-edema-pea-arrest-lbbb.html" target="_blank">October 25, 2021</a> post </b>and — the <b><a href="https://hqmeded-ecg.blogspot.com/2023/07/a-woman-in-her-50s-with-chest-pain-and.html" target="_blank">July 30, 2023</a> post </b>— and, the <b><a href="http://hqmeded-ecg.blogspot.com/2023/04/rbbb-and-lafb-is-it-trifascicular-block.html" target="_blank">April 6, 2023</a> post</b>).</li></ul></div><div><br /></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="font-family: -webkit-standard; margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0WpUq7LDBjkixof7ZGYkxjKByxGwr3K23nnf5R-RYrYLOb9J73mVSL4PfUySGo-47r5Hw9mAdM-wmSwY5U1VNcEYlCQCuRQjV_MRvJL7gpe_c_kiy45jusztBTbuHawZKVpiTv6dd39MgI5wd4Zp35fHthSDn9Peyr8AoHfzb5SXidQ2KAA2EkWEXMVA/s2468/Causes%20of%20AV%20Block.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2382" data-original-width="2468" height="618" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0WpUq7LDBjkixof7ZGYkxjKByxGwr3K23nnf5R-RYrYLOb9J73mVSL4PfUySGo-47r5Hw9mAdM-wmSwY5U1VNcEYlCQCuRQjV_MRvJL7gpe_c_kiy45jusztBTbuHawZKVpiTv6dd39MgI5wd4Zp35fHthSDn9Peyr8AoHfzb5SXidQ2KAA2EkWEXMVA/w640-h618/Causes%20of%20AV%20Block.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b><u>Figure-3:</u></b> Diagnostic considerations for a patient who presents in <b>AV block (</b><i>adapted from Mangi et al</i> — <a href="https://www.ncbi.nlm.nih.gov/books/NBK482359/" target="_blank"><b>StatPearls, 2021</b></a><b>)</b>.<br /><br /></span></td></tr></tbody></table></div><div><br /></div></div></span></div></div></div></div></div><div style="font-family: arial; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"></div> </div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><br /></div><div style="font-family: arial; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; margin-left: 1em; margin-right: 1em;"></span></div></div>Magnus Nossenhttp://www.blogger.com/profile/06004473889664803144noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-52398140840693486022024-01-20T07:00:00.005-06:002024-01-21T08:37:03.357-06:00A man in his 30s with chest pain. How was he managed? What if they had used the Queen of Hearts?<p><span style="font-size: medium;">Written by Pendell Meyers</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity. He stated it did not feel like his prior episodes of reflux. Vitals were within normal limits except some hypertension. </span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Triage ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVnT61u3N4tMsTdlYjAWE85prl406nPkV69SdU9bN0fhbCUTQYwR58fRtPG8SVjX6Y1kwM5pDCBNedi-tEgt2lEN7CxI5rvT5yZhaEN3G5dN740357QI9LGdLKNVB6431tOQ5B0WddtghhddO99sMlJRVRCY_cM2udUMAPGj0sU8mfEA_tt_zcfniwEB3o/s3162/ed1%201532%201.4.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1477" data-original-width="3162" height="299" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVnT61u3N4tMsTdlYjAWE85prl406nPkV69SdU9bN0fhbCUTQYwR58fRtPG8SVjX6Y1kwM5pDCBNedi-tEgt2lEN7CxI5rvT5yZhaEN3G5dN740357QI9LGdLKNVB6431tOQ5B0WddtghhddO99sMlJRVRCY_cM2udUMAPGj0sU8mfEA_tt_zcfniwEB3o/w640-h299/ed1%201532%201.4.png" width="640" /></span></a></div><span style="font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoHGZ3lDSZqqgVtFoeeT2IvDKJsE1RzneBLxFHUtbMg_vriVd6IqP_Gmw8_MGM__i_tGN20mvPzNsb7cFdXLGxNSRp2BkRcfPq1EGDia-qPpgcozqeVVUaS6HM7pvlWklYx89tb0vks-1Kuq5PNhvekS_v-CB6_G5Cd-2a_x7vjffWwLHCOQolcIHMHC9p/s2560/ed1%20qoh%20expl.jpg" style="margin-left: 1em; margin-right: 1em;"></a></span><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoHGZ3lDSZqqgVtFoeeT2IvDKJsE1RzneBLxFHUtbMg_vriVd6IqP_Gmw8_MGM__i_tGN20mvPzNsb7cFdXLGxNSRp2BkRcfPq1EGDia-qPpgcozqeVVUaS6HM7pvlWklYx89tb0vks-1Kuq5PNhvekS_v-CB6_G5Cd-2a_x7vjffWwLHCOQolcIHMHC9p/s2560/ed1%20qoh%20expl.jpg" style="margin-left: 1em; margin-right: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOrIPmeF5_4Z8xVhYluSNHbp9UcpF3F-NQ6vWXSqimVUZoxUrXAoCUECkCHJoUVlX3iH_M8JfAAWzfB4rdjOhWSp0McWa4qAtMitL9a97BifJJq79Nx61ddBwYVZfvGrYXNsW6FiXqEIZX_Xi9F-W8HIYCNr8jAX7KJXERM0pUMXgSKyHxEMu3wuq39Sf2/s830/ed1%20qoh.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="495" data-original-width="830" height="382" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOrIPmeF5_4Z8xVhYluSNHbp9UcpF3F-NQ6vWXSqimVUZoxUrXAoCUECkCHJoUVlX3iH_M8JfAAWzfB4rdjOhWSp0McWa4qAtMitL9a97BifJJq79Nx61ddBwYVZfvGrYXNsW6FiXqEIZX_Xi9F-W8HIYCNr8jAX7KJXERM0pUMXgSKyHxEMu3wuq39Sf2/w640-h382/ed1%20qoh.png" width="640" /></a></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;">And here she explains her assessment:</span></div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvQeLV4BVTFiI4natG_M-6fxJEvof1mI3EiH6-geQWLJOfJ1qAFJxgY_aL2ZukdG5OrhLOI4Nry9U4MAkU1CxebdqO9nLNCpE6sAJOz9Cz7wd8YTZNhr71fb-F_hPChicyi-7ArYcKeCvyzMnBI_1-aPR2By7ppy8aqNRaaP1KjmOykbe91TWuNvHBXzbY/s2560/ed1%20qoh%20expl.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="767" data-original-width="2560" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvQeLV4BVTFiI4natG_M-6fxJEvof1mI3EiH6-geQWLJOfJ1qAFJxgY_aL2ZukdG5OrhLOI4Nry9U4MAkU1CxebdqO9nLNCpE6sAJOz9Cz7wd8YTZNhr71fb-F_hPChicyi-7ArYcKeCvyzMnBI_1-aPR2By7ppy8aqNRaaP1KjmOykbe91TWuNvHBXzbY/w640-h192/ed1%20qoh%20expl.jpg" width="640" /></a></div><br /><span style="font-size: medium;"><br /><br /></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The ECG was read as simply "No ST elevation." Which is true.</span></p><p><span style="font-size: medium;">The initial high sensitivity troponin I returned at around 3300 ng/L. No repeat ECG was done at this time.</span></p><p><span style="font-size: medium;">CT pulmonary angiogram (unnecessary, often done while missing OMI) was unremarkable.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">The diagnosis of "NSTEMI" was made. The physician initiated routine transfer to the local PCI center. Cardiology refused to be the admitting physician because it was "NSTEMI", and forced the ED physician to admit the patient to the hospitalist. </span></p><p><span style="font-size: medium;">Of course, there was terrible boarding and the patient was considered non-emergent (NSTEMI), and so could not leave the ED for some time. </span></p><p><span style="font-size: medium;">Watch what happens in real life to NSTEMIs with refractory chest pain:</span></p><p><span style="font-size: medium;">"During ED course patient received 2 sublingual nitro with no improvement in his pain. I discuss this with cardiology who requested treating his hypertension with metoprolol 25 mg PO which mildly improved his pressure to 130 systolic. Patient received 4mg morphine which improved symptoms to 3 out of 10. Repeat ECG shows no changes."