A man in his 50s with acute chest pain without STEMI criteria. Trop negative. Cath lab cancelled. But how about the ECG and echo?
Case submitted by Matt Tanzi MD, written by Pendell MeyersA man in his early 50s presented with substernal chest pain and that started 1 hour prior to arrival. There was some radiation to the left jaw and diaphoresis. He had ongoing pain on arrival.Initial triage ECG:What do you think?I sent this to Dr. Smith who immediately replied that it is diagnostic of OMI, but difficult to tell whether it is1) anterolateral with de Winter morphology, or instead2) A combination of Aslanger ' s pattern (inferior OMI with single lead STE in III and reciprocal STD in I, aVL, plus widespread STD of subendocardial ischemia) with ...
Source: Dr. Smith's ECG Blog - September 22, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 60s with chest pain and LBBB
Sent by Ali Khan MD, written by Pendell MeyersA man in his 60s with HTN, HLD, known prior LBBB, presented with episodes of chest pain radiating to the left shoulder, with diaphoresis and dyspnea. Episodes started yesterday after starting to exercise, came and went throughout the day, and he decided to present to the ED the next morning after the one of these episodes failed to resolve like the others.Here is his ECG at triage with ongoing pain (prior unavailable):Same image optimized by PM Cardio appWhat do you think?I sent this to Drs. Smith, McLaren, and Grauer all of whom immediately diagnosed LAD occlusion based ...
Source: Dr. Smith's ECG Blog - September 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Unstable Angina still exists. It can be missed especially high sensitivity troponin is not used. Sometimes you can catch it on the ECG.
A 50-something woman with H/o HTN, ESRD, CAD S/p complex PCI to ostial LAD and ramus (10/2020) and CABG x3 (LIMA to LAD, SVG to OM, SVG to ramus)She complained of intermittent episodes of substernal chest pain, radiating to left shoulder, lasting 2-3 minutes.This had been worked up before at another ED on 3 occasions for the same chest discomfort.--The 1st time, she was " ruled out " with a point of care (POC) troponin ＜0.03 ng/mL.--The 2nd time, she was " ruled out " again with a POC troponin ＜0.03 ng/mL.--The 3rd time, she " ruled out " with a laboratory-based 4th generation troponin at 0.018 ng/m...
Source: Dr. Smith's ECG Blog - September 5, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Fight Aging! Newsletter, August 8th 2022
In conclusion, aging research will benefit from a better definition of how specific regulators map onto age-dependent change, considered on a phenotype-by-phenotype basis. Resolving some of these key questions will shed more light on how tractable (or intractable) the biology of aging is.
Does Acarbose Extend Life in Short Lived Species via Gut Microbiome Changes?
https://www.fightaging.org/archives/2022/08/does-acarbose-extend-life-in-short-lived-species-via-gut-microbiome-changes/
Acarbose is one of a few diabetes medications shown to modestly slow aging in short-lived species. Researchers here take a...
Source: Fight Aging! - August 7, 2022 Category: Research Authors: Reason Tags: Newsletters Source Type: blogs
Are Pharmacological Approaches to Slow Aging in Fact Promising?
Today's open access review paper looks over a selection of what I would consider to be largely unpromising small molecules, each with evidence for their ability to slow aging, but very modestly and unreliably in most cases. Looking at the bigger picture, for much of the public it is still surprising to hear that the pace of aging can be adjusted via any form of therapy, so there is probably a role for simple, low-cost small molecule drugs in the process of education that leads to more serious efforts aimed at producing the means of human rejuvenation. Still, entirely too much effort is devoted towards small molecules that ...
Source: Fight Aging! - August 3, 2022 Category: Research Authors: Reason Tags: Medicine, Biotech, Research Source Type: blogs
A Middle Aged Male diagnosed with Gastroesophageal Reflux
This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. He had been at a clinic that day where he had complained of worsening GERD. An EKG was recorded and interpreted as normal by the computer, the clinician, and by the overreading cardiologist.He had an ECG recorded in triage (I am not certain whether the patient had active pain at this time; I believe he didnot):What do you think?Here is the patient ' s ECG from several hours ago (which was essentially the same):This shows minimal inferior ST Elevation that is howeverall but diagnostic of inferior ischemia. There is the o...
Source: Dr. Smith's ECG Blog - July 16, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Acute chest pain and a difficult ECG
Conclusion: Whereas I did not feel we could rule out an OMI from the initial tracing shown in Figure-1 — none of the subsequent tracings in today ' s case were suggestive of an acute event. I suspect that IF the initial ECG would have beenimmediately repeated withaccurate chest lead electrode placement — that there maynot have been any need for concern about a possible acute event from the initial ECG.Learning Point: When clinical decision-making hangs in the balance and you strongly suspect an error in lead placement — it is best toimmediately repeat the ECG —&nbs...
Source: Dr. Smith's ECG Blog - June 25, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?
Written by Jesse McLaren, with comments by Smith and Grauer Four patients presented with cardiorespiratory symptoms, with inferior ST elevation and reciprocal change on their ECG. Which patient had occlusion MI? Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. First let ’s start with each ECG without clinical context. What do you think of each ECG? ECG 1: ECG 2:ECG 3:ECG 4:Now let ’s introduce some clinical context. How would this change management? Patient 1: 30 year old previously healthy, presenting with syncope, now asymptomatic with n...
