tag:blogger.com,1999:blog-549949223388475481.post5615593540353587555..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A woman in her 70s with bradycardia and hypotensionUnknownnoreply@blogger.comBlogger13125tag:blogger.com,1999:blog-549949223388475481.post-72771281783573776392020-01-22T21:12:51.922-06:002020-01-22T21:12:51.922-06:00I would guess the "culprit artery" would...I would guess the "culprit artery" would be the RCA given acute infero-postero involvement + suggestion of acute RV involvement (due to the modest ST depression in V1 compared to marked ST depression in V2). If right-sided leads confirmed acute RV involvement — then we'd know, since it is the RCA that supplies blood to the RV.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-87554574282685030662020-01-22T07:01:48.718-06:002020-01-22T07:01:48.718-06:00Unfortunate case, but very educative in some impor...Unfortunate case, but very educative in some importante concepts about myocardial infarction and rhythm interpretation. Thanks for sharing!How can we know which artery is the culprit?O Poder da Eletrocardiografiahttps://www.blogger.com/profile/11143192155299060176noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-7801269511153998362020-01-21T17:02:22.238-06:002020-01-21T17:02:22.238-06:00Thanks for your comment. One of the goals of this ...Thanks for your comment. One of the goals of this ECG Blog is to "spread the word" — so that hopefully optimal care can be achieved in the future — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-87507156213061522472020-01-21T08:42:45.154-06:002020-01-21T08:42:45.154-06:00Thanks Dr. Wang! I also don't have evidence to...Thanks Dr. Wang! I also don't have evidence to support it, but my belief is that lead I can show reciprocal depression from any cause of elevation in lead III (or other inferior leads). So I would not take lead I as definitive evidence of RV involvement, but this case certainly seems like the RV was involved. Thanks for your comment!Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-72202564723481734242020-01-21T08:00:50.127-06:002020-01-21T08:00:50.127-06:00What an unfortunate case. I could certainly feel t...What an unfortunate case. I could certainly feel the frustration of the ED team as the post progressed. Cases like these are all too common in our field, and they just simply should not occur. The blatant clinical presentation and diagnostic initial EMS ECG would have been enough to go straight to cath for me. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3517049042265532972020-01-20T17:23:18.571-06:002020-01-20T17:23:18.571-06:00@ K — THANKS for your comment! I am NOT doubting t...@ K — THANKS for your comment! I am NOT doubting that there may be acute RV involvement in ECG #1 (I never did) — but if I’m not mistaken, a couple of years ago I seem to remember that you made the same comment (re the finding of ST depression in lead I as an indicator of acute RV involvement) that Steve disagreed with. I don’t have “figures” — but my experience is also that, namely that the finding of ST depression in lead I in association with acute RCA occlusion is NOT a specific indicator of acute RV involvement … Instead (in my experience) — only right-sided leads provide specficity in this regard. I think Steve may have data on this — so I am passing your Comment on to him. I ALWAYS appreciate your input K (!!!) — but I’d like to respectfully agree to disagree with you on this one — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-77305934225768311372020-01-20T16:36:54.988-06:002020-01-20T16:36:54.988-06:00During inferior MI, if the ST segment is depressed...During inferior MI, if the ST segment is depressed in lead I, it indicates that the ST segment is pointing to the patient's right, which proves that the RV is involved. That is the case here. So from the ECG #1, one can be sure that the RV is involved!! In inferior MI, the ST segment will be depressed in aVL always because it is the reciprocal lead of lead III. So, I always pay attention to lead I when I am dealing with an inferior MI. <br />K. Wang. Anonymoushttps://www.blogger.com/profile/04509940285330859355noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-16790881914456404122020-01-20T15:43:52.883-06:002020-01-20T15:43:52.883-06:00Thanks for your comment, and your kind words G.H. ...Thanks for your comment, and your kind words G.H. — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-75599349690521426652020-01-20T15:42:39.909-06:002020-01-20T15:42:39.909-06:00THANKS for your comment Nathan! It is EASY to be f...THANKS for your comment Nathan! It is EASY to be fooled regarding whether or not there is significant RV involvement in patients with acute RCA occlusion — especially when there is no ST elevation in lead V1. In ECG #1 for this case — there is actually some ST depression in V1 (albeit much less than the amount of ST depression we see in lead V2) — so while suggestive of proximal acute RCA occlusion (which IS consistent with this patient’s hypotension) — this initial ECG is clearly NOT definitive (4 cases you’ve seen just not enough to draw any conclusions …). Bradycardia + relative hypotension (from increased vagal tone) is in no way exclusive to proximal RCA vs more distal RCA occlusion — so really the ONLY way to know by ECG if there is or is not acute RV involvement, would be with right-sided leads (which apparently were not done). That said — this case IS different — because my guess is that we are NOT dealing with a single “new” (ie, within 1-4 hours) event, given this patient’s history over a ~1-week period + lack of as much inferior ST elevation as I’d expect if we were dealing with a single acute RCA occlusive event … So it all gets complicated, since increased vagal tone with acute inferior MI tends to be greatest during the first 4-6 hours of the event — and we have NO idea if that is the timespan we are dealing with or not … As to the occurrence of AFib — the SinoAtrial Nodal Artery arises from the RCA in ~60% of people — and this can be infarcted with acute RCA occlusion, leading to arrhythmias including AFib. THANKS again for your comments! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-33770475120216212582020-01-20T01:40:20.162-06:002020-01-20T01:40:20.162-06:00I'm pretty convinced that she had right ventri...I'm pretty convinced that she had right ventricular infarction from either a proximal RCA occlusion (supplying the posterior heart) or with some chronic occlusion in the circ. I've seen this pattern four times over the years--slow "a fib" or junctional bradycardia with small elevation in inferior leads and depression in AVL and V2. In all four cases, ostial RCA occlusion on cardiac cath. I've not seen anyone describe the a-fib pattern in association with RV infarction in the literature--like heart block. I suppose it makes sense. If ischemia can cause ventricular fibrillation, it probably could cause a-fib too.Nathan McNeilhttps://www.blogger.com/profile/12909394946175551914noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-12727135833305011652020-01-19T23:56:28.260-06:002020-01-19T23:56:28.260-06:00Thanks for sharing. I will not discuss the ECG whi...Thanks for sharing. I will not discuss the ECG which already perfectly done by prof ken Grauer .if i will face same case i will be hesitated even to give thrombolytic therapy .for clinical possibility of upper GIT bleeding .elderly low Hb .eipigastric pain .hypotensive ....sometimes we blame the heart but actually it was a victime ....G.Hhttps://www.blogger.com/profile/04853573093492939334noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-37584349228370334152020-01-19T18:27:54.416-06:002020-01-19T18:27:54.416-06:00@ Max — THANKS for you comment. I just now posted ...@ Max — THANKS for you comment. I just now posted a detailed MY Comment to this case — in which I explore in DETAIL interesting aspects of the arrhythmias in the 2nd, 3rd and 4th tracings. You are correct that the beats you mention are escape! — Please READ My Comment above — as there are a LOT MORE interesting aspects to these rhythms — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-79950899948701977852020-01-19T12:04:13.953-06:002020-01-19T12:04:13.953-06:00Such a real situation! Thanks for sharing.
I belie...Such a real situation! Thanks for sharing.<br />I believe the wide beats on ECG#2 are ventricular escape beats.Max Romanchenkohttps://www.blogger.com/profile/17041087696138486491noreply@blogger.com