The difference between Left Main occlusion and Left Main insufficiency
There are many publications stating that ST elevation in lead aVR, with diffuse ST depression elsewhere, is due to "left main occlusion." This is even stated in the lastest 2013 ACC/AHA STEMI guidelines, and they reference an article by Jong et al. (Int Ht J 2006; 47(1):13-20.) as evidence. If you go read that article, "occlusion" was defined as any stenosis greater than 50%. That is not occlusion, which is 100%. There are many other articles that confuse Left Main occlusion with Left Main insufficiency, and these are the sources of the mistaken belief that this ECG pattern reflects LM occlusio...
Source: Dr. Smith's ECG Blog - August 2, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
What are the situations in which patient is taken up for CABG following an attempted primary PCI?
What are the situations in which patient is taken up for coronary artery bypass grafting (CABG) following an attempted primary percutaneous coronary intervention (PCI)?
Coronary anatomy not suitable for PCI
Coronary artery perforation
Inability to cross a critical lesion causing recurrent ischemia (Source: Cardiophile MD)
Source: Cardiophile MD - July 28, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiac Surgery CABG Coronary anatomy not suitable for PCI Coronary artery bypass grafting Coronary artery perforation Inability to cross a critical lesion causing recurrent ischemia Primary PCI primary percutaneous coronary intervention Source Type: blogs
New Study Suggests CME Can Save Significant Healthcare Costs
A recent study by CMEology found that continuing medical education (CME) can save significant healthcare costs. The authors used an educational activity about preventing bleeding-related complications from cardiac and thoracic surgeries for their analysis. The results suggest that even if only a small number of surgeons put into practice what they learned from CME, cost savings could be substantial.
CME has demonstrable value in helping to improve the care physicians provide and the treatment patients receive. Various studies have shown that CME has improved patient outcomes in areas such as multiple sclerosis...
Source: Policy and Medicine - July 17, 2014 Category: American Health Authors: Thomas Sullivan Source Type: blogs
Head On Motor Vehicle Collision. ST depression. Myocardial Contusion?
A woman in her 40's was involved in a head-on motor vehicle collision. EMS noted a facial droop. On arrival she was hypertensive but other vitals were normal. She did complain of back and neck pain, chest pain, and SOB. She also had a facial droop as noted by medics. This droop was apparently new.An ECG was recorded:This shows diffuse ST depression (diffuse subendocardial ischemia) in leads I, II, aVF an V3 to V6, with reciprocal ST elevation in aVR and V1. This is diagnostic of subendocardial ischemia or injury. The ECG was repeated 36 minutes later:The findings are improvingIs this:1. ...
Source: Dr. Smith's ECG Blog - July 1, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Top stories in health and medicine, June 5, 2014
From MedPage Today:
Higher Breast Ca Risk for Childhood Cancer Survivors. Women who survived a childhood cancer were at elevated risk for breast cancer even if they were never exposed to chest radiation during their initial therapy.
Off-Pump CABG: No Lasting Renal Benefit. Performing coronary artery bypass grafting (CABG) without cardiopulmonary bypass has short-term — but not longer-term — benefits for kidney function, a subanalysis of the CORONARY trial showed.
Heart Failure: Early ICD May Boost Survival. Patients with less severe heart failure who received prophylactic implantable cardioverter-defibrillato...
Source: Kevin, M.D. - Medical Weblog - June 5, 2014 Category: Journals (General) Authors: MedPage Today Tags: News Cancer Heart Primary care Source Type: blogs
Acute Cardiogenic Shock: What is the Diagnosis?
Click on this link of a recently posted a similar case with great ultrasound images. Let's see how much you learned and remember.Acute Cardiogenic ShockA 69 yo previously healthy woman had very sudden severe dyspnea. Her husband reported that they had been physically active that day, and that the patient had complained of some chest pain one week prior for which she did not take his advice to go to the ER. She presented in pulmonary edema, hypoxic on high flow O2, and sats at 90% on Noninvasive Ventilation. BP was 130/70 but she was clinically shocky. Cardiac physical exam was unremarkable exc...
Source: Dr. Smith's ECG Blog - May 26, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Picture of Subendocardial Ischemia
This case shows a CT image of subendocardial ischemia. The image is shown at the bottom after the case presentation.This patient presented with a mechanical fall and had chest pain. He had this ECG recorded:There is slight ST elevation in lead III, with reciprocal ST depression in aVL. However, there are also Q-waves inferiorly and the inferior T-waves are inverted, suggesting that this is an old MI with persistent ST elevation, or, alternatively, a subacute or partially reperfused, inferior STEMI. There are somewhat large T-waves in V2 and V3 which are non-specific but could represent posterior rep...
Source: Dr. Smith's ECG Blog - May 23, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Incredible Case Demonstrating the Value of Frequent Serial ECGs
This case is presented and written by Vince DiGiulio, (EMT-Critical Care and emergency department tech). As his title shows, he is a tech. Not a paramedic. Not a nurse. Not a doctor. He is a wizard at reading ECGs and is entirely self-taught. He was the ECG tech on this case, and his skills mean that he recognized the pathology on the ECG and could stand there and keep recording them.A 75 year old female presents with a chief complaint of “reflux.” Starting about five days ago, a couple of times each day she has experienced a burning sensation behind the lower third of her ...
