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The logic of stenting obstructed coronary arteries is simple. A stent unblocks the artery. Subscribe now Stenting stable coronary artery disease has not been convincingly proven to reduce the risk of future heart attacks or death 1. But coronary stenting is not the only way to reduce symptoms of angina. All is fixed.
One of the most common questions I get is, “ Do I need a stent to treat my heart disease?” ” Typically, several of this person’s friends have had stents, so it seems natural to ask. First, we must understand what a stent is and why it is used. The stent ‘unblocks’ it. Flow is restored.
Herein, we describe a single‐step approach to deploy Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA) which is a hybrid laser‐cut, nitinol self‐expanding stent without the need for ELW or lesion re‐access using MINI TREK RX (Abbott Vascular, Inc., There was no restriction on time from last known well (TLKW) to MT.
Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. Nevertheless, the clinical situation made other etiologies unlikely.
In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.
A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The baseline ECG is basically normal with no ischemia. In my opinion, I think it looks more like subendocardial ischemia.
Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI.
The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? The last echocardiography 12 months ago showed HFmrEF.
The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible. Back to the assessment of ischemia: Returning to the ECG, the leads that catch my eye first are -- I, II, V4, V5, V6. Ischemia can be disguised by a wide escape rhythm, which decreases the sensitivity of ECG.
There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] STEMI was activated and the patient went to Cath on arrival.
C ASE C onclusion : Timely cardiac cath was performed on today's patient — with successful reperfusion and stenting of his proximal LAD occlusion. = ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL ( featured in Audio Pearl #2 in this blog post ).
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.
Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. Cath lab was activated, and found a 95% proximal LAD occlusion which was stented. What do you think? But the care of this and other patients could have been improved with earlier detection of OMI.
A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls. It was stented.
I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. A single DES stent was placed, and the patient did well post-procedure. Academic Emergency Medicine 27(S1): S220. Abstract 556.
It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain. 2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. But it is still STEMI negative.
One stent was deployed with restorative TIMI-0 flow. Accurate identification is absolutely necessary as this pattern can be easily misinterpreted for something less nefarious: for example, generic “subendocardial ischemia.” However, when the Troponin I returned 8.4 The red arrow shows a 90% LAD occlusion at the D1 branch.
In other words, the inferior ST segments in the first ECG show more straightening which is more concerning for ischemia. The culprit lesion was opened and stented. Most notably the ST depression in the inferior leads is slightly more upsloping. The QoH interpretation however was the same for both ECGs.
Prior ECG available on file from 2 months before: We do not know the clinical events happening during this ECG, but there is borderline tachycardia, PVCs, and likely some evidence of subendocardial ischemia with small STDs maximal in V5-6/II, slight reciprocal STE in aVR. Culprit lesion was reduced to 0% and stented.
This is where careful discussion with the patient is required, and an explanation of the most recent literature suggests no reduction in future major heart events with stenting in most obstructive coronary artery disease 5. ( 2020 Jan 14;41(3):407-477. 5 ISCHEMIA Research Group. 2020 Apr 9;382(15):1395-1407. N Engl J Med.
This proves that the first one was, surprisingly, due to ischemia!! He was successfully treated with one drug eluting stent. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. 1] Wereski, R., Chapman, A. Gray, A., & & Mills, N.
This is a case written by Dan Lee (One of our fantastic Hennepin Residents, class of 2020 ) edits by Smith A 60 something-year-old man with a history of ESRD, LVH and prior CABG presented after an episode of hypotension during his hemodialysis, run followed by a syncopal episode which caused his run to be terminated early.
This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. Smith's ECG Blog — recognition of acute posterior MI can be greatly facilitated by application of the " Mirror " Test ( Please see My Comment at the bottom of the page in the September 21, 2020 post in Dr. Smith's ECG Blog ).
This is ischemia until proven otherwise. A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock. August 30, 2020 ): Being an “expert” in ECG interpretation is sometimes very humbling.
The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, This alone could be due to LVH, but V4 could NOT be due to LVH.
It was opened and stented. As a result — we do not know if ECG #2 represents a stable “baseline” tracing — or whether it might have been obtained during a period of ischemia in this patient with a history of known coronary disease. Formal bubble contrast echo: The estimated left ventricular ejection fraction 57%.
Delayed angiogram found a 95% mid RCA occlusion that was stented. Ischemic ST-segment depression maximal in V1-V4 (versus V5-V6) of any amplitude is specific for Occlusion Myocardial Infarction (versus nonocclusive ischemia). And notice that the T-waves in V4-V6 are now back down to normal size and "bulk." JAHA 2022 Grosmaitre P et al.
It is not clear by her note what she meant by this (whether or not she recognized this EKG as diagnostic of transmural ischemia, and if so, of what territory) but emergent reperfusion therapy was not pursued. The proximal and mid LAD stenoses were stented and the OM 2 was left alone. Subendocardial ischemia does not localize.
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.
Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. He had a 100% RCA occlusion which was stented.
He had undergone stenting of the LAD several weeks ago (unclear whether elective for stable symptoms, or in response to acute coronary syndrome). That the chief complaint of today's patient was acute CP ( C hest P ain ) with a history of known coronary disease and LAD stent placement a few weeks earlier. He appeared critically ill.
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. Abstract 556.
At cath there was a 100% proximal LAD occlusion, which was opened and stented. In this situation, even after the ischemia is relieved and myocardial blood flow is restored myocardial contractile function remains impaired for a variable period of time (usually days to a few weeks). Transient ischemia may lead to "stunning".
Total proximal LAD occlusion was found and stented at angiography soon after the ECG above. The other challenge posed by the ECG of a patient with marked LVH with "strain" is distinguishing between the ST-T wave inversion in one or more lateral leads due solely to LVH vs that due to acute ischemia or infarction.
It was opened and stented. Compared to TTE from 7/3/24: the anterior regional wall motion abnormality is new and is consistent with ischemia/infarction in the LAD territory == MY Comment , by K EN G RAUER, MD ( 11/20 /2024 ): == There are several insightful aspects of today's case. The November 10, 2020 post — for PTA.
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