Vomiting, Diarrhea, and "Bubbles in my Chest"

A 60-something complained of vomiting, diarrhea overnight, and "bubbles in my chest" that started just prior to calling 911.

He had this ECG recorded prehospital:

Smith interpretation: 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.  

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.

Here is what the Queen of Hearts AI app says:

The patient received aspirin and NTG prehospital, and was transported to the ED.

This ECG was recorded on arrival in the ED:

Here is the interpretation of the conventional algorithm (Veritas):

SINUS BRADYCARDIA

ST ELEVATION, PROBABLY EARLY REPOLARIZATION  [ST ELEVATION WITH NORMALLY INFLECTED T-WAVE]

BORDERLINE ECG 

What do you think?

Smith interpretation: Same analysis, except that the STD in V1-2 is gone and replaced by hyperacute T-waves

Here is the interpretation of the Queen of Hearts:

YOU TOO CAN HAVE THE PM Cardio AI BOT!!  (THE PM CARDIO OMI AI APP)

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.

This is for the version housed on Telegram:

https://share-eu1.hsforms.com/18cAH0ZK0RoiVG3RjC5dYdwfyfsg

You can get the full PM Cardio app here if you live in the UK or EU (or say you do upon registration):

https://qrco.de/bebW8d

Case Continued

The cath lab was activated and the patient received 180 mg of ticagrelor, and then was transported to the cath lab.

Angiogram:

Severe 95% hazy distal LM

Severe 80% ostial LAD, 100% occluded distal LAD thought to be due to distal embolization from the lesion in the proximal LAD.

Mild CAD in LCX

70% eccentric proximal RCA

Management

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

CP is 6/10 after IABP

No PCI was done, since the occlusion was an embolus

Case discussed for urgent revascularization with bypass surgery.

Troponins:

First trop returned later at 14 ng/L.  2 hour trop 403.   4 hour trop 593 ng/L.

No further troponins were ordered

Echo

Normal estimated left ventricular ejection fraction, 72%.

Regional wall motion abnormality-apical septum and inferior wall.

Regional wall motion abnormality-apex, dyskinetic.

Further management

Underwent emergent 4 vessel CABG.  

Post op chest pain

Typical of post-op pericarditis (postpericardiotomy syndrome)

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.

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

Post op 2

Remains typical of Post Op pericarditis.

Postpericardiotomy syndrome (PPS) is a clinical syndrome consisting of worsening or new formation of pericardial and/or pleural effusion, pericardial rub, chest pain with or without dyspnea, fever, and elevated inflammatory markers.