60-something with 2 days of intermittent epigastric pain. Why does the cardiologist disagree?

One of our residents who just graduated 3 months ago texted me this ECG:" Hey Steve, would be grateful for any thoughts on this EKG.  60-something with 2 days of waxing and waning epigastric pain and diaphoresis.  Also diffuse abdominal tenderness. "Presenting ECG:What was my answer?What is the management? My Answer: " Inferior and lateral OMI "Detailed Interpretation:Sinus rhythm.  Left axis deviation, but not quite LAFB (no r-wave in inferior leads; no q-wave in aVL).  There is less than 1 mm STE in inferior leads, with reciprocal ST depression. There are hyperacute T-waves in inferior leads.  There are hyperacute T-waves in V2-V6.His Reply: " Thanks.  On his way to cath now but not before plenty of guff from cardiology.... "Outcome:Initial troponin I = 52.0 ng/mL.  100% proximal RCA occlusion.  Severe RV dysfunction on echo.My Question: " Did my response help you persuade the interventionalist? "His Answer: " The troponin actually came back before your response and that's what did it....although the fact that it happened in the daytime on a weekday did not hurt.  I imagine it would have been more of a struggle if it had been 2 AM. "My Question:" How could they give you lots of " condescending guff " with a troponin like that? "His Answer:" The cardiologist said:'Hard to call this " acute " if he has a couple of days of pain and there a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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DiscussionWhich subacute STEMI should go to the cath lab?Simplified:IF there is subacute STEMI by ECG or other criteria AND:1. Symptoms onset is within 48 hours AND2. There are persistent symptoms OR persistent ST ElevationThen the patient should go for emergent angiogram/PCI.I think it makes sense to extend this beyond 48 hours because ischemia can be so intermittent.Schomig et al. randomized patients with:STEMI12-48 hours of symptomsNo persistent symptomsPersistent ST ElevationNo hemodynamic or electrical instability, no pulmonary edemaThe patients who received emergent PCI had significantly smaller median left ventricul...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
You're reading 5 Surprising Things Stress Can Do to Your Body, originally posted on Pick the Brain | Motivation and Self Improvement. If you're enjoying this, please visit our site for more inspirational articles. You just got off a terrible meeting, your boss gave you an impossible deadline for the next project, your team is pushing you to make extra hours, and you still need to pick up the kids at school. Your body is in a “fight or flight response.” Your stress levels are high, you feel your breath get quicker and even feel your heart beating faster than usual. Although this is all a natural response from y...
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Fight Aging! provides a weekly digest of news and commentary for thousands of subscribers interested in the latest longevity science: progress towards the medical control of aging in order to prevent age-related frailty, suffering, and disease, as well as improvements in the present understanding of what works and what doesn't work when it comes to extending healthy life. Expect to see summaries of recent advances in medical research, news from the scientific community, advocacy and fundraising initiatives to help speed work on the repair and reversal of aging, links to online resources, and much more. This content is...
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A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath.This ECG was recorded on arrival:What do you think?This is technically a STEMI, with 1.5 mm STE in V1 and 1.5-2.0 mm in V2. The current criteria only require 1mm in V1 and 1.5mm in V2 for a female. However, I think many practitioners might not see this as a clear STEMI, and would instead call this " borderline. " The normal QRS complex with STE and large volume underneath the T-waves in V1-V3 confirm Occlusion MI (OMI). There is not technically STD in V6 and I, how...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell Meyers, few edits by SmithA man in his 60s with history of stroke and hypertension but no known heart disease presented with chest pain that started on the morning of presentation at around 8am.Here is his triage ECG when he presented at 1657:What do you think?There is sinus rhythm with normal QRS complex and ST depression in V2-V5, maximal in V3-V4. There is no ST depression in V6, II, III, or aVF, and no significant ST elevation in aVR, all confirming that the ST vector is not consistent with diffuse subendocardial ischemia, but rather a focal ST vector pointed at the posterior wall. It is posterior OM...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This study is unable to comment on whether patients with STEMI(-) Occlusion MI have benefit from emergent cath, because that is not the population studied and this subgroup is not commented on.This study is just the most recent in a long long line of similar literature. Context is everything for understanding this study. See below for an excerpt from theOMI Manifesto which summarizes the existing literature and provides details on each study:-------------------------------------------------------------------------------------------------------------- Counter-argument:“Haven’t there been RCTs showing no benefit ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A 60-something presented with hypotension, bradycardia, chest pain and back pain.She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension.  She had a mechanical aortic valve.  She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing.  BP was 70/49, pulse 60.A bedside echo showed good ejection fraction and normal right ventricle and no pericardial fluid. Here is the initial ECG:What do you think?This ECG actually looks like a left main occlusion (which rarely presents to the ED alive):  ST Elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Several myths surrounding heart diseases state that heart diseases attract only elder people and more men than women are prone to heart attacks. Contrary to the belief, cardiovascular cases are on rise in women than men and it is deadlier than all forms of cancers combined. Both physiological and psychological factors are causing heart diseases and it affects people of all ages with no bias. Women that have suffered from mental illness are more susceptible to attract heart risks like stroke. Mental ill health like schizophrenia, anxiety disorders and bipolar disorders are mostly treated with antidepressants, antipsychotics...
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I was reading through ECGs on the system when I saw this one:Sinus tachycardia, rate 120Computerized QTc = 380 msWhat do you think? I was immediately worried about a proximal LAD occlusion.  Although sinus tachycardia generally argues against ACS, a large anterior MI may result in such poor stroke volume that there is compensatory tachycardia and possibly impending cardiogenic shock. I looked to see if there was an ED cardiac ultrasound, and there was:Parasternal Long Axis:Poor image, but one can see that there is poor apical functionParasternal short axis:This shows poor contractility of the anterior wall.C...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
In this study, we asked people in an open-ended way about their desire for longer life: Would you like to have more time? What age would you like to become? This was something more specific than asking about a preference for survival without reference to any length of time; about one's plans for the future; or whether people see the future as open or limited, as in studies of future time perspective. Our attempt was to discover whether there were preferred temporal spans with which older adults framed their futures and plans. The two-question series about extra years and desired age ("How old would you like to ...
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