I-Movie DEMO for Willy - His "Not Pericarditis" Case (2-12.1-2025)-for_WILLY

Willy — I decided to show you on my "scrap Blogspot Blog" what your cath films can look like with just a few minutes using imovie. It is very easy in just a few minute on imove to load your cath videos and "freeze" in the middle of the vide — cut the video in that precise spot — shot a still screen on imovie at that point — then insert the still there, and leave the still for as long as you want. You can very easily (and quickly) on your computer screen take that still picture you just made and ADD your labels — and then resume the video.

Your 1st video on the "Not Pericarditis" case IS long enough for me to get a feel as to what is going on. You still can TEACH viewers how to see cath findings in REAL TIME by adding a still and then adding a labeled still — and then resuming the video.

Your 2nd video is too short for me to be able to see anything. Even with your description 2-3 seconds is not enough time. So I slowed this down, added a still and then resumed the video. Again, imovie makes perfrect screen shots by selecting "Save Current Frame".

WILLY — I am providing feedback to you because you've indicated that you would like my feedback. But if at ANY point what I provide is "too much" — just tell me and I will stop. I just think you have done soooooo much to facilitate teaching cath film interp. by non-cardiologists — and that the amount of work (and time) that it would take to bring your cath teaching to the "next level" is not much with just a little practice (and OBVIOUS to me from all you've done up to now that you are SKILLED with technical things!

Attached below figure showing how I make a screen shot with imovie. Below that is the Video that I made slowing the video ( = prolonging it) and adding stills. But I did NOT yet add your labeled stills. Ideally these should be done on the screen shots that imovie makes because the "freeze" shot then is PRECISE — and will look so cool when you free — show a blank still — superimposed to your labeled still — and then resume the video — :) This

This screen shots shot shows me freezing the video and selecting "Save Current Frame" to make an imovie screen shot.

This is the little video I made You can make the freezes as long or as short as you like — same for the absolute control you have for slowing down the video — :)

==============================

WILLY Draft (2/12/2025):

Written by Willy Frick

A man in his mid 30s with type 1 diabetes presented with two days of midsternal and epigastric pain, described as both "sharp" and squeezing." There was associated nausea, vomiting, and dyspnea. He said the pain was worse with supination and improved with upright posture.

What do you think?

Despite the noisy baseline, this ECG is easily diagnostic for OMI. The Queen of Hearts diagnoses OMI with 0.99 confidence (near perfect). Here is her explainability.

Here are some of the diagnostic findings:

• Very subtle hyperacute T waves (HATW) in lead I

• STE and HATW in II > aVF

• Subtle STD in V1 and V2

• STE and HATW in V5 and V6

Therefore, we have an inferior, posterior, lateral OMI. In fact, even the GE algorithm got this one (partially) right.

The emergency medicine physician documented, "His initial EKG is riddled with artifact and difficult to interpret but does not look like a STEMI." This is a very bold statement in a type 1 diabetic with very concerning sounding chest pain. One wonders why repeat ECG was not immediately performed if artifact was the problem. The patient was treated with aspirin and a GI cocktail and troponin was obtained, which did not help the pain.

Initial hsTnI resulted at 25,994 ng/L (ref. <35 ng/L). At this point, the physician started heparin and gave nitroglycerin, which improved the pain from 7/10 to 3/10 and performed repeat ECG.

Once again, easily diagnostic for inferior, posterior, lateral OMI. Getting rid of the artifact increased the Queen's confidence from 0.99 to 1.0 (perfect). The ECG remains positive for STEMI by GE. The emergency physician consulted cardiology. Despite apparently hearing the above history together with two diagnostic ECGs and a troponin compatible with OMI, the cardiologist thought the ECG represented pericarditis and recommended echocardiogram.

Several hours passed with no documentation as to the reason for delay. Echocardiogram was finally performed five hours after the first ECG showing STEMI (+) OMI. The report indicates LVEF 35-40% with "globally reduced wall motion with regional abnormalities." The cardiologist then recommended emergent transfer to a PCI center.

Upon arrival at the PCI center, he was immediately taken to cath lab. Angiogram showed thrombotic subtotal occlusion of LCx/OM1. Here is an AP caudal view before and after PCI. 

The true AV groove LCx was "jailed" by the stent and appears occluded in the post PCI image. The OM is a much larger vessel.

