2 pts with CP

[pbruss]

you ahve 2 patients with the exam some history come in at the same time. The both had CP 2 days ago-pressure with sob and diaphoresis lasting 6 hrs. The both have been symptom free since then and have no symptoms in the ER

both of their EKGs are attached. you can only send one to cath lab if you want to.

What do you do?

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[Bjs04f]

the first, but I fear there is a trick coming. looking at ST elevation in V1-5, with qs complaex in same leads makes me think anteroseptal STEMI, activate cath. ekg 2 looks ok to me, incomplete RBBB only

[pbruss]

do you see any st elevation in 2,3,AVF on patient #2?

[Bjs04f]

maybe but the EKG is terrible, too much baseline variation to determine

[pbruss]

here is a better picture of the second ekg

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[pbruss]

I sent patient 1 to the cath lab. Both patients have a history and ekg consistent with sub-acute infarction: pain a few days ago and none in the ER as well as resloving st elevation with t wave inversion. (V4-6 for PT one and 2,3,AVF for pt 2). Pt 2 has developed Q waves and has no recriprical changes which is indicates that the myocardium is already dead and would not benefit from emergent Cath. However Pt 1 looks like he may have some recriprical changes in leads 1 and AVL and has not completley infarcted yet. See attached if your having problems seeing it. for pt 2 the red line is his isoelectric point if its har the see the elevation.

see below fro quick review from teh BJM.

Pathological Q waves

As the acute myocardial infarction evolves, changes to the QRS complex include loss of R wave height and the development of pathological Q waves.
Both of these changes develop as a result of the loss of viable myocardium beneath the recording electrode, and the Q waves are the only firm electrocardiographic evidence of myocardial necrosis. Q waves may develop within one to two hours of the onset of symptoms of acute myocardial infarction, though often they take 12 hours and occasionally up to 24 hours to appear. The presence of pathological Q waves, however, does not necessarily indicate a completed infarct. If ST segment elevation and Q waves are evident on the electrocardiogram and the chest pain is of recent onset, the patient may still benefit from thrombolysis or direct intervention.

When there is extensive myocardial infarction, Q waves act as a permanent marker of necrosis. With more localised infarction the scar tissue may contract during the healing process, reducing the size of the electrically inert area and causing the disappearance of the Q waves.


Resolution of changes in ST segment and T waves

As the infarct evolves, the ST segment elevation diminishes and the T waves begin to invert. The ST segment elevation associated with an inferior myocardial infarction may take up to two weeks to resolve. ST segment elevation associated with anterior myocardial infarction may persist for even longer, and if a left ventricular aneurysm develops it may persist indefinitely. T wave inversion may also persist for many months and occasionally remains as a permanent sign of infarction.


Reciprocal ST segment depression

ST segment depression in leads remote from the site of an acute infarct is known as reciprocal change and is a highly sensitive indicator of acute myocardial infarction. Reciprocal changes are seen in up to 70% of inferior and 30% of anterior infarctions.

Typically, the depressed ST segments tend to be horizontal or downsloping. The presence of reciprocal change is particularly useful when there is doubt about the clinical significance of ST segment elevation.

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