When there is less than 1 mm of ST depression, can you make the diagnosis of posterior OMI?
DiscussionApproximately 10% of OMIs will involve the posterior wall, most of which also have concomitant involvement of the lateral and/or inferior walls (though usually not meeting STEMI criteria). Isolated posterior OMI, however, manifests as STD without associated STE since the subepicardial myocardial ischemia that would normally generate STE on overlying leads is occurring in the opposing or negative vector compared to the recording ECG leads. The majority of isolated posterior OMIs will be due to occlusion of the LCX, RCA, or a variety of their posterior branches.The 4th Universal Definition of Myocardial Infarc...
Source: Dr. Smith's ECG Blog - February 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
The Paradigm Shift That Wasn ’ t: The ISCHEMIA Trial
By ANISH KOKA
A recent email that arrived in my in-box a few weeks ago from an academic hailed the latest “paradigm shift” in cardiology as it relates to the management of stable angina. (Stable angina refers to chronic,non-accelerating chest pain with a moderate level of exertion). The points made in the email were as follows (the order of the points made are preserved):
The financial burden of stress testing was significant ( 11 billion dollars per annum in the USA!)For stable CAD, medical treatment is critical. We now have better medical treatments than all prior trials including ischemia. th...
Source: The Health Care Blog - February 26, 2021 Category: Consumer Health News Authors: Christina Liu Tags: Medical Practice Physicians Anish Koka cardiology ISCHEMIA trial Source Type: blogs
ePLAR: Echocardiographic Pulmonary to Left Atrial Ratio
ePLAR is a simple echocardiographic estimation useful in differentiating pre-capillary from post capillary pulmonary hypertension [1].
ePLAR = TR Vmax/(Mitral E/e’)
ePLAR: Echocardiographic pulmonary to left atrial ratio
TR Vmax: Maximum velocity of tricuspid regurgitation jet by Doppler echocardiography in m/s
E: E wave in the mitral flow Doppler
e’: Septal mitral annular tissue Doppler velocity
ePLAR values are lower in post-capillary pulmonary hypertension. E/e’ reflects left ventricular filling pressure which is left atrial pressure. TR Vmax reflects the pulmonary artery systolic pressure. That is h...
Source: Cardiophile MD - February 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Echocardiography Source Type: blogs
A 30-something with inferior ST Elevation. OMI? Pericarditis? Normal Variant ST Elevation?
This study showed that ANY ST depression in lead aVL is highly sensitive for inferior OMI, and that zero patients with pericarditis had this feature.Of the 154 patients with catheterization laboratory diagnosis of inferior STEMI, 154 patients (sensitivity, 100%; CI, 98%-100%) had some degree of ST depression in lead aVL (at least 0.25mm). In addition, all 154 patients demonstrated T-wave inversion in lead aVL (sensitivity, 100%; CI, 98%-100%). Of the 49 pericarditis patients, zero (0%) had any ST-segment depression in lead aVL (CI, 0%-7%), and 7 (14%) of 49 (CI, 7%-27%) had T-wave inversion in aV...
Source: Dr. Smith's ECG Blog - February 16, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
The Therapeutic Potential of Voice Technology
John Halamka, M.D., president, Mayo Clinic Platform, and Paul Cerrato, senior research analyst and communications specialist, Mayo Clinic Platform, wrote this article.The human voice is capable of extraordinary feats of genius and everyday acts of kindness. It can recite Shakespearean sonnets, teach our children moral values, stir audiences with a dramatic performance, and much more. But few of us ever imagined it capable of assisting in the diagnosis of disease. That ’s about the change, as evidenced by several innovative projects in voice technology.With the right digital tools, it is now possible t...
Source: Life as a Healthcare CIO - February 4, 2021 Category: Information Technology Source Type: blogs
Septal bounce and septal shudder in constrictive pericarditis
Septal bounce
Septal bounce is also called respirophasic ventricular septal shift [1, 2]. It is an early diastolic posterior motion of the interventricular septum. Septal bounce is a sign of ventricular interdependence noted in constrictive pericarditis. The sign may be seen on echocardiography, cardiac magnetic resonance imaging and cardiac computed tomography. Mechanism has been studied by simultaneous cardiac catheterization and echocardiography [2]. Septal bounce was the most consistent sign among 39 cases of constrictive pericarditis evaluated by two independent observers in a study [3]. Septal ‘bounce’...
Source: Cardiophile MD - January 12, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiac Magnetic Resonance imaging Echocardiography respirophasic ventricular septal shift septal bounce septal bounce in constrictive pericarditis septal shudder septal shudder in constrictive pericarditis ventricular interdependence Source Type: blogs
Acute chest pain, ST Depression in V2 and V3, relief with Nitroglycerine, " normal " coronaries, and apical ballooning. Is it takotsubo?
This was submitted by Michael Fischer, one of our outstanding2nd year EM residents at Hennepin Healthcare.CaseA previously healthy female in her 40s presented 1 hour after abrupt onset 10/10 crushing chest pain that started while brushing her hair that morning. The pain radiated to her bilateral jaw and right shoulder, and did not seem to be exertional or pleuritic in nature. Here is her pre-hospital ECG: What do you think?Smith: V2 and V3 have some minimal ST depression with downsloping. This is highly suggestive of posterior MI.This was read by EMS as non-specific. Aspirin 324mg was given by EMS. Ni...