Source: Dr. Smith's ECG Blog - May 23, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Chest pain, shortness of breath, T wave inversion, and rising troponin in a young healthy runner.
In this study, 40 presumably healthy male marathon runners had their cardiac troponin and other findings measured before and after running a marathon. 39 pts (97.5%) had baseline cTnT values below the reference limit (less than 14 ng/L). 38 pts (95%) of participants had post-marathon cTnT concentration rise above this reference limit. The median post-marathon cTnT was 41 ng/L, and the 95th percentile concentration was 90 ng/L. None reported " cardiac symptoms " after the race.See this single post for many examples of BTWI:Understanding this pathognomonic ECG would have greatly benefitted the patient.More cases involving BT...
Source: Dr. Smith's ECG Blog - May 19, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Why is there inferior ST elevation, and would you get posterior leads?
Written by Jesse McLaren, with comments by Smith and Grauer A 75 year-old presented with 8 hours of epigastric pain and one episode of vomiting. They had a history of gallstones but no cardiac history. Vitals were normal except a heart rate of 55, and below is the triage ECG.What do you think?There ’s bradycardia but it is not sinus: while the P wave is upright in I it is inverted in II so it is a low atrial rhythm. Conduction is otherwise normal, axis is indeterminate, and voltages are normal. There is early R wave progression with R>S in V1-2, primary ST depression in V2-3, and a Q wave with hyperacute T wave i...
Source: Dr. Smith's ECG Blog - May 3, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Chest pain, a ‘normal’ ECG, a'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.
Written by Jesse McLaren, with comments from Smith and GrauerA 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. ECG was labeled ‘normal’ by the computer (confirmed by the overreading cardiologist) and the high-sensitivity Troponin I was normal at a value of 11 ng/L (Abbott Alinity assay, where normal is<26 in males,<16 in females; this assay is nearly identical to the Abbott Architect high sensitivity assay). So the patient was low risk according to HEART and EDACS scores. Should this patient be discharged home? How about a stress test? ...
Source: Dr. Smith's ECG Blog - April 22, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 60s with chest pain. Cardiologist refuses to take to the lab. Obvious STEMI, even with criteria. Yet final diagnosis " NSTEMI " . This happens far too often.
Submitted by Anonymous MD, edits by MeyersA man in his 60s with past medical history of multiple sclerosis and hypertension was brought in by EMS from home for chest pain thatstarted acutely just prior to arrival. He rated the pain at 9/10, describes as pressure, radiates towards the left arm with associated shortness of breath, diaphoresis and had one episode of emesis. He did not have a prior history of CAD or other cardiac disease. His pain improved to 6/10 after EMS gave him 3 sprays of sublingual nitroglycerin and 324 mg of aspirin. Prehospital ECGs:What do you think?Both ECGs are diagnostic of acute LAD OMI...
Source: Dr. Smith's ECG Blog - April 15, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Fight Aging! Newsletter, April 11th 2022
In conclusion, plasma levels of IGHA2, APOA and HPT are associated with subclinical atherosclerosis independently of traditional risk factors and offers potential to predict this disease. The panel could improve primary prevention strategies in areas where imaging is not available.
A Lesser Diversity of Circulating Antibodies in the Aging Killifish Immune System
https://www.fightaging.org/archives/2022/04/a-lesser-diversity-of-circulating-antibodies-in-the-aging-killifish-immune-system/
Short-lived killifish are one of the more recently adopted animal models of aging. All such models are a trade-off bet...
Source: Fight Aging! - April 10, 2022 Category: Research Authors: Reason Tags: Newsletters Source Type: blogs
A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?
Case written and submitted by Brandon Fetterolf MD, edits by MeyersA woman in her early 30s with multiple autoimmune disorders including vasculitis presented with 2-3 hours of mid-left side chest discomfort with radiation to neck and left arm and associated with nausea, diaphoresis and dizziness. Initial ECG on presentation at 1554 (no prior for comparison):What do you think is happening to his 30s woman? The ECG shows NSR with a normal QRS except for poor R wave progression and pathologic QS-waves in V2-3. There is STE and hyperacute T waves in V2, I, and aVL with reciprocal STD in II, III, and aVF. This is...
Source: Dr. Smith's ECG Blog - April 8, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Arguing for More, and More Rigorous, Drug Repurposing Efforts to Slow Aging
The authors of today's open access paper argue for much greater effort to be directed towards the repurposing of existing drugs with the goal of slowing aging. I have mixed feelings about the prevalence of drug repurposing in the pharmaceutical industry. The FDA makes it so very expensive to introduce any new drug that industry of course responds to the incentives and spends a great deal of time digging through the existing library of approved drugs in search of those that can be used in different circumstances. It is a great deal easier to take a drug with established safety data and seek approval for a new use than it is...
Source: Fight Aging! - April 7, 2022 Category: Research Authors: Reason Tags: Medicine, Biotech, Research Source Type: blogs