</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Here is that repeat ECG below, around 3 hours after triage:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggvbNnTgtKLw_iZEKs9yqbKVHNucVqvj92mQmCSsXtrfS9cQERgN6QBVLja6ZxDOMPKeTDhcvAxK0gqQCFhveItIg6CHB47jHPYvQU4pDeVf29QK02iNeddzwfFLQC2oJ9EF35IG62NnEPbclJ1uDKXqRH5TpZjAR-8BDv324ICNRL094fE1R4mH5-HaX8/s3147/ed2%201854.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1462" data-original-width="3147" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggvbNnTgtKLw_iZEKs9yqbKVHNucVqvj92mQmCSsXtrfS9cQERgN6QBVLja6ZxDOMPKeTDhcvAxK0gqQCFhveItIg6CHB47jHPYvQU4pDeVf29QK02iNeddzwfFLQC2oJ9EF35IG62NnEPbclJ1uDKXqRH5TpZjAR-8BDv324ICNRL094fE1R4mH5-HaX8/w640-h298/ed2%201854.png" width="640" /></span></a></div><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEit1r6OZaREzZFkqCJEAbZ_etDu6DZH_3kGi5M-_YEynuDr6FhNud5jHixMYCuwu8VUTPvgOAzHdMo47lsMkovynqIOmAlVDVuGV_kFT71o8E49c9KRN5Lc5SiiljaETCZUngIBefn6zRydT8j1knOIMxB1-_z5IyDTSeYo1t_ruwdX-XvZTlyIIXfve6MQ/s832/ed2%20qoh.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="515" data-original-width="832" height="396" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEit1r6OZaREzZFkqCJEAbZ_etDu6DZH_3kGi5M-_YEynuDr6FhNud5jHixMYCuwu8VUTPvgOAzHdMo47lsMkovynqIOmAlVDVuGV_kFT71o8E49c9KRN5Lc5SiiljaETCZUngIBefn6zRydT8j1knOIMxB1-_z5IyDTSeYo1t_ruwdX-XvZTlyIIXfve6MQ/w640-h396/ed2%20qoh.png" width="640" /></span></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7g2V2SWB3s3KkO69Pvlv2Pw-mdK6AMOha8mlv4pgJNKb7SHfUxFRuku-fEAgr9nI1bWRUAF2Pp2QgftszBRsup_hXcCa-22BW9q01mXBz8_CNFkoqyknR1RRET9Dnu6wBztt-bIeUO4EvrfX3z1fS_lCmSNuGUS4xgKXBQEXOnLKxvi0481-Oh8q2V25Y/s2560/ed2%20qoh%20expl.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="767" data-original-width="2560" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7g2V2SWB3s3KkO69Pvlv2Pw-mdK6AMOha8mlv4pgJNKb7SHfUxFRuku-fEAgr9nI1bWRUAF2Pp2QgftszBRsup_hXcCa-22BW9q01mXBz8_CNFkoqyknR1RRET9Dnu6wBztt-bIeUO4EvrfX3z1fS_lCmSNuGUS4xgKXBQEXOnLKxvi0481-Oh8q2V25Y/w640-h192/ed2%20qoh%20expl.jpg" width="640" /></span></a></div><p></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Repeat troponin during delay rose to 18,700 ng/L. </span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Overnight the patient finally got transferred to the PCI center. </span></p><p><span style="font-size: medium;">On arrival the repeat troponin was greater than 25,000 ng/L (the upper limit of reporting in this case). None further were ordered.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Here is the ECG the next morning 8am:</span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><img border="0" data-original-height="1477" data-original-width="3135" height="302" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSD6n0iPUpaqysWimgkI8hcjdGPQmKmo-JpwQuVNM8g7dAOcv-IGxRirs8cWx2P_Wqu-iYfrE9L1xjZbCLwZIR2618qbgzV6xIGwPNKGRYJjmlV3erXyZeNsY3PYq7yqkjuxNDUMEKSAlLJj16MDDytuPzIVbWBH_V-gYsww4iQWwPnozYhzL0a_ZBcx81/w640-h302/ed3%20next%20am%208am.png" style="margin-left: auto; margin-right: auto;" width="640" /></td></tr><tr><td class="tr-caption" style="text-align: center;">Subacute OMI but still ongoing.</td></tr></tbody></table><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSD6n0iPUpaqysWimgkI8hcjdGPQmKmo-JpwQuVNM8g7dAOcv-IGxRirs8cWx2P_Wqu-iYfrE9L1xjZbCLwZIR2618qbgzV6xIGwPNKGRYJjmlV3erXyZeNsY3PYq7yqkjuxNDUMEKSAlLJj16MDDytuPzIVbWBH_V-gYsww4iQWwPnozYhzL0a_ZBcx81/s3135/ed3%20next%20am%208am.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"></span></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSrSZKrXoYHkbZ1BMnKdF3eYzG_dKodrrnvD28V9HbN_Up8I9a4XZFYEuI9O082aXyrwuswtJQeho63dF5lX5N3XQFGB5qFABEJW_7ZMk1Smnsg6A5IfFRpthrYVZ1_TbApxL606ce_ICzjhz7wUqZ2Yb0jzYo_jhUXjogVj4i2AnHVSKjCttu7YN30Dvg/s832/ed3%20qoh.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="500" data-original-width="832" height="384" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSrSZKrXoYHkbZ1BMnKdF3eYzG_dKodrrnvD28V9HbN_Up8I9a4XZFYEuI9O082aXyrwuswtJQeho63dF5lX5N3XQFGB5qFABEJW_7ZMk1Smnsg6A5IfFRpthrYVZ1_TbApxL606ce_ICzjhz7wUqZ2Yb0jzYo_jhUXjogVj4i2AnHVSKjCttu7YN30Dvg/w640-h384/ed3%20qoh.png" width="640" /></span></a></div></div><span style="font-size: medium;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuluKHXIlGbrI5CFpNRT2ouhQIE6DQe_LMhMjd1HzvdcVRdPrWA5tkmxbxHtdkcLVZUPVVw1HU5KD_oF79qFY-98QEg9W91lP_9CzilIpqNuaP1SZiKdqVkNNUkOVVgMhcWafIl7gfzbdX7PImcKOMyQ58WyhtarKOicycj-hHlmjjearG-JCUsbNtp4mt/s1280/ed3%20qoh%20expl.jpg" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="312" data-original-width="1280" height="156" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuluKHXIlGbrI5CFpNRT2ouhQIE6DQe_LMhMjd1HzvdcVRdPrWA5tkmxbxHtdkcLVZUPVVw1HU5KD_oF79qFY-98QEg9W91lP_9CzilIpqNuaP1SZiKdqVkNNUkOVVgMhcWafIl7gfzbdX7PImcKOMyQ58WyhtarKOicycj-hHlmjjearG-JCUsbNtp4mt/w640-h156/ed3%20qoh%20expl.jpg" width="640" /></span></a></div><span style="font-size: medium;"><br /><br /></span><p style="text-align: center;"><span style="font-size: medium;"><br /></span></p><p><b><u><span style="font-size: medium;">Angiogram around 9am:</span></u></b></p><p><span style="font-size: medium;">Culprit lesion mid LAD 100% stenosis TIMI 0</span></p><p><span style="font-size: medium;">TIMI 3 after PCI</span></p><p><span style="font-size: medium;">Severe apical dyskinesis, severe anteroapical akinesis. LV EF 35%.</span></p><p><span style="font-size: medium;">Scattered other nonobstructive CAD.</span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;">Last ECG:</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXBMJ2J3D-TKmG787FPXiYuZjdQNA1M7CRLkNaHo95sZFmMcYG1TSu65fwSwxguYhLc09TnmnHi31depq03gdPqfZ9sSfmeCGqkPp7llkyM_UHOHQXCRkvHSSaH3354dL7ZsqO4KhBEqKqPol5NboGl7pieJmmZSUJyNRR8DspDnyONItRSM71ozcP-iym/s3140/ed5%20last%20in%20file.png" style="margin-left: 1em; margin-right: 1em;"><span style="font-size: medium;"><img border="0" data-original-height="1492" data-original-width="3140" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXBMJ2J3D-TKmG787FPXiYuZjdQNA1M7CRLkNaHo95sZFmMcYG1TSu65fwSwxguYhLc09TnmnHi31depq03gdPqfZ9sSfmeCGqkPp7llkyM_UHOHQXCRkvHSSaH3354dL7ZsqO4KhBEqKqPol5NboGl7pieJmmZSUJyNRR8DspDnyONItRSM71ozcP-iym/w640-h304/ed5%20last%20in%20file.png" width="640" /></span></a></div><p style="text-align: center;"><br /></p><p><span style="font-size: medium;">Final Diagnosis: "NSTEMI"</span></p><p><span style="color: red; font-size: medium;"><b>This patient will likely suffer heart failure and early death due to the diagnosis of "NSTEMI"</b></span></p><p><span style="font-size: medium;"><br /></span></p><p><span style="font-size: medium;"><b><u>Learning Points:</u></b></span></p><p><span style="font-size: medium;">Despite NSTEMI guidelines recommending emergent angiography for NSTEMI patients with refractory ischemic symptoms, this is simply not done in many systems, and this has been<a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/clc.23781" target="_blank"> recorded in a study as well</a>.