subtle LAD occlusion?

[tyson]

50 y/o female presented as first pt of day in Lima. Sternal chest pressure radiating to right arm 30 minutes prior to presentation. Smoker. Doesn't see doctor. Denies any pmh. Have 4 ekgs, 2 here of which i'll show. First one is taken upon presentation. 2nd one is from 5 years previous. 


Look at them and let me know what you think. I sent ekgs to cards who wasn't too impressed, just said he'd see in the CVU. Do you think stemi should have been pushed? Stransky and I looked at Steve smiths equation and I think this would qualify for subtle LAD occlusion. thoughts? agree, disagree? For the attendings, are you pretty aggressive about pushing cardiology to cath the borderline cases? 

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[jpollock]

definitely would do serial ekgs, not sure I would push too much if it is not evolving (I tend to give up easy)

[tyson]

Ended up doing 2 more EKG's, nothing evolved into outright STEMI, though changes did occur with Nitro and came back about 1 hour later.

I followed up on Cath Report today, and it ended up showing 95% LAD occlusion. Very cool. 1 stent.

In this case, using the Steve Smith Subtle LAD occlusion formula (though I did use it 3 days after the fact and required Stransky to hold my hand) was quite accurate.

Formula below:

(1.196 x STE at 60 ms after the J-point in V3 in mm) + (0.059 x computerized QTc) - (0.326 x R-wave Amplitude in V4 in mm).
A value greater than 23.4 is quite sensitive and specific for LAD occlusion.


Tyson

[erinto]

I do what you suggested. I send questionable ones to cardiology, unless the patient looks stone cold normal, and my suspicion is low. I repeat EKG's as often as necessary, sometimes the rhythm will produce changes suspicious for acute elevation, and you can catch it, if you are quick enough.

[pbruss]

i like the smith euqation. there have benn a few cases where it drasticall changed my managment. any time some one has cp and a prolonged qt i use this equation not to send right to cath but help me decide how to manage.