Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.
In this study, the major outcomes were the same for both groups, but of 70 patients in the delayed group,4 required emergent intervention for sudden re-occlusion. You can make your own conclusions. I think I would want to intervene before there is risk of re-occlusion.However, one could make a reasonable argument for delaying, especially if you would need to awaken your cath team in the middle of the night. It requires full antiplatelent and antithrombotic therapy, and, in my opinion, if you delay, you should institute continuous 12-lead ECG monitoring. This is why:1. Why we need cont...
Source: Dr. Smith's ECG Blog - April 22, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Who Needs a CT Coronary Angiogram?
CT coronary angiograms are increasing in popularity as a non-invasive screening test for detecting blocks in coronary arteries.
Coronary arteries are blood vessels supplying oxygenated blood to the heart.
Angiograms are images of blood vessels, usually obtained by injecting medications for contrast from body structures.
CT angiograms are reconstructions from multi slice CT scans following injection of contrast material into a forearm veins.
Veins are blood vessels returning deoxygenated blood to the heart.
CT coronary angiogram can be done as an outpatient test, in the X-ray department.
As of now CT angiograms cannot repla...
Source: Cardiophile MD - April 18, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
ECG in LMCA Stenosis
ECG in a person with persistent anginal pain for the past several hours showing significant ST segment depression anterolateral leads along with sinus tachycardia. ST segment elevation is noted in aVR. Such a pattern is consistent with significant left main coronary artery stenosis.
Clinical evaluation and X-Ray chest showed features of pulmonary edema. Angiography done after initial stabilization showed severe stenosis of distal left main coronary artery. In addition, there were multiple lesions in all three vessels, making a standard indication for an urgent coronary artery bypass grafting.
A similar ECG pattern can also...
Source: Cardiophile MD - April 13, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
No, we can ’ t call OMT, as a re-vascularisation procedure.
Hi, welcome Mr George, I just reviewed your records. You have three blocks in your arteries supplying the heart.
Are they serious Doctor ?
Not really, but one of them appear tight
What should I do Doctor ? But, I am comfortable Doctor.
You may be. But I am not .You need to undergo some re-vascularisation procedure .
What do you mean by that Doctor ?
It means either a percutaneous coronary intervention with a stent or CABG.
Can I get my heart re-vascularised by drugs alone Doctor ?
No we can’t . Hmmm , wait, we do have something called OMT/GDMT. Can you put on hold for some time Mr George, ...
Source: Dr.S.Venkatesan MD - February 25, 2024 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs
Predicting myocardial viability from surface ECG following MI
Once upon a time, long, long ago, cardiologists used to be worried about akinetic segments, scars, dead tissue, and Q waves before attempting revascularization by either PCI or CABG. Now, the concept of myocardial viability has become a cliché ( rather demeaning) at least within the cath labs. Currently ,we follow a self administered whip . Every post-MI patient should be considered for revascularization as a default strategy irrespective of the level of dysfunction or scarring .This can happen either in the IRA territory or non-IRA territory or both.
This strategy is now dis-armed with fresh evidence in the form ...
Source: Dr.S.Venkatesan MD - February 14, 2024 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized acc aha esc guidelines ECG predictors of myocardial viablity PET SCAN FOR VIABLITY REVIVE BRICS STUDY Source Type: blogs
Vomiting, Diarrhea, and " Bubbles in my Chest "
A 60-something complained of vomiting, diarrhea overnight, and " bubbles in my chest " that started just prior to calling 911.He had this ECG recorded prehospital:Smith interpretation:There are hyperacute T-waves in III and aVF, and reciprocal STD in aVL with a reciprocally inverted T-wave in aVL. There are also hyperacute T-waves in V3 and V4. There is STD in V1 and V2. So it appears to be diagnostic of OMI, but it is hard to figure out what exact territory and artery. It could be a proximal RCA with both inferior OMI, posterior OMI (pulling ST down in V1/V2), and RV OMI causing large ischemic...
Source: Dr. Smith's ECG Blog - February 12, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain with anterior ST depression: look what happens if you use posterior leads.
Don ' t forget to watch theWebinar: Smith and Pendell Meyers interpret ECGs for OMI or not OMI on Monday Feb 12 at 11 AM U.S. Central time. Register here:https://zoom.us/webinar/register/7617067094184/WN_LMN0vPb1Rz-HZu12K-QuYQWritten by Jesse McLarenA 65 year old
with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented
with 3 days of fluctuating chest pain, which was ongoing at triage. What do you
think? Do you need posterior leads?There ’s atrial
flutter with controlled ventricular response, a non-specific intra-ventricular
conduction delay, borderline right axis, normal R wave...