</span></p><p><span style="font-size: medium;">Instead, pain is numbed and thus ischemia is obscured with opioids, excuses like hypertension are blamed, and unnecessary CT pulmonary angiograms are focused on. The result is systematic misdiagnosis and delay in treatment for OMI patients with NSTEMI. Once in a while they die during the hospitalization, but I fear that many more like this patient survive for now to develop lifelong increased morbidity and mortality from heart failure.</span></p><p><span style="font-size: medium;">This patient does not show up in the STEMI registry, and the time to reperfusion will likely not be identified as the problem that it was.</span></p><p><span style="font-size: medium;">The STEMI registry will show very high sensitivity of the ECG for STEMI, obscuring the fact the STEMI has low sensitivity for OMI</span></p><p><span style="font-size: medium;">Queen of Hearts sees it easily, like readers of the blog would.</span></p><p><span style="font-size: medium;">Even if you don't have the skill or the technology to see this on the ECG, OMI is a clinical diagnosis that happens to your patients that you must be able to understand and diagnose it better than the current STEMI/NSTEMI paradigm.</span></p><p><span style="font-size: medium;"><br /></span></p><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="color: red; font-family: times; font-size: medium; text-shadow: none;"><b style="text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</b></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"><span style="text-shadow: none;">Here you will sign up for the </span><span style="color: red; text-shadow: none;">Queen of Hearts</span><span style="text-shadow: none;"> on the Telegram app:</span></span></div><p style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="font-family: times; text-shadow: none;"></span></span></p><div style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</a></span></div><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"><span style="font-family: times; text-shadow: none;"> </span></span></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="text-shadow: none;"><span style="font-family: times; text-shadow: none;"><b style="text-shadow: none;">Or, you can get the <u style="text-shadow: none;">PM Cardio app</u> with Queen of Hearts function through this QR code.</b></span></span></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Cambria; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><span style="font-family: "Times New Roman"; text-shadow: none;"><br style="text-shadow: none;" /></span></span></p><p><span style="font-size: medium;"><span style="background-color: white; color: #333333; font-family: times; font-size: medium; text-shadow: none;"></span></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"><span style="font-size: medium; text-shadow: none;">When you register on the app, you need to say you are from a supported country in the EU. You will get <b style="text-shadow: none;">5 free reports.</b> After that, it is $30 per month.</span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"><span style="font-size: medium; text-shadow: none;"><br /></span></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: "Open Sans"; font-size: 13px; margin: 0cm 0cm 0.0001pt; text-shadow: none;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNPqh90H2sMWuGr0juunL4o2Nri3Anom0mvTxEhGosmcoRJ0jUM1w_nmVNvIfb9_6ZiwUnTkQvTjUwdenOCSX1ktjWNy0PiFEUgAm6GhisiW_Ek766XDjtY9k5mMdE9l9yuubOAJ7jUH4AYqOZam65HEMcndDE6PJSRXaTHYYG6Rzrxs9VU9K946L9G92c/s336/QR%20code%20for%20blog.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="278" data-original-width="336" height="265" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNPqh90H2sMWuGr0juunL4o2Nri3Anom0mvTxEhGosmcoRJ0jUM1w_nmVNvIfb9_6ZiwUnTkQvTjUwdenOCSX1ktjWNy0PiFEUgAm6GhisiW_Ek766XDjtY9k5mMdE9l9yuubOAJ7jUH4AYqOZam65HEMcndDE6PJSRXaTHYYG6Rzrxs9VU9K946L9G92c/s320/QR%20code%20for%20blog.png" width="320" /></a></div><br /><span style="font-size: medium; text-shadow: none;"><br /></span><p></p><p><span style="font-size: medium;"></span></p><div style="text-align: justify;"><div style="text-align: left;"><span style="font-family: arial; font-size: medium;"><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial; font-size: medium; margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s1600/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" width="320" /></a></span></div><div><br /></div></div></span></div></div><div style="text-align: justify;"><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>1/20</i></span><span style="color: #454545;"><i>/2024</i><b>):</b></span></span></p><div><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div></div><p><span style="font-family: arial; font-size: medium;"></span></p><div style="text-align: justify;"><div style="text-align: left;"><span style="font-family: arial; font-size: medium;"><div style="text-align: justify;"><div>Today's unfortunate story reviews a case of <b><i><u>deWinter</u></i> T waves</b> that was totally missed. We’ve reviewed multiple variations on this theme in Dr. Smith’s ECG Blog <b>(</b><i>See My Comment at the bottom of the page in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2023/10/what-is-infarct-artery-what-does-post.html" target="_blank">October 6, 2023</a> post</b> — and<i> the</i> <b><a href="https://hqmeded-ecg.blogspot.com/2023/04/compare-these-two-ecgs-do-either.html" target="_blank">April 17, 2023</a> post</b> — <i>to name just two</i><b>)</b>. </div><div><div><div><ul><li><span style="font-family: arial; font-size: medium;">What regularly impresses me about this clinical entity <b>(</b><i>that predicts impending and/or ongoing LAD OMI</i><b>)</b> — is that <b>depending on <u><i>when</i></u> during the process a given ECG is obtained — the ECG “picture” of deWinter T waves may vary</b> in a number of ways from the 8 clinical ECG examples presented in the original NEJM manuscript by deWinter et al (<b><u>Figure-1</u>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">Today’s case presents yet another variation — in that what represents clear indication of a <b><i>deWinter</i></b> <b>T wave </b>in <b>lead V2</b> of today's <b><i><u>initial</u></i></b> <b>ECG</b> — then goes on to manifest a more traditional evolution of an anterior OMI without additional deWinter T waves.</span></li></ul><div><br /></div><div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWZvwbYh_VwD3U26fmhqmuaWMle7Myyh_JxH5ILFGj2VGLn3wt2QTrvQNEsrMXKkdga6r31moge_dcnUppVEgz0OBv_LViOAUU8vmETIMme1LTDzT9lj4X5QcW0SQpoJOsvtVRNvfESBQ/s2048/Figure-2++deWinter+T+Waves-NEJM+%25281-9.21-2021%2529.