tag:blogger.com,1999:blog-549949223388475481.post534736083124741022..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A 50-something woman with atypical chest painUnknownnoreply@blogger.comBlogger12125tag:blogger.com,1999:blog-549949223388475481.post-5110065987605093372016-10-29T08:15:41.062-05:002016-10-29T08:15:41.062-05:00there is definite, and diagnostic, ST elevation in...there is definite, and diagnostic, ST elevation in inferior leads. look closely.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-4243095654024257552016-10-27T06:24:14.978-05:002016-10-27T06:24:14.978-05:00Why PCI for ecg3 no obvious elevation! Why PCI for ecg3 no obvious elevation! Anonymoushttps://www.blogger.com/profile/00844227525926832963noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-36392188998030089632016-08-22T17:16:01.831-05:002016-08-22T17:16:01.831-05:00The RV MI was not evident at that time. Only beca...The RV MI was not evident at that time. Only became clear on the subsequent ECG.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-42016543661312758422016-08-22T16:32:00.849-05:002016-08-22T16:32:00.849-05:00Dr. Smith,
You recommended NTG after the second E...Dr. Smith,<br /><br />You recommended NTG after the second EKG. But this patient ended up having an RV involvement. So should NTG be held? And what are your thoughts of NTG in inferior MI? Thanks <br /><br />-Eric Abrams, MD Who is writing this?https://www.blogger.com/profile/04263291673560984779noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-82442930502873909402016-08-18T09:20:03.577-05:002016-08-18T09:20:03.577-05:00Good question and I was going to comment on it, bu...Good question and I was going to comment on it, but decided not to.<br />That is sometimes useful, but nonspecific. We studied it for anterior MI and it was of no added value to the formula I use. For inferior MI, it may be useful only for RV MI, as in this case. Note that on the first ECG, the TW V1 is smaller than V6, but as time goes on it gets larger. But the inferior leads with aVL show it all anyway. So does it add any value? Maybe a little.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-36032198778381883112016-08-18T09:18:06.268-05:002016-08-18T09:18:06.268-05:00These should be done in the ED, or ICU. There sho...These should be done in the ED, or ICU. There should be no chance of further evolution once a patient goes to an non-ICU setting.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-38587550102747180182016-08-18T09:16:44.886-05:002016-08-18T09:16:44.886-05:00Pendell,
Good question. I think it is a matter of...Pendell,<br />Good question. I think it is a matter of degree and of judgment. Not a lot of data to guide one in either direction. Very early in thrombus formation, aspirin and antithrombotics. along with endogenous tPA, have a good chance of lysing the clot. The longer the thrombus is present, the less likely it is to resolved spontaneously. The longer the clot is there, the higher risk. <br />Not sure I can explain better than that.<br />STeveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-1136103383226160442016-08-18T09:14:36.960-05:002016-08-18T09:14:36.960-05:00thanks, Ken!thanks, Ken!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3102591431206065742016-08-18T08:37:52.883-05:002016-08-18T08:37:52.883-05:00Very interesting post showing, one again, the valu...Very interesting post showing, one again, the value of serial ECGs.<br /><br />In ECG #1 could TV1>TV6 be useful? Thank you.<br />Mario<br />Mario Parrinellohttps://www.blogger.com/profile/07136945770330333718noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-44056588100477830862016-08-18T08:12:12.484-05:002016-08-18T08:12:12.484-05:00In your institution, who typically gets serial EKG...In your institution, who typically gets serial EKG's? Is it the ER? I'm a hospitalist at a large academic institution, and the ER typically does 1 EKG and admits patients to the floor. Just wondering, because the idea of serial EKG's is great but impractical once they are on the floor overnight. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-9669100173783414922016-08-17T18:00:57.332-05:002016-08-17T18:00:57.332-05:00Dr. Smith, could you please explain a little more ...Dr. Smith, could you please explain a little more about the difference between ECGs #2 and #3 from this case, concerning why can we try to avoid emergent cath lab activation in #2 but not #3. To the long time readers, #2 is diagnostic of an occluded RCA, especially in context of #1, as you explained above. So the RCA is occluded during both #2 and #3 (and #4 obviously). If the changes resolve with medications after #2, then it was transient occlusion. I think I've learned previously on this blog that transient occlusion should go emergently to the cath lab. So how can I conceptualize this difference? Unless I can hawk over the patient until the morning and ensure that she gets emergent cath if her symptoms/ECG changes come back overnight, when and why shouldn't transient occlusion go to the lab emergently? Thanks for this great case!Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-68147488218604846502016-08-17T15:34:40.521-05:002016-08-17T15:34:40.521-05:00I put the first 3 tracings together for clarity (w...I put the first 3 tracings together for clarity (which is the 4th Figure shown here), when this case was first discussed in the EKG Club. KEY points I would add to the discussion here in Dr. Smith’s Blog are the following: i) The history we were provided with is lacking — since we don’t know where the patient presented (to the office or ED?), nor do we know the onset of this patient’s chest discomfort — and, most important — we really are not given insight as to whether her symptoms were or were not worrisome.<br /><br />ii) Although The ST segment is coved and the T wave inverted in lead aVL — I was more concerned in ECG #1 by the appearance of the T wave in lead III, which looks disproportionately tall compared to the QRS complex in this lead. Together with lead aVL — these 2 leads (IF onset of symptoms was new and of concern) would make me highly suspicious of early evolving inferior stemi, albeit they are not yet diagnostic.<br /><br />iii) As per Dr. Smith, the 2nd ECG shown here is subtle but diagnostic of acute evolving inferior MI. Inferior leads often manifest low amplitude QRST complexes — so the changes seen are often quite subtle, as they are here. But compared to ECG #1 — the T waves in both leads III and aVF clearly look more prominent relative to the QRS complexes in these leads. This change can be more readily appreciated by also looking at the ST segment preceding the T waves in these leads — which shows ST segment flattening before abrupt rise to the disproportionately tall T waves. The ST-T wave in lead aVL clearly shows “mirror-image” ST-T depression, as is typical with acute inferior infarction. IF onset of this patient’s symptoms was new and her chest pain history was concerning — then I’d be on the phone with the Cardiologist-on-Call at this point in the case. If one wanted further confirmation of an acute evolving event — doing the Echo at this point would provide that.<br /><br />iv) The diagnosis is obvious on review of ECG #3. The point I would stress would be that IF the history was new and of concern — that the diagnosis of acute inferior STEMI should be made on seeing ECG #2.<br /><br />THANKS to Dr. Smith for enriching the previous discussion we had about this case on the EKG Club!<br /><br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.com