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Written by Pendell Meyers Two patients with acute chestpain. Patient 1: Patient 2: Patient 1: A man in his 40s with minimal medical history presented with acute chestpain radiating to his R shoulder. Two patients with chestpain. Do either, neither, or both have OMI and need reperfusion?
Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( ChestPain ). These latter findings are typical of pericarditis, but pericarditis never has reciprocal ST depression. This is OMI until proven otherwise.
Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chestpain similar to his prior MI, but worse. The pain initially started the day prior to presentation. mV compared to 0.05-0.1
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, Pericarditis would be even more unlikely in someone without chestpain.
Written by Pendell Meyers, with edits by Steve Smith A man in his early 40s with history of MI s/p PCI presented with bilateral anterior chestpain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). The patient was still with ongoing chestpain at the time ECG #1 was done.
Below is the first ECG, signed off by the over-reading cardiologist agreeing with the computer interpretation: ST elevation, consider early repolarization, pericarditis, or injury. Theres ST elevation in V3-4 which meets STEMI criteria, which could be present in either early repolarization, pericarditis or injury. What do you think?
Written by Pendell Meyers Two adult patients in their 50s called EMS for acute chestpain that started within the last hour. Of course the patient was saddled with the erroneous "pericarditis" diagnosis after CTs ruled also ruled out PE and dissection. Both were awake and alert with normal vital signs. What do you think?
Written by Pendell Meyers, edits by Smith: Case A 72 year old female with hypertension and COPD presented with sudden shortness of breath and chestpain. On day 3 of hospitalization she underwent coronary angiography, revealing a 95% lesion in the mid-LAD which was stented. There is sinus rhythm with PACs and PVCs.
A 50 something-year-old man with a history of newly diagnosed hypertension and diabetes, for which he did not take any medication, presented a non-PCI-capable center with a vague, but central chestpain. Such an out-of-proportion STE is virtually never seen in pericarditis. STE in lead I and II are more subtle.
Written by Willy Frick A 40 year old woman was at home cooking when she developed chestpain. You can easily imagine this patient getting one of several diagnoses -- vasospasm, MINOCA , pericarditis, or maybe even no diagnosis at all beyond "non-obstructive coronary artery disease." She took an oxycodone and called EMS.
Both were stented. New ST-depression (without LBBB or LVH) in aVL that cannot be blamed on an abnormal QRS is worrisome, and in the context of a patient with acute chestpain is almost certainly due to ischemia. Peak troponin was (0.446 ng/mL) -- very low due to rapid reperfusion. Learning Points Lead aVL is incredibly useful.
60-something with h/o MI and stents presented with chestpain radiating to the back and nausea/vomiting. Pericarditis? It was stented. A straight ST segment virtually never happens in inferior ST elevation that is NOT due to OMI (normal variant, pericarditis) 4. Time zero What do you think?
He denied fevers and chills, abdominal pain, chestpain, or SOB. It was opened and stented. Patients with completed, transmural infarct are also at risk for post-infarction regional pericarditis and myocardial rupture. Patient stated his dry weight is around 85 kg. The emesis is non-bloody and non-bilious.
Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." See this case: Persistent ChestPain, an Elevated Troponin, and a Normal ECG. Here is the angiogram after stent placement.
All of the patients presented with chestpain , and they are all in triage. The patient was referred immediately for cath which revealed RCA occlusion that was stented. Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECG s that has not been overread by a physician.
A middle-aged woman had intermittent angina for 48 hours, then onset of constant, crushing chestpain for 1.5 It was treated with and dual "kissing balloons" and drug eluting stents. MYOCARDIAL RUPTURE AND POSTINFARCTION REGIONAL PERICARDITIS KEY POINTS · Myocardial rupture occurs in 1 to 1.5% hours when she called 911.
Patient 2 : 55 year old with 5 hours of chestpain radiating to the shoulder, with nausea and shortness of breath ECG: sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. This was missed by the treating physician, but the chestpain resolved with aspirin. This was STEMI(-)OMI.
This is a very bold statement in a type 1 diabetic with very concerning sounding chestpain. The patient was treated with aspirin and a GI cocktail, which did not help the pain. The true AV groove LCx was "jailed" by the stent and appears occluded in the post PCI image. The emergency physician consulted cardiology.
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