Pendell-DRAFT- Cool LVH-Hyperacute T waves (4-1.61-2023)-DRAFT

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My Comment by KEN GRAUER, MD (4/1/2023):

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Figure-1: Comparison between the initial ECG in today's case — and a prior baseline tracing on trial. Is there any acute change?

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NOTE — frontal plane axis is different (now LAHB) — so we are not strictly comparing ECGs #1 & #2. But in chest leads — R wave progression IS similar, so comparison of QRST morphology is more likely to be valid.

The KEY lead = V4 — which there is NO WAY this is normal on initial ECG!

Both tracings are consistent with LVH

Minor subtle differences elsewhere — but lead V4 is KEY

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Figure-1: The initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio).

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Pendell DRAFT as of 12-14.1-2022:

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Sent by Anonymous, written by Pendell Meyers

Sent by Anonymous, written by Pendell Meyers

A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. There was associated diaphoresis, but no dyspnea, nausea, vomiting. He reported having covid 2 weeks ago, but had seemingly fully recovered.

Triage 1104:

The ECG was interpreted correctly as "No STEMI." Due to the state of the ED at the time, the patient was placed in a waiting area. 

Two prior / baseline ECGs on file:

The first high sensitivity troponin I returned elevated (upper limit of normal for men in this assay is 20 ng/L) at 25 ng/L. Unfortunately, the only action that was taken at this time was to repeat the troponin (still waiting in waiting area due to miserable boarding and overcrowding problems). 

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain with positive troponin is already an indication for emergent cath, regardless of the ECG!

The second troponin returned higher at 45 ng/L. This finally prompted a repeat ECG at 1341:

1350:

Cath around 14:15 showed 100% stenosis, TIMI 0, culprit lesion of the prox to mid LAD, as well as severe other CAD throughout. The lesion was crossed and stented with resultant TIMI 3 flow.

All subsequent troponins returned at greater than 25,000 ng/L (the upper limit of reporting for this lab)

1608 post cath:

1809:

Formal echo showed EF 20% (previous EF on file 34% 5 months ago), severe global hypokinesis, akinesis of the mid-apical myoardium, akinesis of inferolateral, inferior, and inferoseptal myocardium.

2 months later:

 

He survived to discharge. Long term follow up not available.