A 40-something woman with acute pulmonary edema -- see the Speckle Tracking echocardiogram.

A 49 year old woman with h/o COPD only presented with sudden dyspnea.  She had acute pulmonary edema on exam.  

Prehospital

Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI

Transformed ECG by PM Cardio:

PM Cardio AI Bot interpretation:

OMI with High Confidence

What do you think?

There is STE and hyperacute T-waves in V2 and V3, with significant STE in I and aVL, and inferior reciprocal STD.

This is proximal LAD Occlusion until proven otherwise.

On arrival, lung ultrasound confirmed pulmonary edema (B lines).  An ECG was recorded:

ED ECG 1:

The findings are still present but not nearly as profound now. 

Conventional algorithm interpretation:

SINUS TACHYCARDIA

ABNORMAL RHYTHM ECG

Confirmed by over-reading physician

Transformed ECG by PM Cardio:

PM Cardio interpretation:

OMI with Low Confidence

Dr. Rob Reardon did a bedside echo using Speckle tracking.  

Speckle Tracking tracks the endocardium for excellent visualization of wall motion abnormalities, and graphs the wall motion for each major segment. (see graphs)  

Speckle Tracking Video

 This shows apical ballooning, which can be due to takotsubo, or to an LAD Occlusion (especially a proximal LAD with wraparound to inferior wall, such that the anterior, lateral, and inferior walls are ischemic, which will also lead to apical ballooning).  

Example here: 

DIffuse ST Elevation with Apical Ballooning: is it Takotsubo Stress Cardiomyopathy?

The ECG and echo could be due to either LAD occlusion or takotsubo, and these are often indistinguishable without angiogram.

Therefore, the cath lab was activated.

The initial hs troponin was = 41 ng/L.

ECG 2 was recorded while waiting for the cath team in the middle of the night:

There is much less evidence of OMI now.  I looks as if there has been reperfusion.

PM Cardio AI Bot:

Not OMI with high confidence

Angiogram:

Speckle Tracking of Acute Pulm Edema.MOV from Stephen Smith on Vimeo.

--Mild Plaque no angiographically significant obstructive coronary artery disease.

--This is most likely stress induced cardiomyopathy, formal TTE today

2 hour trop = 1871 ng/L

6 hour trop = 2094 ng/L

This is likely to be near the peak

Formal bubble contrast echo:

Normal left ventricular size with moderately reduced systolic function.

The estimated ejection fraction is 38%.

Regional wall motion abnormality-apex, anterior akinesis.

 

In comparison to the previous study, 11/11/2020, there has been a significant interval deterioration of left ventricular systolic function (previous EF 80%), and there is a new large apical wall motion abnormality.

 

Stress induced cardiomyopathy (Takotsubo like LV dysfunction) possible.

Here is the next day ECG:

Very bizarre wide T-wave inversions in anterior and high lateral leads, with long QT.  Morphology is very typical for takotsubo, but focality is not.  It is usually more diffuse, including inferior leads.

Outcome:

She was diagnosed with stress cardiomyopathy, though it is not entirely classic.  The ECG findings are focal to the anterior and high lateral wall.  The echo findings were similarly focal to those walls.  It is possible that it was a MINOCA instead, possible that it was due to thrombus that lysed, but the management is the same: medical management including aspirin carvedilol, and a statin.

Takotsubo (and Myocarditis) are both frequently impossible to differentiate from acute OMI on ECG, even if augmented by echocardiography and troponins.