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Despite the elevated mortality rates associated with high-risk pulmonaryembolism (PE), this condition remains understudied. Data regarding the effectiveness and safety of invasive therapies such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) in this patient population remains controversial.
Cardiogenicshock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. A slowly maturing evidence base has suggested that cardiogenicshock teams may improve patient outcomes.
Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenicshock). In patients with narrow QRS ( not this patient), this pattern is highly suggestive of acute pulmonaryembolism. In PE, there is almost always some hypoxia without any pulmonary edema.
Smith comment: before reading anything else, this case screamed pulmonaryembolism to me. I would do bedside ultrasound to look at the RV, look for B lines as a cause of hypoxia (which would support OMI, and argue against PE), and if any doubt persists, a rapid CT pulmonary angiogram. There is sinus tachycardia at ~100/minute.
Notice I did not say "pulmonaryembolism," because any form of severe acute right heart strain may produce this ECG. This includes, but is not limited to, PE, asthma/COPD exacerbation, hypoxic vasoconstriction from pneumonia, acute pulmonary hypertension exacerbation. There are filling defects in both main pulmonary arteries.
My answer: "This is classic for PE, but it can also be present in any hypoxia due pulmonary hypoxic vasoconstriction and resulting acute pulmonary hypertension and acute right heart strain. Tachycardia is unusual in ACS unless there is cardiogenicshock or a second simultaneous pathology. This is NOT Wellens.
Assessment was severe sudden cardiogenicshock. and the patient was converted to veno-venous (V-V) ECMO due to persistent pulmonary insufficiency. Clinically — despite an initial 2-fold increased troponin, the normal bedside Echo was reassuring against OMI or pulmonaryembolism. What is it? There is STE in V2-V6.
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