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5 ICSS‐ MRI study (International Carotid Stenting Study Magnetic Resonance Imaging Study), indicated that patients with periprocedural hemodynamic depression had decreased cerebral blood flow and increased the risk of new lesions in imaging.6 This is secondary to delayed postoperative cerebral ischemia and infarction caused by vasospasm.7
The pain will resolve and you will think the ischemia is gone when it is only hidden ! Just before 10 AM, the patient received a stent to the culprit OM. We know that today's patient has had prior inferior OMI with stenting of his proximal RCA ~3 years earlier. Peak troponin was 12 ng/mL. Clinical Cardiology, 45(4), 359–369.
There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. A mid-LAD culprit lesion was identified and stented. References Naidu, S. Tower-Rader, A.
He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. A 99% LAD occlusion was stented. BP 110/67 HR 68 RR 14 (non-labored) SpO2 95 RA Physical exam revealed slight pallor and diaphoresis. Attached is the first ECG. 5] Walsh, B.
Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated. It was opened and stented. 21, 2015 post by Dr. Smith ). The LAD was 100% occluded. Subsequent Peak cTnI was 46.84 ng/mL (consistent with LAD occlusion).
American Heart Journal 170(6):1255-1264; December 2015. So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent. EKG shown here: LAFB with no clear signs of OMI or ischemia. Derivation in LBBB: --> Smith SW. No labs were performed.
Management The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Current treatment is with anti-thrombotics and/or anticoagulation.Lesser option is to alter the flow disturbance caused by the web (surgery or stent). Christopher R. Reference 1.Rainer
He eventually underwent CAG, where a circumflex occlusion was stented. This case highlights how T-waves are very important in the assessment of ischemia and dynamic changes in acute coronary syndrome. I have often seen colleagues worry about T-wave inversions as a sign of ongoing ischemia.
His triage EKG is shown below: There is left bundle branch block, so the EKG must be evaluated for ischemia by Smith-modified Sgarbossa criteria. There is evidence of transmural ischemia of the posterior wall as well. Leads V1 to V4 have down-up shaped T waves typical of ischemia and atypical of LBBB.
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