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2048" data-original-width="1665" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWZvwbYh_VwD3U26fmhqmuaWMle7Myyh_JxH5ILFGj2VGLn3wt2QTrvQNEsrMXKkdga6r31moge_dcnUppVEgz0OBv_LViOAUU8vmETIMme1LTDzT9lj4X5QcW0SQpoJOsvtVRNvfESBQ/w520-h640/Figure-2++deWinter+T+Waves-NEJM+%25281-9.21-2021%2529.png" width="520" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b style="text-align: justify;"><u>Figure-1:</u></b><span style="text-align: justify;"> The <b><i><u>de</u><u>Winter</u> T Wave Pattern</i></b>, as first described by Robbert J. de Winter et al in N Engl J Med 359:2071-2073, 2008. ECGs for the 8 patients shown here were obtained between 26 and 141 minutes after the onset of symptoms. (<i>See My Comment in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2023/04/compare-these-two-ecgs-do-either.html" target="_blank">April 17, 2023</a> post </b><i>for more on this pattern</i>).</span></span></td></tr></tbody></table></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;">=================================== </span></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><span style="font-family: arial; font-size: medium;"><b><u>Today's <i>Initial</i> ECG:</u></b></span></div><div><span style="font-family: arial; font-size: medium;">As we have stressed on many occasions — the importance of recognizing <b><i>deWinter</i></b> <b>T waves</b>, is that in a patient with <b>severe, <i>new-onset</i> CP (</b><i><u>C</u>hest <u>P</u>ain</i><b>)</b>, as in today's case — the diagnosis of an acute OMI <u style="font-style: italic;">until</u> proven otherwise should be <i>instantly</i> made the moment the ECG picture in <b>lead V2</b> of today's <b><i><u>initial</u></i></b> <b>ECG</b> is seen <b>(</b><i>within the RED rectangle in </i><u><b>Figure-2</b></u><b>)</b>.</span></div></div></div></div><div><ul><li>More than just a QS pattern in lead V2 — there has been <b><i><u>loss</u> of r wave</i></b> from lead V1, with <b><i>initial</i></b> <b>fragmentation</b> of this QRS complex <b>(</b>ie, <i>more than just a QS — lead V2 manifests a <b>qrS</b> complex</i><b>)</b>. R wave progression is limited throughout the remainder of the chest leads — with r waves remaining small and transition delayed until lead V5-to-V6.</li><li>That the <b>T wave</b> in <b>lead V2</b> is <b><i><u>hyperacute</u></i></b> can be recognized from across the room. This hugely disproportionate T wave could easily "swallow up" the tiny QRS in this lead — and is all but screaming, <b><i>"Take me to the cath lab — my LAD is acutely occluded!"</i></b></li><li>Although most of the time with deWinter T waves — giant T waves are seen in <i>more</i> than a single lead — the T waves in <b>leads V3-thru-V6</b> <i><u>are</u></i> nevertheless <b>hyperacute</b> <b>(</b><i>BLUE arrows in these leads highlighting disproportionate increase in size, with "fatter"-than-expected T wave peaks for each of these leads</i><b>)</b>.</li><li>ST-T wave changes in the limb leads are more subtle — but still present. Although not appreciably elevated — the <i>shape</i> of the ST-T waves in leads I and aVL looks acute. In this context — I interpreted the straightening of the ST segments in leads III and aVF as a reciprocal change.</li><li><br /></li><li><u style="font-weight: bold;">BOTTOM Line:</u> In this patient with severe <i>new-onset</i> CP — I interpreted the dramatic disproportionality of the T wave in lead V2, in association with much more subtle but nevertheless still hyperacute T wave appearance in the remaining chest leads as consistent with a <b><i>deWinter</i></b> <b>T wave pattern</b>. In association with reciprocal inferior lead changes and the fragmented qrS in lead V2, followed by poor R wave progression — ongoing infarction has to be assumed until proven otherwise. <b>Prompt cath with PCI is <u>needed</u> (</b><i>with this decision justified even <u>before</u> doing repeat ECGs and <u>before</u> learning that troponin was so markedly elevated</i><b>)</b>.</li></ul><div><br /></div><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4lp0mAs2MSaqSQ1B-LZ_UoY7oThndZy8JeZU8LHAAvQN91G90LbpovswPtsUtc63kp6IT6raDLh68pY0PAiTPJ8nXYWhD1MH7iU9qSYWistPaXsJbpjLym5Z1QcCJC_Ag0HiXTbuivW1IOss6qRUq4ZdT5kRmjeO77q05JKVPW_ES4Yuz7JKIlr6bIZg/s3786/Figure-1%20%20ECG-1%20(1-14.23-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-size: medium;"><img border="0" data-original-height="1582" data-original-width="3786" height="268" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4lp0mAs2MSaqSQ1B-LZ_UoY7oThndZy8JeZU8LHAAvQN91G90LbpovswPtsUtc63kp6IT6raDLh68pY0PAiTPJ8nXYWhD1MH7iU9qSYWistPaXsJbpjLym5Z1QcCJC_Ag0HiXTbuivW1IOss6qRUq4ZdT5kRmjeO77q05JKVPW_ES4Yuz7JKIlr6bIZg/w640-h268/Figure-1%20%20ECG-1%20(1-14.23-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;"><b style="text-align: justify;"><u>Figure-2:</u></b><span style="text-align: justify;"> I've labeled the <b><i><u>initial</u></i></b> <b>ECG</b> in today's case.</span></span></td></tr></tbody></table><br /><div><br /></div></div></div></span></div></div>Pendellhttp://www.blogger.com/profile/06506068475871794508noreply@blogger.com0tag:blogger.com,1999:blog-549949223388475481.post-70852196344099221152024-01-17T09:06:00.000-06:002024-01-17T09:06:24.992-06:00Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";"></span></b></span><span style="font-size: medium;"></span><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span></span></span><span style="font-family: "Times New Roman";">Written by Jesse McLaren</span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> <br /></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Two patients
presented with acute chest pain, and below are the precordial leads V1-6 for
each. Patient 1 (ECG on the left) was a 45 year-old male, and patient 2 (ECG is
on the right) was a 70 year-old male. The limb leads have been removed because
there was no ST elevation in those leads, the QRS complexes have been
obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation.<span></span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Using the
current paradigm, can you tell which patient had an acute coronary occlusion? Using
T wave amplitude, can you tell which ECG has hyperacute T waves? What other parts
of the ECG would you like to see, and how will you use this to refine your
