-ECG_Guru-USE.png) |
| Figure-1: The initial ECG in today's case. |
-USE.png) |
| I'll give the LINK to ECG Guru for this Figure !!! (Mirror Test) |
Hi Dawn (1/12/2026)
Acknowledgement — My thanks to Dawn Altman and Natalie Terrana (USA).
Otherwise — I like to give cities for foreign countries and states for the U.S. — so I will acknowledge for Dawn Altman (Tennessee, USA) and Natalie Terrana (What state does she live in?).
P.S. If you give me Natalie’s email address, I can include in any future conversation re this post! — :)
Great case! So much so — that I’d like to ALSO use it as an ECG Blog.
I would present the case BRIEFLY on my ECG Blog, showing the attached ECG.
I would then link to the ECG Guru for your full presentation and my discussion of the case.
- Perhaps you could contact Natalie Terrana (adding a cc with my email address when you write her) — letting her know that I want to do an ECG Blog on her case. I will of course acknowledge Natalie on my ECG Blog site.
So my discussionn is https://www.ecgguru.com/comment/2137#comment-2137
Glad your new horse seems to be working out. Sorry to hear all the difficulties Alyssa is working through …
We have not been doing much horseback riding of late. Very sadly — our horseback riding instructor has metastatic cancer. After mastectomy, she had a good 2 years (virtually asymptomatic) — but now has metastatic spread … She has an amazing support system and maintains positive attitude, but we know how this ends …
Otherwise — our country’s Republican party has embraced dictatorship by a cruel, selfish excuse for a human being. We’ve taken to taping Jimmy Kimmel shows — he is FANTASTIC in his ingenuity for making fun of Trump (We usually just watch his initial dialog for 20 minutes) — it is hilarious, though the reality of it all is of course totally depressing. There HAS been LOTS of national protesting (Rachel Maddow at 9pm on Mondays on MSNOW (used to be MSNBC) is a good one to keep up with on this — but how this ends in our country is not something we are optimistic about …
Otherwise Catherine and I are fine. Glad we are retired — and doing our best to support the grandkids ..
Take care. Please let me know if OK to follow through with an ECG Blog on this case in the way I suggest above — :)
:) Ken
P.S. DAWN — I believe you use “LCA” as the abbreviation for the Left Circumflex in your discussion. Instead — “LCx” is much more commonly used, so you may want to correct this in your discussion — :)
=============================
Positive Mirror Test — in a Patient with Cardiogenic Shock
The ECG in today's case tells a story! As per Dawn — there are ST-T wave changes in EVERY lead. Dawn has highlighted these changes in her excellent discussion. I'll focus on a number of selected points.
The presenting rhythm is rapid AFib. If the AFib is new — this presents yet another reason for acute heart failure (cardiogenic shock in today's case) — as there is loss of the atrial "kick" (which in many such patients is critical to cardiac output) — plus the rapid rate of new AFib disproportionately reduces the period of diastole, which accounts for most ventricular filling.
One might be surprised at the lack of marked ST elevation in this patient with cardiogenic shock. But the principal "culprit" artery is the LCx (Left Circumflex Artery) — occlusion of which in today's case produces acute infero-POSTERO-lateral MI. And the posterior wall of the LV is not directly viewed on the standard 12-lead ECG. Although recommendations are often made to "obtain posterior leads V7,V8,V9" when looking for posterior MI — it is much FASTER and EASIER to familiarize yourself with the "Mirror Test". Acute posterior MI produces maximal ST depression in leads V2,V3 and/or V4 — with this ST depression being the "mirror image" of the ST elevation that one would see in posterior leads V7,V8,V9. More than that — the relative amount of ST depression that you virtually always see in these anterior leads is MORE than the amount of ST elevation you'll see in the posterior leads for the simple reason that ST elevation amplitude is attenuated by the thick musculature of back muscles. In more than 4 decades of comparing the mirror test with posterior lead findings — I do not believe I have EVER seen a case of an acute posterior MI in which posterior leads told me something that was not instantly obvious to me from looking at leads V2,V3,V4 in the standard ECG (Looking at the mirror image insert — Isn't acute posterior MI obvious?)
ST elevation in leads III, and especially aVF — as well as in leads V5,V6 is subtle-but-definitely present (Focus on the coved SHAPE of the ST segments in these leads). Putting this together — an acute inf-post-lat MI in which the relative amount of ST segment displacement is clearly greatest in leads V2,V3 localizes the acute occlusion to the LCx.
The clue to underlying multi-vessel disease is the additional marked flat ST depression in leads I and aVL, in association with ST elevation in lead aVR. So the reason we do not see ST depression in the 3rd inferior lead ( = lead II) — is because the ST elevation that inferior MI would normally produce is attenuated by the ST depression that we would otherwise see in lead II from DSI (Diffuse Subendocardial Ischemia).
To emphasize that the ECG picture can be confusing when there is multivessel disease — rapid AFib (in which the fast rate by itself may produce diffuse ST depression) — and an acute MI in a patient with multivessel disease and the often resultant unpredictable patterns of collateralization. BOTTOM LINE — I immediately suspect MULTI-vessel disease whenever I see acute changes with ST-T wave abnormalities in virtually every lead that are not completely "explainable" (ie, Figuring out why we don't also see ST elevation in lead II).
Fortunately in today's case — excellent care resulted in prompt decision-making leading to 5-vessel CABG with the patient doing well despite his presentation in cardiogenic shock. A GREAT success story with many lessons embedded within the initial ECG.
DAWN — rather than "LCA" for the Left Circumflex — the most commonly used abbreviation is the LCx
DAWN Wrote:
Hi, Ken,
Thanks for the great comments! You hit every area I was hoping you would (a fib causing decreased CO, Lead II having opposing forces, etc. You also wrote with much more clarity than I did.
I meant to say "LCA" because that sentence referenced that the LCA was responsible for the entire heart - LAD for the anterior wall and Cx with collaterals for the rest. I will see if I can rewrite that more clearly. Imagine if he had had an occlusion at the bifurcation! We would never had seen his ECG.
Natalie says we can both use her case and her name She works in the cath lab as an RN, but was my paramedic student years ago.
I'm sorry your friend and riding instructor is so sick. I hate cancer! I hope you and Catherine will find a way to keep riding. Make the most of each day.
I follow Rachel Maddow, Jimmy Kimmel, and also several others. Heather Cox Richardson (Substack, YouTube, social media) is a great source. She is a PhD historian, and a very brave reporter of current events.
I am just learning about testimony from Sascha Riley, re Epstein and Trump, and I'm afraid this is the end of us. Trump will stop at NOTHING to hide his crimes.
Thanks again! — Dawn
I REPLIED:
Hi Dawn. Glad you found my comments helpful.
I had to look up “LCA” — because I had never seen that abbreviation before … I always use LMain (for the Left Main Coronary Artery). AI does give LCA as a common abbreviation, so I guess it just depends on the “local vocabulary” wherever you happen to work. That said — No One will mistake what the LMain stands for. When I write Blogs, I always underline (ie, Left Main) — but since we can’t do that with the ePub format your web site uses, perhaps will be less confusing to simply write this as "LMain (Left Main) Coronary Artery … "
Otherwise — I like to give cities for foreign countries and states for the U.S. — so I will acknowledge for Dawn Altman (Tennessee, USA) and Natalie Terrana (What state does she live in?).
Take care! —: ) Ken
P.S. If you give me Natalie’s email address, I can include in any future conversation re this post! — :)
No comments:
Post a Comment