tag:blogger.com,1999:blog-549949223388475481.post2105887057431040169..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A case of misinterpreted troponins, in spite of a very suspicious ECG....Unknownnoreply@blogger.comBlogger9125tag:blogger.com,1999:blog-549949223388475481.post-59655083282007301162020-07-23T15:18:49.683-05:002020-07-23T15:18:49.683-05:00Yes, that is a normal troponin profile. After larg...Yes, that is a normal troponin profile. After large MI it stays high for a couple weeks.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-21222865715373640542020-07-23T07:31:14.378-05:002020-07-23T07:31:14.378-05:00Thanks for your comment Kyle! We are all aiming fo...Thanks for your comment Kyle! We are all aiming for that “optimal balance” between not allowing value time ( = myocardium) to pass — while at the same time being as certain as possible of the correct diagnosis. MY thought — looking first at electrolytes that might cause ST elevation (I’ve seen this, though it is RARE with hyperCalcemia; — BUT — the peaked T waves of hyperKalemia are a COMMON potential mimic of deWinter T waves). With hyperCalcemia — in my experience, you need a VERY HIGH serum calcium level for their to be enough change to potentially mimic acute MI (ie, probably >13 mg/dL) — and in addition to that being a RARE situation, there will OFTEN be a clue in the history (ie, a patient with known lung or breast, multiple myeloma, leukemia or other cancer that is likely to produce hypercalcemia).<br /><br />With hyperKalemia — We’ve reviewed numerous such cases on Dr. Smith’s blog. One looks for peaked T waves (typically with a narrow base) — QRS widening — loss of P waves — unusual axis (often right axis) — unusual conduction defects AND often a clinical setting (such as renal failure or K+-retaining medications) likely to predispose to hyperkalemia. And IF hyperKalemia is suspected from the appearance of the ECG — faster than waiting for a “stat” lyte panel — Give IV Calcium !!! (minimal downside and VERY positive upside).<br /><br />And among those lyte disorder likely to cause ST flattening and/or depression — that usuallly will NOT be an indication for emergent cath UNLESS: i) You see dynamic ST-T wave changes (which by definition means that some time has already passed … = probably enough time to get lytes back) or ii) Your patient is having SEVERE refractory chest pain in the midst of an ECG that probably looks something like diffuse subendocardial ischemia (in which case you can contact Cardiology on call and make plans for cath activation (which should give you at least some time, which often will be enough to get lab results back). But without knowing statistics — I would BET there is a small MINORITY of cases in which you will have a single ECG on a patient with ST depression that mandates immediate cath. We WELCOME submission of any such cases! — :)<br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-29329626619444169772020-07-23T01:47:37.619-05:002020-07-23T01:47:37.619-05:00Do you know of any studies into the length of time...Do you know of any studies into the length of time Troponins stay elevated after MI? I recently had a case where patient presented 2 weeks after STEMI with Troponin T 650 and then 620. Their Troponin T on their first admission was 6,000+. May this be his original Troponin still coming down or another acute event?Anonymoushttps://www.blogger.com/profile/03755742225975434330noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-34694230796777636192020-07-22T21:55:34.711-05:002020-07-22T21:55:34.711-05:00Thought I'd chime in because I took a differen...Thought I'd chime in because I took a different point from what Tom said. I believe his point is if you are ever reluctant to activate cath due to the possibility of Potassium/Mag imbalance: Getting an urgent electrolyte panel while you wait for troponin might allow you to activate faster than the normal thought process of "wait for trops".<br /><br />Kyle Van Pattenhttps://www.blogger.com/profile/06964706853788023460noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-58620126403526803162020-07-22T13:07:20.328-05:002020-07-22T13:07:20.328-05:00The 2nd ECG has dynamic changes (as well as ECG 2 ...The 2nd ECG has dynamic changes (as well as ECG 2 at ED month earlier), typical for LCx in my opinion - More positive T at 3 and aVF with reciprocal negative T at 1 and aVL plus reciprocal depression at the side precordial leads. Thank you for your work! From Russia. Sergeyhttps://www.blogger.com/profile/16682435340457533983noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-85893189953818874952020-07-22T08:28:25.566-05:002020-07-22T08:28:25.566-05:00Hi Tom. GREAT to see you back! As per the detailed...Hi Tom. GREAT to see you back! As per the detailed description in My Comment (above) of ECG #1 ( = the initial ECG in this last ED visit) — My “Bottom Line” thoughts on this tracing were, “Consistent with previous inferior MI, with ST-T wave changes in multiple leads consistent with ischemia of uncertain age, possibly recent. Clearly more information needed to decide on optimal management of this patient.” I thought the subtle U waves might reflect electrolyte imbalance (chem profile presumably pending). But since I did not see definitive acute changes on ECG #1 — I thought NO emergent cath was needed at that time until more information was gathered.<br /><br />The 2nd ECG done in this last ED visit ( = ECG #4) showed definite improvement in chest lead ST-T wave changes. Since this apparently was correlated with reduction in chest pain — this defined the change that we saw in ST-T wave appearance as “dynamic ECG changes” in a patient with known coronary disease who presented with new symptoms. Therefore, even without the abnormal troponin values — I thought timely cath was indicated prior to discharge from the hospital. That wasn’t done …<br /><br />To address your question — IF the sequence of symptoms and ECG changes would have been reversed (ie, if this patient’s chest pain in that last ED vist after arrival in the ED would have gotten worse AT THE SAME TIME as ST-T wave changes were increasing) — then urgent cath for PCI would have been indicated. Often, “Ya gotta be there” to best judge this essential relationship between onset and severity of symptoms with each of the serial ECGs that are done.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-42213033823589257072020-07-22T07:43:03.318-05:002020-07-22T07:43:03.318-05:00@ Sergey — THANK YOU for your comment. What you me...@ Sergey — THANK YOU for your comment. What you mention is the KEY teaching point for this case. The clinical history — serial ECGs that show dynamic ST-T wave changes in association with corresponding change in symptom severity + subtle-but-definitely-positive serial troponin values ideally would have (should have) prompted earlier cath in this case. This serves as the important lesson — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-83926119833078794592020-07-22T07:40:02.573-05:002020-07-22T07:40:02.573-05:00excellent, gentlemen...
(sorry! I've been awa...excellent, gentlemen... <br />(sorry! I've been away for a while. ) <br />thank you both for this case...<br />in ecg 1 of this last ER visit: the question for me I think is "when to pull the trigger", ie, Cath lab. yes, it's abnormal. <br />suppose we hadn't the benefit of the ekgs of a month before. then... with U waves across the precordium, may this be all electrolyte abnormality? <br />but, with chest pain, maybe rapid serial Ecg's, and electrolyte results an urgent PCI can be done.<br />I hate waiting even two hours for the next trop.<br /><br />thank you both.<br />tom tfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-71365563089976615052020-07-22T01:57:02.634-05:002020-07-22T01:57:02.634-05:00This ECG and clinical picture is very suspicious f...This ECG and clinical picture is very suspicious for Cx artery desease. Angio must had been done immediately.Sergeyhttps://www.blogger.com/profile/16682435340457533983noreply@blogger.com