Source: Dr. Smith's ECG Blog - January 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain after motor vehicle collision with an abnormal ECG - blunt cardiac injury? OMI? normal variant?
Discussion:Significant cardiac trauma occurs in approximately 10% of patients with severe blunt chest trauma. Isolated coronary artery dissection from blunt trauma is a very rare event. Traumatic dissections are most often seen in the LAD, followed by the RCA and LCX. It is thought that this is due to the relative anterior position of the LAD. The ECG is a report from the myocytes of their condition. They do not know the etiology of acute complete ischemia. No matter if its typical ACS, traumatic dissection causing acute occlusion, or spasm, it is the same result to the myocytes, and the same findings can be present o...
Source: Dr. Smith's ECG Blog - December 30, 2020 Category: Cardiology Authors: Pendell Source Type: blogs
Extreme widespread ST depression, with ST Elevation in aVR. What do you think?
ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - December 16, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 60s with VFib arrest and no STEMI on her post-ROSC ECG.
This study had a fatal flaw: they did not keep track of all the " Non-STEMI patients " who were NOT enrolled, but instead were sent for immediate angiogram. It was done in Europe, where the guidelines suggest taking all shockable arrests emergently to the cath lab. So it is highly likely that physicians were very reluctant to enroll patients whom they suspected had Occlusion MI (OMI), even if they didnot have STEMI. These physicians did not want a patient with an OMI that was not a STEMI to be randomized to no angiogram. This strong suspicion is supported by their data: only 22 of 437 ...
Source: Dr. Smith's ECG Blog - November 17, 2020 Category: Cardiology Authors: Pendell Source Type: blogs
Extreme shock and cardiac arrest in COVID patient
This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. He was moderately hypoxic. He had the following EKG recorded:Low voltage, suggests effusion.(see Ken ' s discussion of low voltage below)There is a QS-wave in V2.There is minimal, probably normal STE in V2-V6.A bedside cardiac ultrasound was normal, with no effusion. He had troponins ordered, and the first returned at 72 ng/L (Abbott Architect hs cTnI; URL for males = 34 ng/L). An elevated troponin in a COVID patient confers about 4x the risk of mortality than a normal one.He was admitted on oxygen and was&...
Source: Dr. Smith's ECG Blog - November 12, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
Robotic Catheterization for Mitral Valve Repair: Interview with Mark Barrish, CEO of Moray Medical
At present, mitral heart valve failure is treated through invasive surgery or via a transcatheter procedure called Transcatheter Edge-to-Edge Repair (TEER). However, this procedure is difficult to perform, potentially resulting in suboptimal outcomes in challenging cases and if done by inexperienced clinicians.
To address this, Moray Medical, a company based in Mountain View, California, has developed a robotic catheter and associated technology, including augmented reality and a 3D digital interface, designed to make the job easier. In fact, the company claims that using its technology to deliver cardiac therapies can ...
Source: Medgadget - October 28, 2020 Category: Medical Devices Authors: Conn Hastings Tags: Cardiac Surgery Exclusive Radiology Source Type: blogs
Dynamic ST Elevation
A 70-something male with 3 CAD risk factors developed intermittent left sided chest discomfort 29 hours prior. It began again 2 hours prior to first ECG. Pain was 7/10 radiating to left arm with SOB and diaphoresis.Here was the prehospital ECGSinus rhythm. Slight ST depression in I, aVL, and V4-V6, consistent with ischemia.These medics were smart and well trained, and so they recorded another several minutes later due to persistent symptoms:New ST Elevation in V4-V6, with obliteration of the S-waves.There is also new subtle STE in inferior leadsThey arrived in the ED and another ECG was recorded:Chest pain stil...
Source: Dr. Smith's ECG Blog - October 14, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
ECG and CXR in ventricular septal defect
ECG in ventricular septal defect
ECG is normal in a small ventricular septal defect. Large VSD with large left to right shunt will have left ventricular volume overload with small q, tall R and upright T waves in lateral leads. Large VSD progresses to biventricular overload when there is hyperdynamic pulmonary hypertension. The ECG pattern of biventricular hypertrophy is called Katz – Wachtel phenomenon with tall biphasic (R=S) QRS complexes with amplitude over 50 mm in mid precordial leads. This pattern is usually seen in children. Since the QRS amplitude is high it often overshoots the margin of the ECG graph as seen ...
Source: Cardiophile MD - October 10, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: HBC Katz – Wachtel phenomenon peripheral pruning Source Type: blogs
A woman in her 60s with chest pain and prominent J waves
Case submitted by Dan Singer MD and Ryan Barnicle MD, Written by Pendell MeyersA woman in her 60s with history of smoking presented to the ED with left sided chest pain radiating to the left arm and back, starting at about 1330. She described the pain as a " heaviness, " without exacerbating or alleviating factors. Her pain at the time of arrival was 10/10.Here is her triage ECG (no prior for comparison):What do you think?Findings: - Sinus rhythm at around 100 bpm - Grossly normal QRS complex - 1.0 mm STE in lead III, and just a hint of STE in aVF (both of which have to be measured just after significant J w...
Source: Dr. Smith's ECG Blog - September 22, 2020 Category: Cardiology Authors: Pendell Source Type: blogs
