INTERMACS classification for advanced heart failure
INTERMACS classification for advanced heart failure was developed as a sub classification for advanced heart failure, typically for those in advanced NYHA (New York Heart Association) Functional Class III and IV. Interagency Registry for Mechanically Assisted Circulatory Support
(INTERMACS) developed this classification with seven clinical profiles and an arrhythmia modifier [1]. This was to allow optimal selection of patients for medical and pacing therapies, cardiac transplantation and mechanical circulatory support.
They found that 80% of current devices are being used in 2 profiles with the highest level of clinical...
Source: Cardiophile MD - November 24, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs
Shark fin post arrest: do you understand the ECG?
Case submitted by Dr. Daryl Williams, written by Pendell Meyers, peer reviewed by Smith and BraceyA physician bystander witnessed a middle-aged or slightly elderly man suddenly collapse while walking down the street, very close to the hospital. The physician immediately started CPR and called EMS. EMS arrived quickly and found the patient to be in VFib. After several shocks the patient achieved ROSC.A minute or so after arrival to the ED, he went back into VFib and was immediately shocked back out into sinus rhythm.His EMS ECG during initial ROSC was available for the ED team:Here is his ED ECG:What do you think?Both ...
Source: Dr. Smith's ECG Blog - November 22, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
PEA cardiac arrest, ROSC, and no STEMI on ECG. Randomized trials say emergent reperfusion is not indicated, right?
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 did not 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 o...
Source: Dr. Smith's ECG Blog - November 4, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Acute Pulmonary Edema, PEA Arrest, LBBB, First degree AV Block, and STD maximal in V3, V4
An elderly woman had sudden SOB and 911 was called. Medics found her with labored breathing and 75% saturations. She was put on high flow oxygen. After placing her in the ambulance, she had a PEA arrest. She was intubated and ventilated, and given compression decompression CPR with theResQPod andResQPump.Aside:these 2 devices were invented by researcher Keith Lurie, who is in the Department of EM here at Hennepin; this isthe only method of CPR ever proven in a randomized trial to improve outcome in cardiac arrest see this ResQTrial, published in Lancet in 2011:Treatment of out-of-hospital cardi...
Source: Dr. Smith's ECG Blog - October 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
An elderly man who dies 12 hours later - could he have been saved?
Sent by Anonymous, written by Pendell Meyers and Steve SmithAn elderly man with good neurologic baseline but history of CABG presented to the ED with acute lightheadedness, shortness of breath, and chest pressure radiating to both arms. He had just recently been admitted for similar symptoms which had been diagnosed as an NSTEMI, and he received a stent to the ostial LCX one week ago. At that time his EF was 30%. He returned to the same hospital where he had just received his LCX stent.Here is his first ECG at triage, with chest pain temporarily resolved:He then had spontaneous return of chest pain while in the ED, wi...
Source: Dr. Smith's ECG Blog - October 22, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Cardiac Arrest at the airport, with an easy but important ECG for everyone to recognize
Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - September 23, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Arrest at the airport, with an easy but important ECG for everyone to recognize
Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - September 23, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Crushing Chest pain, Tachycardia, and Very Elevated Blood Pressure in a 40-something Man.
A 40-something male called 911 for 2 hours of crushing, non-radiating, chest pain at about 11 AM. He reported a similar episode last year when his blood pressure was very out of control and that again he has not taken his BP meds for 2 months. He stated he had drunk 12 cans of Mountain Dew (high caffeine content) overnight. On exam, he was very anxious, holding his chest, breathing normally. Chest pain was worse with palpation. His BP was 250/150 with a heart rate of 150.Here are 2 prehospital ECGs, 6 minutes apart:Heart rate 156. ST Elevation. Large T-wavesThe computer re...
Source: Dr. Smith's ECG Blog - August 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
Hypotension, altered mental status, and aVR sign - activate the cath lab?
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 - July 21, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Percutaneous left ventricular assist devices
This study also documented significantly greater increases in cardiac index and mean arterial blood pressure as well as significantly greater decreases in pulmonary capillary wedge pressure with TandemHeart. Severe adverse events and overall mortality were not significantly different between the two groups.
So we need more large scale studies on both types of percutaneous left ventricular assist devices and possibly improvements in their technical aspects to have a greater impact on survival in cardiogenic shock. Ongoing DanShock trial is one such study to look forward to.
References
Ergle K, Parto P, Krim SR. Percutaneou...
Source: Cardiophile MD - June 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life
Case submitted and written by Dr. Jesse McLaren (@ECGcases), ofEmergency Medicine CasesReviewed by Pendell Meyers and Steve SmithAn 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. The paramedics found the patient with ROSC and a GCS 7, and an ECG showing LBBB with possible lateral ST elevation. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. On arrival, GCS was 13 and the patient complained of ongoing chest pain. Vitals were HR 58 BP 167/70 R20 sat 96%. Below is the first ED ECG, labeled LBBB by the machine. Are there any indicat...
Source: Dr. Smith's ECG Blog - June 11, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Why is there ST Elevation in lead V2? Think Lead Placement.
I was shown this ECG of a 40-something intoxicated male with altered mental status. The provider was very worried about LAD occlusion.What do you think?There is ST Elevation in lead V2, but there is also an RSR ' wave which creates a kind of saddle ( " saddleback pattern " ). This is rarely due to anterior MI. There is also tachycardia, which unless a patient has cardiogenic shock, is also uncommonly due to ACS. And, of course, without chest pain, the pretest probability is very low.RSR ' and saddleback can be due to leads being placed too high, but since the P-wave is upright in lea...
Source: Dr. Smith's ECG Blog - May 27, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 30s with greater than 12 hours of chest pain
Written by Bobby Nicholson MD, with edits by MeyersA man in his early 30s presented at 7:35am to the ED with chest pain (7/10) beginning suddenly at 7:30pm the night prior. The note did not specify whether the pain had been truly constant for 12 hours, or whether it had been intermittent. He had associated nausea, vomiting, hot flashes, chills, dyspnea, and cough. He had uncontrolled type 1 diabetes and smoking history. Vitals were normal. Physical exam was unremarkable. No prior ECG was on file.At 0742, this ECG was obtained in triage:What do you think?Raw Findings: - Sinus rhythm - QRS is narrow wit...
Source: Dr. Smith's ECG Blog - May 7, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
PRAMI Trial – Review
PRAMI Trial – Review
Preventive Angioplasty in Myocardial Infarction Trial (PRAMI) was conducted at five centres in the United Kingdom between 2008 and 2013. The study enrolled 465 patients with acute ST elevation myocardial infarction (STEMI) including 3 with left bundle branch block. Patients undergoing infarct related artery or culprit artery percutaneous intervention were randomized to either preventive PCI or no preventive PCI [1]. After primary PCI, subsequent PCI was recommended only for refractory angina with objective evidence of myocardial ischemia. Primary outcome measure in the PRAMI trial was a composit...
Source: Cardiophile MD - April 22, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Coronary Interventions Source Type: blogs
CULPRIT-SHOCK Clinical Trial – Review
CULPRIT-SHOCK Clinical Trial – Review
Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial investigated two strategies for percutaneous coronary interventions (PCI) in acute myocardial infarction with cardiogenic shock [1]. It was a multicenter randomized trial involving 706 patients who were randomized to either immediate PCI of the culprit lesion only with option for staged PCI of non-culprit lesions or immediate multivessel PCI. Primary composite endpoint included death and severe renal failure leading to renal replacement therapy within 30 days after randomization. Primary co...
Source: Cardiophile MD - April 8, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Angiography and Interventions Coronary Interventions Source Type: blogs