interpretation?</span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span> Patient 1<span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> Patient 2</span></span><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcWf0mMx3ghyphenhyphenDSSAaW9qFz4-HXIa-E4Orhe6xI4-jC9OODVon1m8LMONASdDRIdGmf7vzFQFnLD8OuCp3_9wPWfq7zxHdN-36K5z9TZ5Afd14_9Mx7BMnU1CyvmbCg7xpsa-_3mm0KUHe7NdOjfbeptSA0wQqPJdvA_ayeODcdkVfMpsRPfjRcaB-IoMA/s1157/qrs.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="398" data-original-width="1157" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcWf0mMx3ghyphenhyphenDSSAaW9qFz4-HXIa-E4Orhe6xI4-jC9OODVon1m8LMONASdDRIdGmf7vzFQFnLD8OuCp3_9wPWfq7zxHdN-36K5z9TZ5Afd14_9Mx7BMnU1CyvmbCg7xpsa-_3mm0KUHe7NdOjfbeptSA0wQqPJdvA_ayeODcdkVfMpsRPfjRcaB-IoMA/w640-h220/qrs.png" width="640" /></a></div><br /><span style="font-size: medium;"><br /></span><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;">
</p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">STEMI criteria
is based only ST elevation millimeter criteria measured in isolation from the QRS
and stratified by age/sex, so this is the only information provided above. Based
on age/sex, STEMI criteria for both patients is ST elevation in 2 contiguous
leads of 2mm in V2-3 and 1mm in all other leads.<span></span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">You have all the
information you need to apply STEMI criteria: the ECG on the left is STEMI
positive and the ECG on the right in STEMI negative. So based on the current
paradigm, the cath lab should be activated for the patient on the left but not
the patient on the right. If you look at T wave amplitude in isolation, both
ECGs have similar sized T waves, so this doesn’t seem to help at
differentiating these ECGs. <span></span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">STEMI vs OMI<span></span></span></b></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Now let’s see the
rest of the ECG: can you tell which patient has an acute coronary occlusion,
and which ECG has hyperacute T waves?<span></span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Patient 1 (from top
ECG on the left): what do you think?<span></span></span></span></p><span style="font-size: medium;">
</span><div><span style="font-size: medium;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtAzoyDIlox1i-6Q9V3ceMExt5lr2FhekKgAQbwVf5rEzc2mWaaHPfJKj-ZFzhw-aIdIRzi8i9UiXi2i1sZz16cc5nHor8x8Z7F4oC-1BttYzfW0Uim0aWgUrqk3bQjTbJdrFammUGsffYiAML5_WoqtwKGNFJ_p9Rzlt7LBeLMU7TB2hd1FeKxsMLPus/s1102/QRS1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="552" data-original-width="1102" height="321" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtAzoyDIlox1i-6Q9V3ceMExt5lr2FhekKgAQbwVf5rEzc2mWaaHPfJKj-ZFzhw-aIdIRzi8i9UiXi2i1sZz16cc5nHor8x8Z7F4oC-1BttYzfW0Uim0aWgUrqk3bQjTbJdrFammUGsffYiAML5_WoqtwKGNFJ_p9Rzlt7LBeLMU7TB2hd1FeKxsMLPus/w640-h321/QRS1.jpg" width="640" /></a></div><br /><div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Now that we can
see the QRS we notice large voltages, spilling off the page in V4, with
proportional ST/T waves. Smith showed that LAD occlusion and normal variants
can have similar ST elevation and T wave amplitude, but what distinguishes them
is the QRS in V2, R wave in V4 and QT interval [1] – all of which are
reassuring here.<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">But STEMI
criteria ignore all this and look at ST segments in isolation. The initial
computer and final cardiology interpretation was a differential: “ST elevation,
consider early repolarization, pericarditis, or injury.” Based on STEMI
criteria and unhelpful computer interpretation, the patient was rushed to the
cath lab. But coronaries were normal, serial troponin was normal, CT chest was normal,
and the patient was discharged. <span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Patient 2 (from
top ECG on the right): what do you think?</span></span></p></div><div><br /><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjz4PR0_0xoVU3AD_IhPHkqISLGmWCqQHYvzR5l4LkQnftR_ac61emd1c07ihTZsRPj2HqQfzz44FxT-GMQe_ANV24ZFOc_WqNZ2pxBonDAXfi9aDLyiAlcDGkp3xCbpKY4aoQ_iyfD8e2AZVDXGlfu-lu6XZAetEET_h_V9XOPygaSWAN_C4aykcPVPDw/s1136/qrs2.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="313" data-original-width="1136" height="176" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjz4PR0_0xoVU3AD_IhPHkqISLGmWCqQHYvzR5l4LkQnftR_ac61emd1c07ihTZsRPj2HqQfzz44FxT-GMQe_ANV24ZFOc_WqNZ2pxBonDAXfi9aDLyiAlcDGkp3xCbpKY4aoQ_iyfD8e2AZVDXGlfu-lu6XZAetEET_h_V9XOPygaSWAN_C4aykcPVPDw/w640-h176/qrs2.png" width="640" /></a></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"> </span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Looking at the
QRS, we see small Q waves in V2-3 and loss of R wave in V3 – which excludes
normal variant. The QRS amplitude in V2 and R wave in V4 are much smaller than
the ECG above, which makes the anterior ST elevation more concerning. And relative
with the QRS in V2-3, the T waves are massive. This is enough to diagnose LAD
occlusion, but looking at the rest of the ECG we also see down/up ST segment in
III reciprocal to a hint of ST elevation in aVL – which localizes the occlusion
to the proximal LAD. <span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">But the initial
computer interpretation was “<b>normal ECG</b>”,
which was signed off by a physician, so the patient stayed in the waiting room.
Fortunately their first troponin was elevated at 97ng/L (normal <26 in
males) so the patient was brought into a room for a repeat ECG:<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX5hGqacxeuMVnDwYA7OVT94__sEgx2gvdrlAKW9AxOIRunACw14f_dunfXaKIVrHHMchOxn2xQhLSA6GISfZqpCuupeWNrg7rza_sNWKa2PvMciF-rUrg4be4peyuAIyZy1hnEOcQeR1TJ-BJgctn6j78k8GMsmxKWsnBrSIajC2XwYbf3jVAay4i1SM/s1167/qrs4.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="328" data-original-width="1167" height="167" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX5hGqacxeuMVnDwYA7OVT94__sEgx2gvdrlAKW9AxOIRunACw14f_dunfXaKIVrHHMchOxn2xQhLSA6GISfZqpCuupeWNrg7rza_sNWKa2PvMciF-rUrg4be4peyuAIyZy1hnEOcQeR1TJ-BJgctn6j78k8GMsmxKWsnBrSIajC2XwYbf3jVAay4i1SM/w593-h167/qrs4.png" width="593" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Now there’s a
full Q wave in V2 but the T waves have deflated, suggesting some reperfusion at the time of the ECG. The cath lab was activated and
found a 100% LAD occlusion, with peak troponin I 8227 ng/L. This case was one of
the 4% of true positive Code STEMI with an initial ECG labeled ‘normal’ by
computer interpretation,[2] and there are dozens more such cases detailed <b><a data-saferedirecturl="https://www.google.com/url?q=http://hqmeded-ecg.blogspot.com/search/label/Normal%2520ECG%2520by%2520computer%2520algorithm&source=gmail&ust=1705504329462000&usg=AOvVaw3esU5rgxY613dUoBYM0gYu" href="http://hqmeded-ecg.blogspot.com/search/label/Normal%20ECG%20by%20computer%20algorithm" style="color: blue; text-decoration: underline;" target="_blank">here</a></b>.
