tag:blogger.com,1999:blog-549949223388475481.post6315944090808848502..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: Only the ECG Diagnoses Acute Coronary Occlusion. Do not be Fooled by a Negative High Sensitivity Troponin.Unknownnoreply@blogger.comBlogger17125tag:blogger.com,1999:blog-549949223388475481.post-43865838643096157762017-01-03T12:47:44.781-06:002017-01-03T12:47:44.781-06:00Michael,
You are correct.
Thanks,
SteveMichael,<br />You are correct.<br />Thanks,<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-16216404384539560992017-01-03T12:47:10.553-06:002017-01-03T12:47:10.553-06:00You are correct!! But it is fun to do it anyway.You are correct!! But it is fun to do it anyway.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-44670431200022304652017-01-03T12:46:32.937-06:002017-01-03T12:46:32.937-06:00Theoretically, but not studied, as morphine has be...Theoretically, but not studied, as morphine has been:<br /><br />Meine, T. J., et al. (2005). "Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative." Am Heart J 149(6): 1043-1049.<br /> see pdf at clinical pathway/myocardial infarction/morphine.pdf<br /><br />BACKGROUND: Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments. METHODS: The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin. RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups. CONCLUSIONS: Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.<br />Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-51658533725994984132017-01-01T19:52:02.365-06:002017-01-01T19:52:02.365-06:00This is a great case! Thanks for sharing. My only ...This is a great case! Thanks for sharing. My only question is regarding usage of the equation to differentiate benign STE from STE from LAD occlusion. Correct me if I am wrong but I do not think it would be appropriate to use the equation in this case as there are signs of ischemia (TWI and ST depression).Anonymoushttps://www.blogger.com/profile/15170173043281781714noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-60614476489433542262017-01-01T17:12:23.454-06:002017-01-01T17:12:23.454-06:00Correct me if I am wrong but wouldn't it be in...Correct me if I am wrong but wouldn't it be inappropriate to use the formula for differentiating normal STE from STE from LAD occlusion due to obvious signs of occlusion on these ECGs (ST depression and TWI)?Anonymoushttps://www.blogger.com/profile/15170173043281781714noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-51185529726061498852017-01-01T12:43:38.913-06:002017-01-01T12:43:38.913-06:00Hmm, never thought of it that way! Would that mean...Hmm, never thought of it that way! Would that mean fentsnyl would have the same effect and be equivalent to morphine for cardiac related chest pain?Cully Whttps://www.blogger.com/profile/08213913140427187209noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-7551164570018178152017-01-01T07:02:20.234-06:002017-01-01T07:02:20.234-06:00Thanks, Mario!Thanks, Mario!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-35140989534912330582016-12-30T16:20:50.371-06:002016-12-30T16:20:50.371-06:00Thanks, Ken! Great editing of my case, Steve! Thanks, Ken! Great editing of my case, Steve! P Hammarlundhttps://www.blogger.com/profile/12795866723817205360noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-33651679199836194172016-12-30T11:44:02.418-06:002016-12-30T11:44:02.418-06:00The present case is really excellent from the lear...The present case is really excellent from the learning point of view. I learned constantly from this blog to beware hyperacute and large T waves. Despite my initial troubles with the Cabrera format, I highly appreciated the entire case. Thanks for posting!Mario Parrinellohttps://www.blogger.com/profile/07136945770330333718noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-545465660011653062016-12-30T09:30:13.783-06:002016-12-30T09:30:13.783-06:00Yes!Yes!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-9411624768361082282016-12-30T09:29:39.003-06:002016-12-30T09:29:39.003-06:00Only a repeat troponin with a very short interval ...Only a repeat troponin with a very short interval (30 minutes, or 1 hour) will detect such an infarct quickly enough to prevent much loss of myocardium.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-12267108511197507802016-12-30T09:28:37.963-06:002016-12-30T09:28:37.963-06:00thanks, Ken!thanks, Ken!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-38695165296098398992016-12-30T09:28:17.978-06:002016-12-30T09:28:17.978-06:00It masks the symptoms, makes you believe that you ...It masks the symptoms, makes you believe that you have helped the underlying problem. That is why it is associated with increased mortality.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-19981837173945088292016-12-30T07:24:04.216-06:002016-12-30T07:24:04.216-06:00As I said before, EKG cycle is going much faster t...As I said before, EKG cycle is going much faster than any hyperSensitive Troponin Cycle!!!Nicolas Peschanskihttps://www.blogger.com/profile/07436778751052243538noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-71740862327395325292016-12-29T16:22:45.894-06:002016-12-29T16:22:45.894-06:00Hi Dr Smith Thanks for a brilliant concise post. I...Hi Dr Smith Thanks for a brilliant concise post. I'm a junior doctor. One of my consultant only looks at first trop. Is there any role for 2nd or even 3rd (4..5.. etc.) trops in cardiac sounding chest pain? Thanks.Anonymoushttps://www.blogger.com/profile/15462771870390393603noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-44747509242847244122016-12-29T16:02:12.385-06:002016-12-29T16:02:12.385-06:00Great case by Peter (who is known to us for his pe...Great case by Peter (who is known to us for his periodic contributions to various ECG forums). While a similar display format (with no more than minor variation) is used for ECG recording throughout the United States — variations in format are used in many countries. Since many of us only rarely (if ever) see ECG recording formats that differ significantly from our own — it is easy to miss important findings when other formats are used. Given the exponentially increasing use of the internet for international medical correspondence (with now literally scores of international Facebook ECG forums) — plus ever expanding daily use of smart phone photographs for rapid remote consultation with experts regarding problematic ECGs — the clinical reality is that virtually ALL clinicians will from time-to-time encounter ECG formats that differ from a format we are used to. Thus, it clearly IS beneficial to post at least occasional tracings with Cabrera format and/or 50mm/second recording speed (as is used in a number of countries). I fully admit that the “picture” of 25mm/second recordings is etched ever-so-unforgettably in my brain. This is why after viewing numerous thousands of tracings over the past 40+ years — I am usually able within no more than a few seconds (if not instantly) to recognize all key abnormalities. However, with Cabrera format + 50mm/second speed recording — I am back to “square one” as a beginner — simply because of unfamiliarity (and without my brain’s picture reservoir of what is or is not “normal”). That is why it is so GOOD to continue being exposed to ALL ECG formats — because in this world made so much smaller by instant internet availability — we ALL will certainly see more tracings sent to us from countries using formats that differ to the one we are most accustomed to. — P.S. — Compression of 50mm/sec recordings to half their width is a PEARL that immediately put my brain “at ease”, and tremendously facilitated my confidence in that what I thought I was seeing (at 50mm/sec) was indeed real, and highly suggestive of a DeWinter T wave pattern. THANKS again to Drs. Steve Smith & Peter Hammarlund for this intriguing post!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-29330784959280021062016-12-29T10:35:12.875-06:002016-12-29T10:35:12.875-06:00What's the thought behind avoiding morphine?What's the thought behind avoiding morphine? Cully Whttps://www.blogger.com/profile/08213913140427187209noreply@blogger.com