With the delays and recognition and transit, time from first diagnostic ECG to balloon was 15 hours and 47 minutes. This far out, the benefit of PCI is very attenuated. Troponin peaked above the upper limit of quantitation 60,000 ng/L. Echocardiogram showed LVEF 33% with akinesis of the lateral wall.

Here is the wall motion diagram. The view above is enclosed in a red box.

Final diagnosis written in the chart: NSTEMI

Discussion:

It is hard to understand how this can happen, but unfortunately the blog has innumerable similar cases. If I had to guess, I think some of the cognitive errors that may have contributed to this case are:

• The patient was young, in his mid 30s. But you are never too young to have an OMI. Even if it is not atherosclerotic, young people can have embolic OMIs.

• The ECG was perceived as having diffuse ST elevations. But it is not really diffuse -- it is inferior, posterior, and lateral. The anterior leads clearly show reciprocal change.

• The absolute degree of ST elevation (although enough to meet STEMI criteria), was still relatively small.

We also see that in the end the patient was labeled as NSTEMI, despite meeting STEMI criteria and having acute coronary occlusion. So the diagnosis does not reflect the ECG or the pathology. Instead, the diagnosis reflects how urgently he was treated.

Now, when the data are sent to the National Cardiovascular Data Registry, it will appear that the patient was treated appropriately as an NSTEMI! There is no external auditing of diagnoses selected by treating cardiologists, so missed door-to-balloon time metrics can easily be avoided by simply calling cases NSTEMI.

SCRATCH Post-2 — to Embed PDF into Blogspot (1-25.1-2025)

This is from ECG Blog #272 —

The patient is a man in his 70s — with symptoms for the past 3 days. He presented to the ED with worsening chest pain. His initial ECG is shown in Figure-1.

 

QUESTIONS:

• Should you activate the cath lab?
• How many of the 12 leads manifest abnormal ST-T wave changes?
• Is the low voltage a relevant finding?

Figure-1: Initial ECG in the ED — obtained from a man in his 70s with 3 days of chest pain.  (To improve visualization — I've digitized the original ECG using PMcardio).

 

=======================================

NOTE: Some readers may prefer at this point to listen to the 4:00-minute ECG Audio PEARL before reading My Thoughts regarding the ECG in Figure-1. Feel free at any time to refer to My Thoughts on these tracings (that appear below ECG MP-80).

=======================================

—  —

Today's ECG Media PEARL #80 (4:00 minutes Audio) — Reviews the ECG finding of Low Voltage (and potential clinical implications of low voltage in the setting of acute MI).

NOTE: For more on "Voltage Discordance" (ie, when there is low voltage in the limb leads — but normal voltage in the chest leads) — See the ADDENDUM at the bottom of this page.

=============================

MY Approach to the ECG in Figure-1:

As always — I favor a Systematic Approach for interpretation of every ECG I encounter (This Systematic Approach is reviewed in ECG Blog 205).

• Rate & Rhythm: The rhythm is sinus at ~70/minute. 
• Intervals: The PR, QRS and QTc intervals all appear normal.
• Axis: The frontal plane QRS axis is normal (close to zero degrees — as the QRS complex in lead aVF is nearly isoelectric).
• Chamber Enlargement: None

  

PEARL #1: Did YOU note the relatively Low Voltage throughout this tracing? Although strict criteria for low voltage are not quite met in this tracing (ie, the QRS complex in all 6 limb leads is not ≤5 mm — because the R wave in lead I is taller than this). That said — 5 of the 6 limb leads satisfy this low voltage criterion — and all 6 chest leads are of small amplitude!

• As we are about to contemplate the possibility of acute or recent infarction — it is helpful to be aware of potential causes associated with low voltage.
• Relevant potential causes of Low Voltage to consider in today's case include the following: i) Pericardial effusion; ii) Takotsubo cardiomyopathy; and, iii) A large acute (or recent) infarction, that may result in myocardial "stunning" (See the above Audio Pearl and/or ECG Blog #262 for more on this subject).

 

Continuing My System — Regarding Q-R-S-T Changes:

• Q Waves — Assessment is challenging because of the small amplitude of the beats in lead III, and especially in lead aVF. That said — a QS wave is seen in at least 2 of the 3 beats in lead III. It looks like an ever-so-tiny initial positive deflection (r wave) is present in the middle beat in this lead. 
• I find it even more difficult to assess lead aVF for the presence of Q waves — as QRS amplitude is tiny (no more than 2 mm) in this lead. What can be said about lead aVF — is that all 3 of the beats that we see in this lead are notched (ie, fragmented).