Source: Dr. Smith's ECG Blog - February 9, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Acute chest pain in a patient with LVH and known coronary disease. What does the ECG show?
A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain.Here is his ED ECG:What do you think?There is a flat and downsloping ST segment in V2 and V3. This could be due to posterior OMI. Is there an old ECG for comparison?Here is the most recent previous ECG:Indeed, there was some normal ST elevation in V2 and V3, discordant to a relatively deep S-wave which could be due to some LVH.Here is another previous ECG:So it looks like a posterior OMI.2 years prior he had an angiogram which showed 90% proximal stenosis of the circumflex. It...
Source: Dr. Smith's ECG Blog - January 25, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
How cardiogenic shock in NSTEMI is different from STEMI?
Cardiogenic shock (CS)is the most feared event following STEMI. The incidence is up to 5 to 10% with a mortality rate of around 50-60%. Still, we are finding it hard to bring this down below 50 % .There is one less addressed issue in ACS literature. We tend to perceive CS as an exclusive complication of STEMI. The fact is that NSTEMI can also result in CS is less recognized. The incidence is half of that of STEMI, i.e., 2.5-5%.
Mechanism of CS in NSTEMI
One may ask, how can CS occur in NSTEMI with partial occlusion with a non trans-mural MI. ACS pathophysiology is not that simple. Ischemic LV dysfunction (Global stun...
Source: Dr.S.Venkatesan MD - December 30, 2023 Category: Cardiology Authors: dr s venkatesan Tags: acute coronary syndrome Uncategorized acc aha esc guidlines on stemi shock cardiogenic shock cardiogenic shock in stemi vs nstemi cs in stemi vc nstemi grace registry how is cardiogenic shock in nstemi different from stemi ? iglobal lv stu Source Type: blogs
Rules of myocardial revascularisation REVIVEed : Quantify ” non-viable tissue ” first.
”It looks like, science oftentimes struggles at the hands of scientists“
The weakest link in medical research is framing the right research question. How will you explain the drama of research on myocardial viability studies that have been going on full steam for more than 3 decades,? Which has become junk now.
This truth came out from a secondary analysis of the famous REVIVED-BCIS2 trial. For the busy guys, the conclusion is given in the box below.
JAMA Cardiol. 2023;8(12):1154-1161.
Final message
We realize, in the game of myocardial revascularisation t...
Source: Dr.S.Venkatesan MD - December 20, 2023 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized accc aha esc guid;ines on myocardial revascularisation cabg cabg patch study ischemic dcm myocardail viablity pet scan for myocardial viablity REVIVED BCIS2 viablity study myocardial Source Type: blogs
A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith. Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 50-something with Regular Wide Complex Tachycardiaa: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith. Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Judge for yourself the management of this patient with " NSTEMI, multivessel disease "
DISCUSSION:The administration of
opioid analgesia prior to cath in patients with concern for ACS is associated
with longer door-to-balloon times, and greater peak troponin levels. The rate
of Occlusion MI in those who received pre-cath opioids was double the rate of
those without pre-cath opioids, and STEMI(-) OMI patients who received pre-cath
opioids waited 10 hours on average longer to get cath than those who did not
received opioids. These results add support to our hypothesis that a major
mechanism of harm caused by opioid medications in ACS patients involves delays
to the cath lab for patients with STEMI(-) OMI.=====...
Source: Dr. Smith's ECG Blog - September 10, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
63 year old with " good story for ACS " but negative troponins.....
This was texted to me from a former resident, while working at a small rural hospital, with the statement:" I can ’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS. " (Chest pain or discomfort)What do you think?Here was my response:" Suspicious for inferior posterior OMI. Get serial ECGs "He then sent a previous from 4 years prior:" This is totally normal, which confirms that the first EKG does indeed represent OMI "Then the patient ' s chest pain resolved and he recorded another:The ST depression in aVL is gone and the T-waves are less hyperacu...
Source: Dr. Smith's ECG Blog - July 2, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
75 year old with 24 hours of chest pain, STEMI negative
Written by Jesse McLaren A 75 year old
with a history of CABG called EMS after 24 hours of chest pain. HR 40, BP
135/70, RR16, O2 100%. Here ’s the paramedic ECG (digitized by PMcardio). What
do you think? There ’s sinus
bradycardia, normal conduction, normal axis, delayed R wave progression, and
normal voltages. There are inferior Q waves and lead III has mild concave ST
elevation, with subtle reciprocal ST depression in I/aVL. This is diagnostic of
inferior OMI, likely from the RCA. The patient has a hi story of CABG so some of
these changes could be old, but with ongoing chest pain and bradycardia in a
hig...
Source: Dr. Smith's ECG Blog - June 8, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
