How is pulmonary embolism treated? Cardiology Basics
Pulmonary embolism is obstruction of pulmonary arteries due to emboli migrating from other parts of the body. It is a potentially life threatening condition if a major branch or multiple branches are obstructed. More emboli can travel to the lungs from the original source and hence pulmonary embolism may worsen later even if the initial episode involves only a small portion of the lungs. So, it is important to treat pulmonary embolism even if it is mild. Treatment options will depend on the severity of the situation. Initial treatment will be with parenteral anticoagulants like heparin or low molecular weight heparin. Aft...
Source: Cardiophile MD - October 18, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs

What is thrombolytic therapy for myocardial infarction? Cardiology Basics
Thrombolytic therapy used to be an important mode of early treatment of acute myocardial infarction. Though it has been largely superseded by primary angioplasty, thrombolytic therapy may still be useful in certain situations. It is still an important form of treatment in resource limited locations. Myocardial infarction is usually due to sudden occlusion of a coronary artery by thrombus formation on a pre-existing partial obstruction by an atherosclerotic plaque. Plaque rupture with local thrombus formation is the usual mechanism.  Dissolving the thrombus soon after the occurrence of a myocardial infarction can salv...
Source: Cardiophile MD - October 14, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs

What is myocardial stunning and hibernation? Cardiology Basics
Just as you can get stunned for some time if hit on the head, part of the myocardium can also stop functioning following transient coronary obstruction. This usually occurs following a myocardial infarction after which the occluded coronary artery gets opened up spontaneously or by thrombolytic therapy or primary angioplasty. After a variable period of time, the stunned myocardium usually recovers full function. During the period of stunning, if a large part of myocardium is involved, the person may have features of heart failure due to decreased left ventricular systolic function. Myocardial stunning is the reason for he...
Source: Cardiophile MD - October 13, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs

Right ventricular infarction
Right ventricular infarction can be associated with inferior wall infarction. It is due to occlusion of the right ventricular branches of the right coronary artery. The actual prevalence of right ventricular infarction may be underestimated because right sided chest leads are not part of routine 12 lead ECG. In a study which included right sided chest leads V3R, V4R, V5R and V6R, ST elevation of 1 mm or more in any of these leads was found to be a reliable sign of right ventricular involvement. It was a study of 67 patients who underwent serial electrocardiograms and 99mtechnetium pyrophosphate scintigraphy and a dynamic ...
Source: Cardiophile MD - June 25, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology 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

Getting It Right Despite the Wrong Paradigm
Written by Alex Bracey, edits by Meyers and SmithA 50 something year old male presented to the ED as a transfer from an outside hospital with chest pain. As EMS gave report I looked through the transfer packet for the initial ECG:Sinus bradycardia with loss of R-wave progression and hyperacute T-waves in V2-V5, slight STE in aVL and I without meeting STEMI criteria. There is a down-up T-wave in lead III, which is a very specific reciprocal finding in high lateral OMI. Very highly suspicious of OMI. Applying the 4-variable formula for detection of subtle anterior OMI would yield: STE60V3 = 2.5, QTc = 360, RV4 = 3, QRSV2 = 5...
Source: Dr. Smith's ECG Blog - April 12, 2021 Category: Cardiology Authors: Bracey Source Type: blogs

A man in his early 40s with chest pain: STD in V1-V4, but posterior lead are negative
This study by Shah et al. shows that the STD of subendocardial ischemia (in contrast to posterior OMI) is maximal in V5 and V6.Shah A, Wagner GS, Green CL, et al. Electrocardiographic differentiation of the ST-segment depression of acute myocardial injury due to the left circumflex artery occlusion from that of myocardial ischemia of nonocclusive etiologies. Am J Cardiol [Internet] 1997;80(4):512 –3. Available from: https://europepmc.org/article/med/9285669However, STD in V1-V4 can occasionally be due to subendocardial ischemia.  If posterior leads also show ST depression, then subendocardial ischemia is probable!!&...
Source: Dr. Smith's ECG Blog - February 14, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Chest Pain and Ischemic ST Depression — but there is no Cath Lab available. Thrombolytics?
===================================MY Comment by KEN GRAUER, MD (7/14/2020):===================================This middle-aged man with hypertension and hyperlipidemia presented to the ED with 2 hours of new-onset chest pain — and the ECG shown in Figure-1. The patient was hemodynamically stable. No prior tracing was available for comparison.HOW would you interpret the ECG shown in Figure-1?Immediate cath lab activation was not an option in this hospital. Should acute thrombolysis be used?Figure-1: The initial ECG in the ED (See text).My THOUGHTS on ECG #1...
Source: Dr. Smith's ECG Blog - July 14, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

