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
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| 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 — :)
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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.
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.
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