PEARL #2: The finding of an isolated QS complex in lead III and/or lead aVF is not diagnostic of previous inferior infarction. 

• Higher specificity for the occurrence of inferior infarction at some point in time is only obtained when Q waves of a "certain size" (ie, larger and/or wider than normal septal q waves) are seen in all 3 inferior leads (ie, leads III, aVF and also lead II).
• That said, in my experience — the finding of an isoelectric or predominantly negative QRS complex that is fragmented in one or more inferior leads (as seen in lead aVF in Figure-1) — significantly increases the likelihood that inferior infarction occurred at some point in time.
• In Figure-1 — there is no Q wave in lead II. As a result — the question of a QS complex in lead III by itself does not reliably predict inferior infarction at some point in time. However, in association with the tiny, notched (fragmented) complex in lead aVF — I'd suspect an inferior infarction may have occurred at some point. Whether this event began 3 days ago (at the time of symptom onset in today's patient) — or whether the inferior infarction is old and unrelated to the ST-T wave changes we are about to assess in the chest leads — can not be determined from this single ECG.

 

 

Continuing My System — Regarding R Wave Progression:

The zone of "Transition" — is said to occur where the height of the R wave becomes taller than the depth of the S wave in the chest leads. Transition is normally seen between lead V2-to-V4. Because of common usage — I've retained the term, "R wave progression" as part of my Systematic Approach to 12-lead interpretation — though defining the zone of "transition" provides us with more useful information (See ECG Blog #269 — for full review on R Wave Progression).

• R Wave Progression: In Figure-1 — R wave progression is "poor", because transition is delayed to between lead V4-to V5.
• Other than the QS complex in lead V1 — Q waves and/or QS complexes are not seen in other chest leads. That said — the delayed transition is relevant in today's case! This is because the reduced r wave amplitude in anterior leads, and small size of the R waves in leads V5 and V6 — may reflect loss of anterior forces from recent infarction.

 

Finally — Regarding ST-T Wave Changes:

ST-T wave abnormalities (some subtle — some not subtle) are seen in at least 9 of the 12 leads in today's tracing. For clarity — I've labeled some of these findings in Figure-2:

• The most remarkable abnormal ST-T wave findings — are the hyperacute T waves in leads V2-thru-V6. It is challenging to define the term, "hyperacute" in reference to T wave appearance. My definition is that in the "right" clinical setting (ie, in a patient with cardiac-sounding chest pain) — 1 or more T waves take on a "hypervoluminous" appearance — in that they appear taller-than-expected given QRS amplitude in the lead being looked at — as well as being "fatter"-at-their-peak and wider-at-their-base than would normally be expected (See ECG Blog #218, as well as the Audio Pearl in that post for more on defining hyperacute T waves).
• The 3 leads in Figure-2 in which T waves are most obviously "hyperacute" — are leads V3, V4 and V5. In each of these leads — T waves tower over the small-amplitude R waves. Not only are these T waves much taller than the R waves — but these T waves are clearly "fatter"-at-their-peak and wider-at-their-base than one would expect, given the size of the R waves (and QRS complex) in these respective leads.

PEARL #3: By the concept of "patterns of neighboring leads" — Since the ST-T waves in leads V3, V4 and V5 are so obviously abnormal — the somewhat less obvious ST-T wave changes in neighboring leads V2 and V6 are also most probably abnormal.

• In lead V6 — although the T wave is not taller than the R wave — this T wave in lead V6 is still much taller-than-one-would-expect given small size of the R wave in this lead.
• Height of the T wave in lead V2 is not as pronounced as T wave amplitude in lead V3. However, the ST segment "takeoff" is unusually straight (ie, parallel to the slanted RED line in lead V2 of Figure-2). In addition, considering how small the r wave is in lead V2 (ie, 2 mm) — the T wave in this lead is once again "hypervoluminous" (ie, clearly with a much-wider-than-it-should-be base). I would therefore interpret leads V2 and V6 as also being "hyperacute".
• ST-T wave changes in lead V1 are subtle — but nevertheless "real". Normally in this lead — there is no more than minimal ST elevation. Although the T wave in lead V1 may normally be inverted (PURPLE arrow in Figure-2) — the shape of the ST segment in this lead (ie, coved or "frowny"-configuration, as schematically shown by the curved RED arc) — in association with the ST elevation seen (with respect to the dotted RED line in lead V1 — showing the PR segment baseline) is not a normal finding (especially given obvious ST-T wave abnormalities in the 5 other chest leads)!

