A man in his sixties with chest pain at midnight with undetectable troponin

Written by Pendell MeyersA male in his 60s with no known past medical history presented at midnight with chest pain over the past 3 hours. The pain started just after eating, and at first he thought it was " reflux, " however he decided to call 911 after a few hours when it did not improve.Here is his presenting ECG:What do you think?Here are the relevant findings:Slight STE in V12.5 mm STE in V2Slight STD in V4-V6Definite STD in II, III, and aVFHyperacute T-waves in V2, and likely also in aVLThese findings are highly specific for LAD occlusion. We have many cases of this pattern on this blog, involving STE and hyperacute T-waves in V1-V2, with STD in the lateral leads (see below for links). In this case there is also reciprocal STD in inferior leads and hyperacute T-waves in aVL. Side note: Sometimes this pattern includes morphology which some have described as " new tall T-wave in V1, " or sometimes " T-wave in V1 greater than in V6 " which is essentially just a description of a hyperacute T-wave in V1, with the exception that it would be better described as both tall and fat/large/wide/bulky T-waves, not just " tall " . Dr. Smith noted " new tall T-wave in V1 " in 14% of cases of early repolarization vs. 34% of subtle LAD occlusions in the derivation study of the anterior OMI formula. This initial ECG does not have this pattern, however lookout for this pattern in the serial ECGs.Our team recognized that this ECG repre...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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Conclusion: This represents the largest study of patients with VPR and angiographically-proven ACO. The MSC were highly sensitive and specific for the diagnosis of ACO in patients presenting to the ED with VPR and symptoms of acute coronary syndrome.===================================MY Comment by KEN GRAUER, MD (10/4/2020):===================================Today ’s case provides a superb example of how acute OMI can sometimes be definitively recognized even in the presence ofpacing. Unfortunately, this was not recognized by the cardiology team despite...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
ECG changes in coronary artery disease (CAD) can be in any of the waves or segments. Diagnosis of acute myocardial infarction in the emergency room still relies mostly on the ECG, though other investigations are there to supplement. P wave abnormalities P wave being an atrial event, is not usually involved directly by CAD. But indirectly, there can be evidence of atrial enlargement if there is left ventricular dysfunction. Atrial arrhythmias are observed in atrial infarction. Abnormalities of PR segment PR segment contains the atrial repolarization wave (Ta) though it is not usually evident. PR segment depression can occu...
Source: Cardiophile MD - Category: Cardiology Authors: Tags: HBC atrial infarction juvenile pattern Juvenile T inversion Loss of R wave progression Pardee’s sign pathological Q waves PR segment depression primary ventricular fibrillation ST segment abnormalities T wave abnormalities Source Type: blogs
Now that we’re in the middle of a pandemic, more people than ever are experiencing anxiety, especially those who struggled with mental health issues before COVID-19. And to make things even worse, many of our coping mechanisms, like going to the gym or hanging out with friends, have been taken away. In today’s show, our host, Gabe Howard, talks with Dr. Jasleen Chhatwal, who helps explain why so many people are having anxiety symptoms and what we can do about it. We want to hear from you — Please fill out our listener survey by clicking the graphic below! SUBSCRIBE &REVIEW   Guest informatio...
Source: World of Psychology - Category: Psychiatry & Psychology Authors: Tags: Anxiety and Panic Disorders Mental Health and Wellness The Psych Central Show Source Type: blogs
A ~40 year old woman started having chest discomfort.  She called 911 after an uncertain amount of time.  EMS arrived and recorded thisprehospital ECG:Obvious Anterior and Inferior STEMI, consistent with LAD occlusionAfter recording this ECG, the patient went intoventricular fibrillation.She was rapidly defibrillated.The cath lab was activated by the paramedics.She arrived complaining of chest pain, with a BP of 110/70.An ED ECG was recorded:It looks worse stillAside: Should the patient receive antidysrhythmics to prevent recurrent VT/VF?  See discussion below on both beta blockers and other anti-dysrhythmic...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
CONCLUSION to the Case: The interventionalist finally took the patient to the cath lab. There was 100% occlusion of the RCA, which was stented.================NOTE: My sincere THANKS to Emmanuel Reisman (New York) for sharing the tracings and this case with us!================SmithQuickComments:Ken,Great case and great discussion!The modified Sgarbossa criteria are only 84% sensitive (if you use 20%) in our studies (Meyers Validation study), and if used on a consecutive group of chest pain patients with LBBB, it would probably be lower.  So indeed we need to look beyond these criteria in order to NOT mi...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
hat H Abstract PURPOSE: Individuals with poor physical and mental health may face elevated risk for suicide, particularly suicide by firearm. METHODS: This retrospective cohort study used statewide, longitudinally-linked ED patient record and mortality data to examine 12-month incidence of firearm suicide among emergency department (ED) patients presenting with a range of physical health problems. Participants included all residents presenting to a California ED in 2009-2013 with nonfatal visits for somatic diagnoses hypothesized to increase suicide risk, including myocardial infarction, congestive heart fail...
Source: Annals of Epidemiology - Category: Epidemiology Authors: Tags: Ann Epidemiol Source Type: research
A 58 yo male was out working in the hot sun for 2-3 hours. He stated he almost passed out, and bystanders called 911. They give him water with salt, as he thought he was dehydrated.When medics arrived, he was alert, sweating, and felt weak.  He walked to the ambulance for evaluation.  He denied headache, chest pain, nausea / vomiting and dyspnea. He had no cardiac history, meds, or risk factors. Vitals were obtained, and placed on cardiac monitor, including this 12 lead prehospital ECG: QTc =  320 ms; (QTc = 374 ms)The computer measures the ST Elevation at the J-point for you.Here it is 4.08 mm in ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This study is the first to provide a direct link between this inflammation and plaque development - by way of IFITM3. Scientists know that the production of IFITM3 starts in response to activation of the immune system by invading viruses and bacteria. These observations, combined with the new findings that IFITM3 directly contributes to plaque formation, suggest that viral and bacterial infections could increase the risk of Alzheimer's disease development. Indeed, researchers found that the level of IFITM3 in human brain samples correlated with levels of certain viral infections as well as with gamma-secretase activ...
Source: Fight Aging! - Category: Research Authors: Tags: Newsletters Source Type: blogs
Fight Aging! publishes news and commentary relevant to the goal of ending all age-related disease, to be achieved by bringing the mechanisms of aging under the control of modern medicine. This weekly newsletter is sent to thousands of interested subscribers. To subscribe or unsubscribe from the newsletter, please visit: https://www.fightaging.org/newsletter/ Longevity Industry Consulting Services Reason, the founder of Fight Aging! and Repair Biotechnologies, offers strategic consulting services to investors, entrepreneurs, and others interested in the longevity industry and its complexities. To find out m...
Source: Fight Aging! - Category: Research Authors: Tags: Newsletters Source Type: blogs
Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
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