Source: Dr. Smith's ECG Blog - April 18, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain in a patient with previous inferior STEMI. Scrutinize both the ECG and the history!
I was looking through a stack of ECGs (I can't help myself) and saw this one, which caught my eye:What do you think? Computerized QRS duration is 120 ms.My thought was that it looked like there was likely very subtle anterior injury. In spite of the slightly prolonged conduction, I applied the anterior STEMI calculator (see sidebar excel applet, or "subtleSTEMI" iphone app), using:1. ST elevation at 60 ms after the J-point in lead V3: 2 mm (it is probably really 2.5 mm, but I wanted to be conservative)2. computerized QTc = 413 ms3. R-wave amplitude in V4 = 9 mmResult = 23.83 (greater than 23.4 and thus indicati...
Source: Dr. Smith's ECG Blog - April 9, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Why I don't Always Follow Guidelines, My Response To Barron Lerner
Barron Lerner thinks he understands doctor's motives. In his recent article in the Atlantic he laments that physicians act on tradition and emotion over adopting new science. In defense of his position, he sites the example of how cardiologists use angioplasty and coronary artery bypass to treat coronary disease. He states:cardiologists have been remarkably slow to abandon the old hypothesis, continuing to perform hundreds of thousands of bypass operations and angioplasties annually not only in the setting of heart attacks (when they are appropriate) but also to try to prevent them.He, of course, makes th...
Source: In My Humble Opinion - April 6, 2014 Category: Primary Care Authors: Jordan Grumet Source Type: blogs
A Very Unstable Angina. No STEMI present, but needs the cath lab now.
An elderly woman with h/o diabetes and hypertension but no prior cardiac history had been having exertional chest pain for months, though with a normal stress test. She had onset at rest of severe substernal chest pressure radiating to the neck. There was associated SOB and diaphoresis. EMS came and recorded this ECG:What is it? See annotated ECG below.I have put arrows where I think the P-waves are. They march out regularly, but are non-conducting. This is complete, 3rd degree, AV block. The escape is regular at a rate of about 36 and looks like a right bundle branch block and lef...
Source: Dr. Smith's ECG Blog - April 4, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Non STEMI that needs the cath lab now.
A male in his 60's called 911 for chest pain. He had some cardiac risk factors including hypertension, on meds, but no previous coronary disease. His pain was intermittent and he was vague about when it was present and when it was resolved. Here is his prehospital ECG:Diagnosis? He had an immediate ED ECG:There is artifact, but the findings appear to be largely gone nowThe diagnosis is acute MI, but not STEMI. There is slight ST elevation in lead III with reciprocal ST depression in aVL. The T-wave is inverted in III, indicating reperfusion (what I like to call "inferior Wellens' s...
Source: Dr. Smith's ECG Blog - April 2, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ventricular Fibrillation During Echocardiogram, Then Spontaneous Reversion Without Defibrillation
A 47 yo male presented to the Echo Lab one day after being seen in the ED for syncope. During the echocardiogram, the tech noted that the heart stopped. The monitor showed ventricular fibrillation. Before the patient could be defibrillated, he spontaneously reverted to an organzied rhythm:Ventricular Fibrillation, then a period of asystole, then a slightly wide escape rhythm. One might question whether this is polymorphic VT, especially torsade. I have a very long strip and it is definitely ventricular fibrillation, also as read by an electrophysiologist.This happened several times before othe...
Source: Dr. Smith's ECG Blog - March 18, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
45 year old with chest pain
A 45-year-old male was in his usual state of health until three hours prior to arrival, when he developed left-sided chest pressure with radiation to the neck while walking. His pre-hospital ECG is identical to the first emergency department ECG shown in Figure 1. Based on this, the paramedics activated the cath lab, administered nitroglycerin, and the pain resolved.There is at least 2-mm ST-elevation at the J-point in leads V2 and V3, but the morphology of the T-wave is typical of early repolarization (slow upstroke, fast downstroke). There is minimal ST elevation in leads I, aVL, V5, and V6. There is no inferior ST-depre...
Source: Dr. Smith's ECG Blog - January 26, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Cangrelor – a potential drug for anti platelet bridge therapy
In this study, cangrelor was discontinued 1-6 hours prior to surgery, while aspirin was continued through out the perioperative period. Bridging with cangrelor did not increase major bleeds prior to surgery, though minor bleeds, mostly ecchymosis at venipuncture site, was higher. P2Y12 assay documented sufficient platelet inhibition corresponding to levels required for anti thrombotic effect [Angiolillo DJ et al; BRIDGE Investigators. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA. 2012;307:265–274]. Cangrelor is awaiting approval and more large ...
Source: Cardiophile MD - January 9, 2014 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