Figure-2: I've labeled some of the abnormal ST-T wave changes from Figure-1.

Regarding ST-T wave Changes in the Limb Leads:

• The ST-T waves in leads II, III and aVF are all clearly abnormal. ST segments in each of these inferior leads are "scooped", with suggestion of slight ST depression. That said — the most remarkable finding is the terminal T wave positivity in each of these 3 inferior leads (upward-pointing BLUE arrows in Figure-2 — with the most prominent terminally positive T wave being seen in lead II). 
• Depending on the clinical situation (and the stage of evolution during an acute cardiac event) — this finding of terminal T wave positivity in association with ST flattening or depression is clearly abnormal, and may represent the beginning reperfusion changes (ie, the mirror-image of inverting T waves in leads which manifested ST elevation).
• Without the benefit of a prior (baseline) ECG for comparison — I was uncertain if the ST-T waves in leads I and aVL were abnormal. I thought the apearance of the QRST complex in lead aVR was unremarkable.

PEARL #4: When assessing an ECG for the possibility of acute ischemic heart disease — the more leads that are abnormal, the greater the chance that the abnormalities you identify are real! I find it helpful to start with a few leads that obviously show acutely abnormal ST-T wave findings — and then to apply the concept of "patterns of neighboring leads" as I look closely to identify more subtle findings in the remaining leads.

• As described above in Figure-2 — We have identified definite ST-T wave abnormalities in no less than 9/12 leads. This provides strong support in favor of a recent (or still ongoing) cardiac event.

Putting It All Together:

The ECG in Figure-2 shows sinus rhythm — low voltage — a question about a QS in lead III (with a tiny, fragmented complex in lead aVF) — poor R wave progression (with low-amplitude R waves until leads V5, V6) — worrisome hyperacute T waves in leads V2-thru-V6 — with apparent reciprocal ST-T wave changes in the inferior leads (including terminal T wave positivity that probably represents upright reperfusion T waves).

• Given the history of 3 days of symptoms in this older man who finally presented to the ED because of worsening chest pain — I interpreted this tracing as suggesting acute and/or ongoing extensive anterior infarction. Although none of the chest leads manifest J-point ST depression — the disproportionately large chest lead T waves are consistent with a deWinter-like T wave pattern (See ECG Blog #183 for "My Take" on this concept). That said — I wasn't certain about WHEN it was during the patient's 3 days of symptoms that acute infarction took place — or whether perhaps there was an ongoing "stuttering" course with spontaneous opening and closure.
• The course of acute infarction is not always "all or none". By this I mean — that the "culprit artery" (most likely the proximal or mid-LAD in today's case) — may acutely occlude — then spontaneously reopen — followed by spontaneous reopening and reclosure a number of times until a final state is reached for the "culprit" artery.
• Regardless of when during the patient's 3 days of symptoms acute coronary occlusion first occurred — the lack of anterior Q waves, in association wth marked hyperacute T wave changes in this patient who presented to the ED for increased symptoms — strongly suggests that there is still a large area of jeopardized myocardium that may benefit from prompt reperfusion. Cardiac cath was clearly indicated to define the anatomy and guide clinical decision-making.

 

Case CONCLUSION:

Cardiac cath was performed on the patient in today's case. Not surprisingly, this revealed total occlusion of the mid-LAD (Left Anterior Descending) coronary artery. Minor lesions were found in the LCx (Left Circumflex) and RCA (Right Coronary Artery).

• This patient subsequently developed arrhythmias — that I discuss as this case is continued in my next ECG Blog #273.

 

==================================

Acknowledgment: My appreciation to 유영준 (from Seoul, Korea) for making me aware of this case and allowing me to use this tracing.

==================================

 

=============================================

ADDENDUM (1/25/2025):

What is Voltage Discordance?

• On occasion there may be low voltage in the limb leads (ie, all QRS voltage in the limb leads ≤5 mm) — but normal QRS voltage in the chest leads. This is called, "Voltage Discordance" (Chinitz et al — J Electrocardiol 41(4):281-286, 2008).
• Low voltage isolated to the limb leads will be associated with the same list of potential causes as I noted above under today's Audio Pearl — in only about 50% of cases.
• In the remainder of cases of "Voltage Discordance" — the patient will have a dilated cardiomyopathy. Physiologic explanation for why this ECG phenomenon is seen is discussed in the PDF below (this PDF adapted from presentation by Ahmed ElBorae, MSc — 2022, from Cairo University).

