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The patient was transported to the CCU for further medical optimization where a pulmonaryartery catheter was placed. DISCUSSION: The 12-lead EKG EMS initially obtained for this patient showed severe ischemia, with profound "infero-lateral" ST depression and reciprocal ST elevation in lead aVR.
Clinical evaluation and X-Ray chest showed features of pulmonary edema. Angiography done after initial stabilization showed severe stenosis of distal left main coronaryartery. In addition, there were multiple lesions in all three vessels, making a standard indication for an urgent coronaryarterybypassgrafting.
Many patients suffer from a systemic inflammatory response and local myocardial ischemia after off-pump coronaryarterybypassgrafting, which is related to an adverse prognosis. The rate of pulmonary infection in the low group was significantly higher than in the normal group.
I suspect pulmonary edema, but we are not given information on presence of B-lines on bedside ultrasound, or CXR findings. Anything that causes pulmonary edema: poor LV function, fluid overload, previous heart failure (HFrEF or HFpEF), valvular disease. The patient was started on heparin for possible NSTEMI vs demand ischemia.
Watch what happends as the heart recovers from its episode of ischemia. The ECG shows inferior ischemia. By itself seeing this ECG pattern does not necessarily mean that the patient has a pulmonary embolism. Are the T-waves in leads I and II hyperacute? Hard to tell. How can we know? By the evolution of the ECG!
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