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Total 33 results found since Jan 2013.
Thrombus, tumor or vegetation?
This question is often faced by the echocardiographer while evaluating a mass detected on the heart valves or cardiac chambers. Usual method is to take it in the clinical context. There could also be non-infective vegetations of marantic endocarditis which are almost impossible to differentiate from infective vegetations. Marantic vegetations can be suspected in the presence of small and multiple vegetations changing from one examination to another, without associated abscess or valve destruction [1]. It may be noted that echocardiography is neither 100% specific nor 100% sensitive for the diagnosis of infective endocardi...
Source: Cardiophile MD - December 15, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said " Nothing too exciting. "
This article fails to specify whether it was troponin I or T, but I contacted the institution and they used exclusively troponin I during that time period.Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy. J Electrocardiol [Internet] 2022;Available from: http://dx.doi.org/10.1016/j.jelectrocard.2022.09.009Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%)V Fib Cardiac arrestProlonged QTCNSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different)Moderate sin...
Source: Dr. Smith's ECG Blog - November 30, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
What is Door in – Door Out Time?
What is Door in – Door Out Time?
Door in door out time is applicable when a person presents with ST segment elevation myocardial infarction to a centre which does not have the facility to perform primary angioplasty by percutaneous coronary intervention or PCI.
Recommended door in – door out time in ST elevation myocardial infarction presenting to non-PCI capable center is less than 30 minutes. Primary angioplasty being the best option to open up the infarct related coronary artery, it has to be done at the earliest. So time should not be lost by undue observation at a non PCI capable centre. When the person presen...
Source: Cardiophile MD - November 26, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
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
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
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
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
Chest pain and Concordant ST Depression in a patient with aortic valve and previously normal angiogram
p.p1 {margin: 0.1px 0.0px 0.1px 0.3px; font: 10.0px Helvetica}60-something presents with acute onset of chest pain.His pain was accompanied by shortness of breath. It awoke him from sleep.Here is the prehospital ECG:What do you think?The rhythm appears to be atrial fibrillation. There are no pacing spikes and the morphology is not right for a paced rhythm. There is a wide complex that appears to be RBBB + LAFB. There is excessive ST depression in V1 and V2. Where normally RBBB would manifest a large R ' -wave in V3, the lead may have been placed to far lateral and, instead, there is ...
Source: Dr. Smith's ECG Blog - October 10, 2017 Category: Cardiology Authors: Steve Smith Source Type: blogs
Right precordial ST depression in a patient with chest pain
Conclusion:Nobody would miss the precordial ST-depressions in this case. The problem is not in identifying these abnormalities, but rather in identifying their etiology. Patients with Isolated Posterior STEMI often do not receive appropriate reperfusion therapy simply because infarction of this anatomical area of the myocardium may manifests without ST Elevation on standard 12-Lead ECG. Tips for recognizing Acute Posterior STEMI:1. Pattern recognition is one of the most powerful - and often subconscious - mechanisms by which we read ECGs. Remember this classic pattern of Posterior STEMI of Standard 12-Lead ...
Source: Dr. Smith's ECG Blog - August 3, 2017 Category: Cardiology Authors: Steve Smith Source Type: blogs