NOTE: You may need to allow Cookies to see this embedded PDF below (This PDF should display on Safari and Chrome — but it may not display on Firefox.).

NOTE: For more on "Voltage Discordance" (ie, when there is low voltage in the limb leads — but normal voltage in the chest leads) — See the ADDENDUM at the bottom of this page.

=============================================

Related ECG Blog Posts to Today’s Case: 

• ECG Blog #205 — Reviews my Systematic Approach to 12-lead ECG Interpretation (outlined in Figures-2 and -3, and the subject of Audio Pearl MP-23-LINK in Blog #205).
•  
• ECG Blog #269 — Reviews assessment of R-Wave Progression (with a Video Pearl in this post on the subject).
•  
• ECG Blog #218 — Reviews of the concept of WHAT is a "Hyperacute" T Wave (Also see the Audio Pearl in this post). 
•  
• ECG Blog #183 — Reviews a case of deWinter-like T Waves (with the Audio Pearl in this post discussing some variants of the deWinter T wave pattern).
• ECG Blog #53 — Reviews another case of deWinter T Waves.
•  
• ECG Blog #258 — Reviews the concept of HOW to "Date" an Infarction (Also see the Audio Pearl in this post).
• 
  
• ECG Blog #193 — illustrates use of the Mirror Test to facilitate recognition of acute Posterior MI. This blog post reviews the basics for predicting the "culprit artery". NOTE: The Audio Pearl reviews the concept of why the term "OMI" ( = Occlusion-based MI) should replace the more familiar term STEMI.
•  
• ECG Blog #262 — Reviews a case of recent acute Infero-Postero MI with group beating from Wenckebach conduction and Low Voltage (with a list of the causes of Low Voltage).
•  
• The January 24, 2020 post in Dr. Smith's ECG Blog — Reviews a case in which Low Voltage (with progressive reduction in QRS amplitude on serial ECGs) was due to myocardial stunning  (See My Comment at the bottom of the page). 
• The November 12, 2020 post in Dr. Smith's ECG Blog — Reviews a case in which Low Voltage was seen in a patient with Covid-19 and cardiogenic shock, in which low voltage seemed to precede (? predict) reduced LV function! (See My Comment at the bottom of the page).

SAVE_THIS! - How to insert Excel File (using the QTc Calculator model — 1-20.1-2025)

   ="0" scrolling="no" src="https://onedrive.live.com/embed? 

============================= 

NOTE: This web page reviews the process I used to embed an Excel file into Blogspot (specifically this was for the QTc Calclator that we published on Dr. Smith's ECG Blog on 1/12/2025).

• Please be aware that I used a Mac computer — and Safari for my browser to embed this Excel file. 
• After doing so — this embeded Excel file worked on Mac computer — ipad — and iphone using Safari, Firefox and Safari browsers.
• I suspect this embedding process will work on any device — although specifics for the embedding process might vary, depending on the device/browser you are using.

=============================

STEPs for Embedding an Excel File into Blogspot:

As I often do these days when initiating trial at anything new — I did a Google Search for help with "embedding an Excel File into Blogspot".

• This VIDEO was helpful — but did not completely work for me. It did clue me into the need for uploading the Excel file that we want to embed into OneDrive (on Microsoft).
• Uploading to my Google Drive or Dropbox didn't work for me ...
• So — Upload the Excel file to OneDrive!

============================= 

After you have uploaded your Excel file to OneDrive — You should see something similar to what I show in Figure-1:

Figure-1: This is what my computer screen looked like after I uploaded the desired Excel file to my OneDrive. After doing do — Click on FILE (within the RED rectangle).

=============================

Legends in the Figures below review the sequential steps I took:

Figure-2: After clicking on FILE — You should see a menu that looks like the lefthand panel shown here. Click on SHARE — which should take you to Figure-3.

=============================

Figure-3: After clicking on SHARE — You should see an option to EMBED. 

=============================

Figure-4: After clicking on EMBED — You should see an option to GENERATE an iframe file. This is the KEY file that you will need to insert on your Blogspot page in order to embed the Excel file. Clicking on GENERATE should take you to Figure-5.