CDK5 as a Target to Reduce Cell Death Following Ischemic Stroke
In this study, we synthesized a membrane-permeable peptide (Tat-CDK5-CTM) that specifically disrupts the binding of CDK5 and NR2B and then leads to the degradation of CDK5 by a lysosome-mediated pathway. We found that the administration of Tat-CDK5-CTM not only retards calcium overload and neuronal death in oxygen and glucose deprivation (OGD)-treated neurons but also reduced the infarction area and neuronal loss and improved the neurological functions in MCAO (middle cerebral artery occlusion) mice. The peptide-directed lysosomal degradation of CDK5 is a promising therapeutic intervention for stroke. Link:...
Source: Fight Aging! - October 18, 2019 Category: Research Authors: Reason Tags: Daily News Source Type: blogs

How does acute left main occlusion present on the ECG?
Post by Smith and MeyersSam Ghali (https://twitter.com/EM_RESUS) just asked me (Smith):" Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR? "Smith and Meyers answer:First, LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.But if they do present:The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion, though it might be due to subtotal LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia.  In these ...
Source: Dr. Smith's ECG Blog - August 8, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

What happens when a patient with LAD OMI does not go immediately to the cath lab?
This patient was extremely elderly, and although the diagnosis was recognized, she did not go to the cath lab for reasons related to age and patient/family choice.Nevertheless, there is a lot to learn from the ECGs.I was shown this ECG without any information:QTc = 431 msWhat was my response?I immediately said:" Acute LAD occlusion. OcclusionMI (OMI) "  (And sinus rhythm with a PVC.) (Not quite a STEMI, but same effect.)Why did I diagnose LAD occlusion?There isST elevation in V2-V4 that does not quite meet " STEMI criteria. "  Is it normal ST elevation?  No!  How do I know?  First, there is re...
Source: Dr. Smith's ECG Blog - April 2, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

One of the Great Books of Emergency Medicine Just Published: Extraordinary Cases in Emergency Medicine
This article that established thrombolytic therapy for STEMI as the domain of emergency medicine, not of cardiology.  It made me realize I needed to recognize coronary occlusion on the ECG and differentiate it from PseudoSTEMI patterns.  We emergency physicians could only rely on ourselves to make the right and timely diagnosis because waiting for a cardiologist was to wait too long.Doug and Hennepin (Ernie Ruiz, Joe Clinton, Dave Plummer, and more) taught me long ago that we Emergency Physicians must be the deciders.And that is just one of his countless contributions to EM over a 37 year career.Doug has collecte...
Source: Dr. Smith's ECG Blog - January 8, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

If you had recorded an ECG during chest pain, what would it have shown?
CaseA 40-something male presented to triage.  He had suffered a couple bouts of typical chest pain in the last 24 hours.  This ECG (ECG #3) was recorded immediately after the last episode of pain spontaneously resolved.  The pain had lasted about one hour.There are classic Wellens ' waves in V2-V5.This is " terminal " T-wave inversion: the latter part of the T-wave turns down (inverts).There are preserved R-waves in the involved leads (necessary to be called Wellens ' waves)There is no LVH in the involved leads.  This is important, as LVH can causePseudoWellens ' waves.This Wellens ' pattern with t...
Source: Dr. Smith's ECG Blog - June 28, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs

ST-Elevation in aVR with diffuse ST-Depression: An ECG pattern that you must know and understand!
This case comes from Sam Ghali  (@EM_RESUS). A 60-year-old man calls 911 after experiencing sudden onset chest pain, palpitations, and shortness of breath. Here are his vital signs:HR: 130-160, BP: 140/75, RR:22, Temp: 98.5 F, SaO2: 98%This is his 12-Lead ECG:He is in atrial fibrillation with a rapid ventricular response at a rate of around 140 bpm. There are several abberantly conducted beats. There is ST-Elevation in aVR of several millimeters and diffuse ST-Depression with the maximal depression vector towards Lead II in the limb leads and towards V5 in the precordial leads.ECG reading is all ab...
Source: Dr. Smith's ECG Blog - February 28, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs

Incredible case of evolution of terminal QRS distortion, then resolution after thrombolytics
For more on Terminal QRS distortion, see these posts:Best Explanation of Terminal QRS Distortion in Diagnosis of Electrocardiographically Subtle LAD Occlusion4 Cases Discussing Terminal QRS Distortion in Diagnosis of Anterior MIThe paramedic crew of Rick Morton and Kim Baker, of Ambulance Victoria in Australia, took care of this patient.  Their friend Shane Chapman sent the case to me.  He asked some questions which I put and answer at the bottom.CaseA 60 something year old gentleman presented with chest pain radiating into left arm and a recent hx of SOB on exertion and fatigue for past 2 days.Here are the ECGs ...
Source: Dr. Smith's ECG Blog - January 11, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs