tag:blogger.com,1999:blog-549949223388475481.post3921001771587761103..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A Middle-Aged Woman with 3 days of Chest pain and Posterolateral Injury on the ECGUnknownnoreply@blogger.comBlogger7125tag:blogger.com,1999:blog-549949223388475481.post-67473710078818057102016-03-20T06:39:22.739-05:002016-03-20T06:39:22.739-05:00Mario,
Very good question. Yes, they did give asp...Mario,<br />Very good question. Yes, they did give aspirin, P2Y12 inhibitor, and heparin. Given the fever and "flu" and pericardial effusion, I think I would wait for the angiogram to give those medications. But even if the angio showed occlusion, hemopericardium could be present. I think, however, that it is unlikely to be hemopericardium as there is no evidence of clot in the percicardium. With hemopericardium, there is usually some fluid and some echogenic clot.<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-44774712377814877072016-03-20T06:36:17.658-05:002016-03-20T06:36:17.658-05:00Thanks, Ken, especially for catching that typo (wh...Thanks, Ken, especially for catching that typo (which I corrected)!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-55593788694354418812016-03-19T08:27:23.705-05:002016-03-19T08:27:23.705-05:00Another very interesting case.
The present case is...Another very interesting case.<br />The present case is very interesting not only because of the difficulties on the differential diagnosis between STEMI and myocarditis (ECG first) but also on the management.<br />Due to the presence of pericardial effusion with some echo signs of tamponade, there is the real risk of subacute miocardial rupture or ‘simple’ tamponade.<br />How did they manage the patient before angiogram? Did the patient receive aspirin, P2Y12, antigoagulants or did the clinicians wait for the result of the angiogram? Many thanks.<br />Mario ParrinelloMario Parrinellohttps://www.blogger.com/profile/07136945770330333718noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-11344210218222483392016-03-18T12:16:49.359-05:002016-03-18T12:16:49.359-05:00GREAT case skillfully presented (as always). I ini...GREAT case skillfully presented (as always). I initially thought we were dealing with acute left circumflex occlusion given isolated and marked ST elevation in leads I,aVL (with loss of R wave in these leads) plus “telltale” reciprocal ST depression (mirror-image in III compared to aVL) — at least until the cath came back normal — at which point acute myopericarditis became the diagnosis by exclusion. BUT, all the clues WERE there from the start = “flu-like syndrome” (that the patient insisted she had) + low-grade fever + “burning” chest pain that resolved at the time she was seen. In retrospect we might ask if the degree of ST segment deviation in the limb leads after 3 days of symptoms wasn’t a bit disproportionate considering loss of high lateral R wave (and the QS in aVL) — but given how much more common acute coronary occlusion is compared to localized acute myopericarditis — there is clearly a tendency to “assume” acute STEMI rather than the less commonly thought about localized myocarditis … So this case is an EXCELLENT reminder not to forget acute myopericarditis in the differential. And, as William Osler always said, “Listen to the patient and he/she will tell you the diagnosis” (ie, think acute myocarditis esp. with an abnormal ECG + recent flu-like illness). THANKS for presenting!<br /><br />P.S. I think there is a typo under your learning point. You said it was impossible to differentiate between “acute MI and pericarditis” but perhaps meant to say acute MI “and myocarditis (or perimyocarditis)” …ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-65305192325401560132016-03-18T11:15:07.624-05:002016-03-18T11:15:07.624-05:00Al,
MRI would clinch the diagnosis. Otherwise, it...Al,<br />MRI would clinch the diagnosis. Otherwise, it could possibly be a false negative cath.<br />Thanks,<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-90638645642079798732016-03-18T10:54:14.360-05:002016-03-18T10:54:14.360-05:00interesting and educative case.
Thanks Dr. Smithinteresting and educative case.<br />Thanks Dr. SmithKostehttps://www.blogger.com/profile/10080592850323840751noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-39576768448350069422016-03-18T09:42:00.133-05:002016-03-18T09:42:00.133-05:00at the end could we say (maybe after MRI) focal (p...at the end could we say (maybe after MRI) focal (postero-lateral) MyoPericarditis (or better<br />PeriMyocarditis because of decreased EF - M. Imazio) ?<br /><br />merci beaucoup Dr Smith !<br /><br />Al Alswissnoreply@blogger.com