<span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The discharge
ECG showed ongoing loss of R wave in V2, and anterolateral reperfusion T wave inversion:<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4cFeupAK3EuR62MvVwl9jtBp-UFRZpIUNYBScVlcJ5y0cvcKJnVn0UwrYsgJ_e5Ou4biP5qDHXfCaLSJHGHly9_z0hDvJ64CNExM6eiug7BMdTU4UA1ZreNojazYFazMbngjCEoGbKONn7qoi5BSfgicOTM7usKGN3ni9cUhqma_yDOylIX_KEQS-aGE/s1204/qrs5.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="329" data-original-width="1204" height="163" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4cFeupAK3EuR62MvVwl9jtBp-UFRZpIUNYBScVlcJ5y0cvcKJnVn0UwrYsgJ_e5Ou4biP5qDHXfCaLSJHGHly9_z0hDvJ64CNExM6eiug7BMdTU4UA1ZreNojazYFazMbngjCEoGbKONn7qoi5BSfgicOTM7usKGN3ni9cUhqma_yDOylIX_KEQS-aGE/w599-h163/qrs5.png" width="599" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">STEMI computer interpretation vs OMI AI<span></span></span></b></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">Comparing the
two ECGs including the QRS, the ST elevation on the left is greater but this is proportional to
large voltages. The amplitude of T waves is similar, but relative to their
respective QRS the T waves on the left are normal and those on the right are
hyperacute. That’s why the key to assessing hyperacute T waves is
proportionality relative to the QRS.[3]<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><span> </span><span> Patient 2<span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> Patient 2</span></span><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbYX3t1siepLCribg61bLYlsZoxcG6a4QYOjK-RSXbzsQ2XJ53591N_1OHei6ESN8VJj-FhxdtbcTKN16lHEBU8mhEyiVOqasocANx5VAsByR597-cPKeYAMp6W4h1undJ_F7Sb9YEeHRqBBocv15koyS-IgMnYjUGHV0cOWZ3m11P5QUo4eG32sXCoXs/s907/qrs3.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="280" data-original-width="907" height="185" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbYX3t1siepLCribg61bLYlsZoxcG6a4QYOjK-RSXbzsQ2XJ53591N_1OHei6ESN8VJj-FhxdtbcTKN16lHEBU8mhEyiVOqasocANx5VAsByR597-cPKeYAMp6W4h1undJ_F7Sb9YEeHRqBBocv15koyS-IgMnYjUGHV0cOWZ3m11P5QUo4eG32sXCoXs/w600-h185/qrs3.png" width="600" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">The STEMI
paradigm, and the computer interpretations based on it, only look at ST
segments and measure it in isolation from the QRS. Not surprisingly, this leads
to high rates of false positives and false negatives. ECG signs of OMI -
including looking at the ECG in totality and assessing ST segments and T waves
based on proportionality – are much more accurate [4] and have been taught to
AI.[5] <span></span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p>
<p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">I sent the first
ECGs from each patient to the Queen of Hearts:<span></span></span></span></p>
</div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><span> Patient 1<span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> Patient 2</span></span><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2gNK2RbykuVA9a8_NLT300zHVDrcQUdh7hwwBTIlNu3CXKpQ5gJsIyLqf7vioomuBmdGSbdcF9xhPjD2mhtcvlTqkYp_eBCTM6LHhvUxPZLxEvGMWBWrTgl2IKmoB1P6Wuyl904E3-nSsan_A0NCI0bV7BP5Xl3bIGQxDNl8I5_Lzfd0u3qckVvKgpVM/s888/qrs6.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="312" data-original-width="888" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2gNK2RbykuVA9a8_NLT300zHVDrcQUdh7hwwBTIlNu3CXKpQ5gJsIyLqf7vioomuBmdGSbdcF9xhPjD2mhtcvlTqkYp_eBCTM6LHhvUxPZLxEvGMWBWrTgl2IKmoB1P6Wuyl904E3-nSsan_A0NCI0bV7BP5Xl3bIGQxDNl8I5_Lzfd0u3qckVvKgpVM/w640-h225/qrs6.png" width="640" /></a></div><br /><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">So the Queen was
highly confident that the ‘STEMI positive’ ECG was Not OMI, and highly
confident that the ‘normal’ ECG was OMI. This could have prevented an unnecessary
cath lab activation for the first patient with normal coronaries, and
accelerated cath lab activation for the second patient with an LAD occlusion.<span></span></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><br /></span></span></p><div style="background-color: white; color: #333333; text-shadow: none;"><span style="color: red; font-family: times; font-size: medium; text-shadow: none;"><b style="text-shadow: none;">YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)</b></span></div><div style="background-color: white; color: #333333; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; color: #333333; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;">If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.</span></div><div style="background-color: white; color: #333333; text-shadow: none;"><span style="font-family: times; font-size: medium;"><br style="text-shadow: none;" /></span></div><div style="background-color: white; text-shadow: none;"><span style="font-family: times; font-size: medium;"><span style="color: #333333;">Here you will sign up for the </span><span style="color: red;">Queen of Hearts</span><span style="color: #333333;"> on the Telegram app:</span></span></div><p style="background-color: white; color: #333333; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"></span></p><p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: times;"></span></span></p><div style="background-color: white; color: #333333; text-shadow: none;"><span style="font-family: times; font-size: medium; text-shadow: none;"><a href="https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg" style="color: #0090ff; text-decoration-line: none; text-decoration: none; text-shadow: none;">https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg</a></span></div><span style="font-family: times; font-size: medium;">
</span><p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span><span style="font-family: times;"> </span></span></span></p><p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span><span style="font-family: times;"><b>Or, you can get the <u>PM Cardio app</u> with Queen of Hearts function through this QR code.</b></span></span></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span><br /></span></span></span></p><p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;">When you register on the app, you need to say you are from a supported country in the EU. You will get <b>5 free reports.</b> After that, it is $30 per month.</span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizRlJe02C4uaqT89-_53Zc0RyhyphenhypheneN_BgM6sWIHN-f6VTOrTZAFp29U5U0aTGgXCReDQ6S2GoBdARwXFpuCZmPWtmnH1-1KjUViu96jByatehfpnOUVNKs3K6U2L5c2T4HruTqNYJRtD0eRHEAgO6x7U4_OcJNID_uqvYJPdxXoogtMv16LNYGHnwOMWjVN/s336/Cover_1%20(6).png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="278" data-original-width="336" height="265" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizRlJe02C4uaqT89-_53Zc0RyhyphenhypheneN_BgM6sWIHN-f6VTOrTZAFp29U5U0aTGgXCReDQ6S2GoBdARwXFpuCZmPWtmnH1-1KjUViu96jByatehfpnOUVNKs3K6U2L5c2T4HruTqNYJRtD0eRHEAgO6x7U4_OcJNID_uqvYJPdxXoogtMv16LNYGHnwOMWjVN/s320/Cover_1%20(6).png" width="320" /></a></span></span></div><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><br /><span><br /></span></span></span><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span></span></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span><br /></span></span></span></div><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span><br /><br /></span></span></span><p></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">Take away<span></span></span></b></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria; margin: 0cm 0cm 0.0001pt 36pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>1.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">STEMI
criteria only look at ST segments and measure them in isolation from the QRS, which
leads to high rates of false positives and false negatives<span></span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria; margin: 0cm 0cm 0.0001pt 36pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>2.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">ECG signs of OMI include looking at the ECG in totality (including acute Q waves, loss of R waves,
reciprocal ST depression, subtle ST elevation, and hyperacute T waves), and with assessing ST/T relative to QRS<span></span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Cambria; margin: 0cm 0cm 0.0001pt 36pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>3.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">Conventional
computer interpretations are unreliable (including those labeled ‘normal’), but
expert-trained AI is much more accurate<span></span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span> </span></span></span></p><span style="font-size: medium;">
</span><p class="MsoNormal" style="font-family: Cambria; margin: 0cm 0cm 0.0001pt;"><span style="font-size: medium;"><b><span style="font-family: "Times New Roman";">References<span></span></span></b></span></p><span style="font-size: medium;">
</span><p style="font-family: Times; margin: 0cm 0cm 0.0001pt 54pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>1.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">Driver
et al. A new 4-variable formula to differentiate normal variant ST segment
elevation in V2-V4 (early repolarization) from subtle left anterior descending
coronary occlusion – adding QRS amplitude of V2 improves the model. J
