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Watch what happens when "pericarditis" and morphine cloud your judgment

Dr. Smith's ECG Blog

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 chest pain similar to his prior MI, but worse. Remember, pericarditis is the thing you say and write down when youre actively trying to miss an OMI.

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Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

These latter findings are typical of pericarditis, but pericarditis never has reciprocal ST depression. This led to immediate cath lab activation — which revealed total occlusion of a large 1st diagonal branch that was stented. == Below is the ECG of Patient #3 — recorded from a 35-year old man with sudden, new-onset CP.

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Will this case be flagged for Quality Improvement in the STEMI/NSTEMI Paradigm?

Dr. Smith's ECG Blog

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?

STEMI 80
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Quiz post: 2 similar patients with similar ECGs. Which, if any, or both, are OMI? Will you outperform the Queen of Hearts?

Dr. Smith's ECG Blog

Queen of hearts interpretations: Patient 1, ECG1: Patient 2, ECG1: Patient 1 Clinical Course and Outcome: The EM physician did not see that the S wave voltage has been truncated and squared off at 10 mm, thereby greatly limiting the assessment of proportionality. He diagnosed anterior "STEMI" and activated the cath lab. But he did well.

STEMI 125
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Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

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." Here is the angiogram after stent placement. link] Opiates are associated with worse outcomes in Myocardial Infarction.

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Initial Reperfusion T-waves, Followed by Pseudonormalization. Diagnosis?

Dr. Smith's ECG Blog

It was treated with and dual "kissing balloons" and drug eluting stents. Here is the post stent ECG: There is greater than 50% resolution of ST elevation (all but diagnostic of successful reperfusion) and Terminal T-wave inversion (also highly suggestive of successful reperfusion). Myocardial Rupture and Postinfarction Pericarditis.

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What is lurking underneath this new right bundle branch block?

Dr. Smith's ECG Blog

On day 3 of hospitalization she underwent coronary angiography, revealing a 95% lesion in the mid-LAD which was stented. Peak troponin, echocardiographic findings, and long term outcome are unknown. One can say with full confidence that is was completely occluded at the time of the presentation ECG. Learning Points: 1.