ecg

[pbruss]

we did not talk about this one but let me know what you think. pt with chest pain

Attachments:

[pbruss]

looked into this case a little more, was seen by one of our residents, an epno attending and cards, lets see who can pick it up

[tyson]

incomplete RBBB, right heart strain, sinus tach, S1Q3T3. can make argument for PE.

also, most of p waves are flipped. wonder if this is junctional rhythm?

what else am i missing?

[pbruss]

nice interp but there is something else that was initially missed that did result in a bad outcome. look at the precordial leads.

[tyson]

i guess you could make argument for anterior stemi.
v2 has about 2 mm of elevation with 1 in V3, V4.

[pbruss]

V2 and V3 have the wellns wave. trop mildly elevated at 1. ecg faxed to cards. given lovenox and admitted at 7pm. trops climbed to 25 overnight. ecg at 7 am shows elevation in v1, 2 and 3. went to cath had stent in LAD. very interesting case

[tyson]

that's an interesting EKG. I do a poor job of picking up wellens. especially if i don't see anything obvious in V1. But good reminder that wellen's waves are mostly seen in V2-V3.

Of interest, if wellens waves are highly specific for LAD occlusion and so are deWinter T-waves, why such a different pattern for the same arterial occlusion in the heart. LAD?

[pbruss]

wellns is technically a "critical, unstable stenosis" while dewinters is an actuall occlusion. see below

Understanding The T Wave Changes

The following sequence of events is thought to occur in patients with Wellens’ syndrome:
1.A sudden occlusion of the LAD, causing a transient anterior STEMI. The patient has chest pain & diaphoresis. This stage may not be successfully captured on an ECG recording.
2.Re-perfusion of the LAD (e.g. due to spontaneous clot lysis or prehospital aspirin). The chest pain resolves. ST elevation improves and T waves become biphasic or inverted. The T wave morphology is identical to patients who reperfuse after a successful PCI.
3.If the artery remains open, the T waves evolve over time from biphasic to deeply inverted.
4.The coronary perfusion is unstable, however, and the LAD can re-occlude at any time. If this happens, the first sign on the ECG is an apparent normalisation of the T waves — so-called “pseudo-normalisation”. The T waves switch from biphasic/inverted to upright and prominent. This is a sign of hyperacute STEMI and is usually accompanied by recurrence of chest pain, although the ECG changes can precede the symptoms.
5.If the artery remains occluded, the patient now develops an evolving anterior STEMI.
6.Alternatively, a “stuttering” pattern may develop, with intermittent reperfusion and re-occlusion. This would manifest as alternating ECGs demonstrating Wellens’ and pseudonormalisation/STEMI patterns.

This sequence of events is not limited to the anterior leads — similar changes may be seen in the inferior or lateral leads, e.g. with RCA or circumflex occlusion. Also, the inciting event does not necessarily have to be thrombus formation: Wellens’ syndrome may also occur in normal coronary arteries following an episode of vasospasm, as in this case of cocaine-induced vasospasm. However, it is safer to assume the worst (i.e. critical LAD stenosis) and work the patient up for an angiogram.

[DD]

Yeah but what does Wellens smell like?

[pbruss]

weakness and shame

[kemple]

May 29, 2015 19:37:13 GMT -5 pbruss said:

weakness and shame

So Dustin has Wellens?