Electrocardiol 2017<span></span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Times; margin: 0cm 0cm 0.0001pt 54pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>2.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">McLaren,
Meyers, Smith and Chartier. Emergency department Code STEMI patients with
initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year
retrospective review. Acad Emerg Med 2023<span></span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Times; margin: 0cm 0cm 0.0001pt 54pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>3.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">Smith,
Meyers. Hyperacute T waves can be a useful sign of occlusion myocardial
infarction if appropriately defined. Ann Emerg Med 2023<span></span></span></span></p><span style="font-size: medium;">
</span><p style="font-family: Times; margin: 0cm 0cm 0.0001pt 54pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";"><span>4.<span style="font-family: "Times New Roman"; font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant-alternates: normal; font-variant-caps: normal; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-numeric: normal; font-variant-position: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-family: "Times New Roman";">Meyers,
Bracey et al. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis
of acute coronary occlusion myocardial infarction. IJC Heart and Vasc 2021<span></span></span><span style="font-family: "Times New Roman";"><br /></span></span></p><p style="font-family: Times; font-size: 10pt; margin: 0cm 0cm 0.0001pt 54pt;"><span style="font-size: medium;"><span style="font-family: "Times New Roman";">5. Herman,
Meyers, Smith et al. International evaluation of an artificial
intelligence-powered electrocardiogram model detecting acute coronary occlusion
myocardial infarction. Eur Heart J Dig Health 2023</span></span>
</p></div><div><br /></div><div><br /></div><div style="font-family: arial;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><br /></span></span></div><div style="font-family: arial;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><br /></span></span></div><div style="font-family: arial; text-align: center;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><br /></span></span></div><div style="font-family: arial; text-align: center;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><img border="0" data-original-height="24" data-original-width="613" height="12" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQBhn086We0HyNL3QgojZEmwS5S_7ANP5aN8W31DH13Zm3GN4zDgyBzu5gUYKFLxa7n46GvC_MTD1sY12iUT3JCYywwHYuGq0-isfPeP0D0PyeWLS9JTZEFsWDoEGAUEzGIC5e3oYFhgU/s320/0++-+Figure-6-RED+LINE-+Use+in+Blogs.png" style="caret-color: rgb(0, 0, 238); color: #0000ee; text-align: center; text-decoration: underline;" width="320" /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial;"><br /></span></span></div><div><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><span><span style="caret-color: rgb(255, 0, 0); color: red; font-family: arial; font-size: medium;">===================================</span></span></div><p style="margin: 0in;"><span style="font-family: arial; font-size: medium;"><b><span style="color: #454545;"><i>MY Comment</i>, by </span></b><b><span style="color: red;">K</span></b><b><span style="color: #454545;">EN </span></b><b><span style="color: red;">G</span></b><span style="color: #454545;"><b>RAUER, MD (</b><i>1/17/</i></span><span style="color: #454545;"><i>2024</i><b>):</b></span></span></p><div style="text-align: justify;"><span style="color: red; font-family: arial; font-size: medium;">===================================</span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">Today’s post by Dr. McLaren once again emphasizes the importance of <b><i>“<u>proportionality</u>”</i></b> — for assessing the clinical significance of ST-T wave appearance in a patient who presents with CP (<i><u>C</u>hest <u>P</u>ain</i>).</span></div><div style="text-align: justify;"><ul><li><span style="font-family: arial; font-size: medium;">While fully agreeing with the <i>KEY</i> concept conveyed by Dr. McLaren <b>(</b><i>namely, that literal usage of the still all-too-commonly-accepted “STEMI Paradigm” results in far too many erroneous diagnoses</i><b>)</b> — I’ll suggest an additional perspective on how I consider these ideas.</span></li></ul></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">My perspective employs recollection of one or more of the following short phrases that may serve as <b>“ECG <u>Mantras</u>” (</b> = <i>clinical reminders</i><b>)</b> of these <i>KEY</i> principles. These phrases include:</span></div><div style="text-align: justify;"><ul><li><span style="font-family: arial; font-size: medium;">“Are there <i>1 or 2 of the 12 leads</i> that give you the answer”</span></li><li><span style="font-family: arial; font-size: medium;"> “Shape <span style="text-decoration: underline;"><i>more</i></span> important than amount.”</span></li><li><span style="font-family: arial; font-size: medium;"> “<i>Neighboring</i> leads? — and the <u style="font-style: italic;">rest</u> of the ECG!"</span></li><li><span style="font-family: arial; font-size: medium;"> "Can you explain <i>all</i> the findings?"</span></li></ul></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="text-align: justify;"><b><u><span style="font-family: arial; font-size: medium;">The CHALLENGE:</span></u></b></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">I’ll expand on these ECG Mantras momentarily — but FIRST — <i>Take another LOOK</i> at the 2 initial ECGs in today’s case, that for clarity — I have put together in <b><u>Figure-1:</u></b></span></div><div style="text-align: justify;"><ul><li><span style="font-family: arial; font-size: medium;"><i>HOW might one or more of the above ECG Mantras apply to the 2 ECGs in </i><u>Figure-1</u>?</span></li></ul></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div style="text-align: justify;"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVVnsVVZH6mHoi5k51mt8fjxqkly6KuBzdMndCmtm973SFbPdxAdFQ3DGB2aFVY9xWSsEiAFHCXe5aJG-I4_-1amRIdK54mLJfXtNl0aDsUunij2N71lVWrJCVPkQXJ1U1cNNon7e_WsLN4UuYKhZuDKQo-daAaUD4r_Pm5Wt3m8-XJDQUZ7DxvZa8ry4/s3102/Figure-1%20%20ECGs-1,2%20(1-16.21-2024)-USE.png" style="margin-left: auto; margin-right: auto;"><span style="font-family: arial; font-size: medium;"><img border="0" data-original-height="2730" data-original-width="3102" height="564" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVVnsVVZH6mHoi5k51mt8fjxqkly6KuBzdMndCmtm973SFbPdxAdFQ3DGB2aFVY9xWSsEiAFHCXe5aJG-I4_-1amRIdK54mLJfXtNl0aDsUunij2N71lVWrJCVPkQXJ1U1cNNon7e_WsLN4UuYKhZuDKQo-daAaUD4r_Pm5Wt3m8-XJDQUZ7DxvZa8ry4/w640-h564/Figure-1%20%20ECGs-1,2%20(1-16.21-2024)-USE.png" width="640" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: arial; font-size: medium;"><b><u>Figure 1</u></b><span> – I've labeled the <b><i><u>initial</u></i></b> <b>ECGs</b> on <u>Patient-1</u> and <u>Patient-2</u>.</span></span></td></tr></tbody></table><span style="font-family: arial; font-size: medium;"><br /><span><br /></span></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">==================================</span></div><div style="text-align: justify;"><span style="font-size: medium;"><span style="font-family: arial;"><b><u><i>Application</i> of the <i>above</i> ECG Mantras:</u> </b></span><span style="font-family: arial;">Given the presentation of </span><i style="font-family: arial;">new-onset</i><span style="font-family: arial;"> CP for both patients in today's Blog post — </span><b style="font-family: arial;"><i>time-efficiency</i></b><span style="font-family: arial;"> for determining the need for prompt cath is essential for optimal outcome.</span></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium;">==================================</span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium; text-align: start;"><br /></span></div><div style="text-align: justify;"><span style="font-family: arial; font-size: medium; text-align: start;"><b><i><u>Are there 1 or 2 Leads</u> that give you the answer?</i></b></span></div><div style="text-align: justify;"><ul><li><span style="font-family: arial; font-size: medium;"><span style="text-align: start;">"Armed" with the knowledge that </span><u style="text-align: start;"><b>Patient-2</b></u><span style="text-align: start;"> was a 70yo man with </span><i style="text-align: start;">new</i><span style="text-align: start;"> CP — it literally took me <i><u>less</u></i> than 5 seconds to </span><u style="font-style: italic; text-align: start;">know</u><span style="text-align: start;"> that prompt cath was indicated. My "eye" immediately focused on the 2 leads within the <i>RED rectangle </i>in <u>ECG #2</u>. As per Dr. McLaren — the <b><i><u>hyperacute</u></i></b> <b>T waves</b> in <b>leads V2</b> and <b>V3</b> are <b>massive</b> <b>(</b><i style="font-weight: bold;"> </i><i>= equal or exceeding the height of the R wave in the same lead — with T waves "fatter"-at-their-peak and wider-at-their-base than expected given QRS amplitudes in V2,V3</i><b>)</b>. </span></span></li><li><span style="font-family: arial; font-size: medium; text-align: start;"><b>So, as soon as I saw the ST-T waves in leads V2,V3 of <u>ECG #2</u> — I <i>knew</i> that prompt cath with PCI for this acute OMI was needed.