=============================

Figure-5: You should now see parameters similar to that shown in this Figure. Within the RED rectangle is the Embed Code (which you'll note begins with the words iframe width). This is the code that you need to copy. KEY: This code is many lines long. We only see 2 lines here. So you need to "copy ALL" of this code!
=  =  =  =  =
Note on the top line of this iframe code the numbers 402 and 346. These parameters are the size that the current iframe code is set for (ie, You'll see these same numbers under Dimensions (BLUE rectangle). But for my Blogspot page — this size was too small. So you can easily change the size to whatever you like. You can "play" with some different numbers (depending on your computer and browser). For Dr. Smith's Blog — I found that 500 and 550 (for Width and Height) worked great. I show how I changed this sizing in Figure-6.

=============================

Figure-6: To change the size of your embedded Excel file — just click on the numbers under Dimensions (You'll see that I change the 402 and 346 — to 500 and 550 in this Figure — and then when I clicked on the screen — this changed the sizing in the iframe embed code. The RED arrow shows that the new size is now in the iframe that you need to copy.
=  =  =  =  =
Important: Within the large RED rectangle — You'll see that I checked "Let people type into cells". If you fail to check this box — then the embedded code will not allow users to type in numbers into the Excel code! As it says within the RED rectangle — "their changes will not be saved". So for the QTc Calculator that we embedded — this will change your iframe code so as to allow users to type in heart rate, QT interval — and get the QTc values — which after they "refresh" the page will disappear so that the Excel QTc Calculator can now estimate a new QTc value.

=============================

Next Series of STEPS:

Now that you have prepared your iframe embed code — We need to insert it into the Blogspot page that you want to use. This is my iframe code:

 

<iframe width="500" height="550" frameborder="0" scrolling="no" src="https://onedrive.live.com/embed?resid=1697A7711DCFBCD6%21120&authkey=%21AM8lCkp1zB18N8E&em=2&wdAllowInteractivity=False&AllowTyping=True&wdHideGridlines=True&wdHideHeaders=True&wdDownloadButton=True&wdInConfigurator=True&wdInConfigurator=True"></iframe> ="0" scrolling="no" src="https://onedrive.live.com/embed?

You'll note that this is a long code. It must be copied in its entirety. Do not change its formatting at all ... Then — GO TO Figure-7.

=============================

Figure-7: Your iframe embed code must be inserted from the HTML view. To get there — Click on the PENCIL in the menu (within the RED rectangle) — as shown in Figure-8.

=============================

Figure-8: I do not know HTML code. So I always write up my Blogspot drafts in the "Compose view". So after clicking on HTML view. This will give you a blank page. Copy your entire iframe code on a fresh (new) Blogspot page. It should look something like what I show below in Figure-9.

=============================

Figure-9: By now you'll recognize "iframe" as the first word — and you'll recognize the 500 and 550 width and sizes you selected.
=  =  =  =  =
Important: For reasons I can't explain (I'm not a programmer) — this iframe code did not work for me unless I copied the iframe code at the very top of a new page! You can move the embedded Excel code around later — but first, to embed it Be Sure to copy your iframe code at the very top of a new page in HTML mode. After doing so — You can Save the file — and then switch back to Compose View. Once you are back in Compose View — you can continue working on text below the embedded Excel file (as shown in Figure-10).

=============================

Figure-10: This figure shows the result after the Excel file has been embedded and saved — and after you have switched back to Compose View. You can now continue writing your text for the rest of your Blogspot page. Once you publish this Blogspot page — your embedded Excel file will look like Figure-11, and it should be operative!

=============================

Figure-11: I've published this Blogspot page — and my QTc Calculator appears at the top of the page (since I entered the iframe code at the top of the page in HTML mode). You can see that I've entered in the number 70 for heart rate ...
=  =  =  =  =
NOTE: If you want to lower the location of your Excel file and write some text above it — You can do this in Compose View. Place your cursor just to the LEFT of the vertical BLUE line shown in the above figure, and tap RETURN a few times to add some lines above this Excel file. And then in Compose View, you can write text as you like on those lines that you've added. You are done!
=  =  =  =  =
P.S.: I am not a programmer. I had to "play" with the above steps a bit until I got them to work. Best to copy your work often (so as not to lose anything). Be familiar with the Undo Command (usually Control-z, depending on your computer).

=============================