</b> Assessment of ECG findings in other leads supported my assessment — <b><i>but these 2 leads were all that I needed for "the Answer".</i></b></span></li><li><span style="font-family: arial; font-size: medium; text-align: start;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><span style="text-align: start;">With regard to </span><u style="font-weight: bold; text-align: start;">Patient-1</u><span style="text-align: start;"> — Assessment of the QRST complex within the </span><i style="text-align: start;">RED rectangle</i><span style="text-align: start;"> once again immediately suggested the answer to me. This is because QRS amplitude in <b>lead V4</b> is huge — in association with a relatively <i>short</i> QTc — J-point notching <b>(</b><i>the BLUE arrow in this lead</i><b>)</b> — and the very characteristic ST segment "face" of a repolarization variant, with benign-looking terminal T wave inversion <b>(</b><i>See My Comment at the bottom of the page in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2022/05/chest-pain-shortness-of-breath-t-wave.html" target="_blank">May 19, 2022</a> post </b><i>in Dr. Smith's ECG Blog</i><b>)</b>.</span></span></li></ul></div><div style="text-align: justify;"><div style="text-align: start;"><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><i><span style="font-family: arial; font-size: medium;"><u>Shape</u> More Important than Amount!</span></i></b></div><div><span style="font-family: arial; font-size: medium;">This ECG Mantra regarding the <i><u>shape</u></i> of ST-T wave deflections — incorporates the concept of <b>"<u>proportionality</u>" (</b><i>since a "normal" ST-T wave shape is dependent on relative size with respect to the QRS complex in the lead being looked at</i><b>)</b>. In addition — <i>small</i> ST-T wave deflections of an <i>abnormal</i> <u>shape</u> may prove to be more important than a certain <i><u>amount</u></i> of ST segment deviation.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;"><b><u>To Emphasize</u></b> — that while I completely agree with Dr. McLaren that <u style="font-weight: bold;">ECG #1</u> is almost certain to represent a repolarization variant and <u style="font-style: italic;">not</u> an OMI — my "eye" could not help but notice the <b><i>abnormal</i></b> <u style="font-weight: bold;">shape</u> of the <b><i>straightened </i>ST segment takeoff</b> in <b>leads V1</b>,<b>V2</b>,<b>V3 (</b><i>straightened RED lines in these leads</i><b>)</b>. Normally, there should be gentle upsloping (<i>rather than straightening</i>) of ST segments in these anterior leads. <b>So while I strongly favored the conclusion of <i>"<u>not</u> an OMI" </i></b>in this 45yo man who most probably has LVH and a repolarization variant — I felt the <u style="font-style: italic; font-weight: bold;">shape</u> of the elevated and abnormally straightened ST segments in 3 consecutive anterior leads merited <i>additional</i> information before I could be 100% convinced that <u>ECG #1</u> did not represent a superimposed acute change.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;">Another example on the role of <u style="font-style: italic; font-weight: bold;">shape</u> is also evident in <u style="font-weight: bold;">ECG #2</u> — in the form of <b>T-QRS-D (</b><i><u>T</u>erminal <u>QRS</u> <u>D</u>istortion</i><b>)</b> — if not in <b>lead V2 (</b><i>where the truncated s wave almost reaches the baseline</i><b>)</b> — then in <b>lead V4</b> <b>(</b><i>See My Comment and illustration of T-QRS-D in the </i><b><a href="https://hqmeded-ecg.blogspot.com/2019/11/a-50-something-with-left-shoulder-pain.html" target="_blank">November 14, 2019</a> post</b><i> of Dr. Smith's ECG Blog</i><b>)</b>.</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><span style="font-family: arial; font-size: medium;"><i><u>Neighboring</u></i> Leads? — and the <i><u>Rest</u></i> of the ECG!</span></b></div><div><ul><li><span style="font-family: arial; font-size: medium;">I've highlighted above how one look at <b>lead V4</b> in <u><b>ECG #1</b></u> — strongly suggested probable LVH and a repolarization variant <b>(</b><i>and <u>not</u> an OMI</i><b>)</b>. I next apply the concept that <b>the <i>more</i> leads showing <i>similar</i> findings in the <i>same</i> anatomic area — the greater the likelihood that your impression is accurate</b>. Thus, my impression of probable LVH in a patient with a repolarization variant is strengthened by the J-point notching in <b><i><u>neighboring</u></i></b> <b>leads</b> <b>(</b><i>BLUE arrows not only in lead V4 — but also in leads V5,V6 of ECG #1</i><b>) </b>— as well as by the very tall R waves in leads V5,V6.</span></li><li><span style="font-family: arial; font-size: medium;"><br /></span></li><li><span style="font-family: arial; font-size: medium;"><span>In <u style="font-weight: bold;">ECG #2</u> — I've highlighted how one look at the 2 leads within the <i>RED rectangle</i> in ECG #2 was enough to convince me of the need for prompt cath. The suggestion of <b>T-QRS-D</b> in <b><i><u>neighboring</u></i></b> <b>lead V4</b> provides further support </span><b>(</b><i>BLUE arrow showing failure of the s wave in V4 to descend to the baseline</i><b>)</b><span>.</span></span></li><li><span style="font-family: arial; font-size: medium; text-align: start;">In this context — <i style="font-weight: bold;">loss of r wave</i> from lead V1, with resultant <i>small-but-significant</i> <b>q waves</b> in not only leads V2,V3 — but also in <b><i><u>neighboring</u></i></b> <b>leads V4</b>,<b>V5</b>,<b>V6</b> <u>is</u> significant <b>(</b>ie, <i>Septal q waves may normally be seen in leads V4,V5,V6 — but they should <u>not</u> be seen as far anterior as leads V2,V3 — and the Q wave in lead V2 should <u>not</u> be larger than the q wave in leads V5,V6</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">As per Dr. McLaren — the <u style="font-style: italic; font-weight: bold;">Rest</u> of ECG #2 is consistent with an LAD OMI, in that there is a subtle hyperacute (<i>if not slightly elevated</i>) ST segment in <b>lead aVL</b> — as well as subtle reciprocal changes in <b><i>inferior</i></b> <b>leads III</b> <b>(</b><i>depressed ST segment shape with down-up terminal T wave</i><b>) </b>and <b>aVF (</b><i>flattened ST segment</i><b>)</b>.</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><i><span style="font-family: arial; font-size: medium;">Can you Explain <u>all</u> the Findings?</span></i></b></div><div><span style="font-family: arial; font-size: medium;">While our 1st priority in assessing the patient with new CP is to determine if prompt cath is needed — if we see no indication of OMI, but the ECG is <i><u>not</u></i> "normal" — I like to look for a reason <i>WHY</i> the ECG is not normal <b>(</b>ie, <i>Could the patient's CP be the result of a tachyarrhythmia or pulmonary embolism?</i><b>)</b>.</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">For example, in today's case — Cardiac cath performed on <u style="font-weight: bold;">Patient-1</u> was normal, and acute OMI was ruled out. But <u style="font-weight: bold;">ECG #1</u> is <u style="font-style: italic;">not</u> "normal". Instead — there is significant increase in voltage for a 45yo man — with tall initial R waves in leads V1,V2 <b>(</b><i>7 mm in lead V1 and 15 mm already by lead V2!</i><b>)</b>. These ECG findings could be consistent with <b>HCM (</b><i><u>H</u>ypertrophic <u>C</u>ardio<u>M</u>yopathy</i><b>)</b> — which could be responsible for this patient's CP. <b>[</b><i>Presumably — significant HCM if present, would have been seen on cath — but the point is that the BEST way to feel totally comfortable with your interpretation — is when you can explain all abnormal findings</i><b>]</b>.</span></li></ul></div><div><span style="font-family: arial; font-size: medium;">===========================</span></div></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div><div><b><i><span style="font-family: arial; font-size: medium;"><u>Today's "Take-Home</u>"</span></i></b></div><div><span style="font-family: arial; font-size: medium;">Among the lessons to be learned from today's case are a number of <i>KEY</i> concepts that aren't found in textbooks. These include:</span></div><div><ul><li><span style="font-family: arial; font-size: medium;">Applying <i><b>proportionality</b></i> in your assessment <b>(</b><i>Failure to account for such proportionality is one of the major reasons for failure of the STEMI paradigm</i><b>)</b>.</span></li><li><span style="font-family: arial; font-size: medium;">Appreciation of <i><b><u>shape</u></b></i> rather than a certain millimeter amount of ST segment deviation. </span></li><li><span style="font-size: medium;"><span style="font-family: arial;"><b><i>Looking for 1 or 2 leads</i></b> that can <i>instantly</i> give you the answer — and then looking at <i><b><u>neighboring</u></b></i> <b>leads</b></span><span style="font-family: arial;"> to further support your answer.</span></span></li><li><span style="font-family: arial; font-size: medium;">Trying to <b>understand <i>abnormal</i> ECG findings</b>, even if you don't think it's an OMI.</span></li></ul><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div><div><span style="font-family: arial; font-size: medium;"><br /></span></div></div></div><p> </p>Jesse McLarenhttp://www.blogger.com/profile/05809707984126529952noreply@blogger.com0