WWJMFKD?

[jmfkmd]

This is a real time post, y'all!  Just had a patient with Rinto who came in via squad for unprovoked, asymptomatic Syncope that quickly resolved.  Patient is sitting there in the room with no complaints of CP, SOB, no nothing... literally sitting there staring at me with her strabismatic eyes with a "Why am I here?" look on her face.  Well, you know how we all work up Syncope, so here's her EKG:



Patient is in her 60's, hx of 2 stents for MI in 2007, smoker, HTN, DM, blah blah.  No recent/interval stress or caths since 2007....

So, what do you guys think?  Would you call a STEMI alert?  ST elevation in AvR, slightly in V1 with reciprocal depressions in the inferior lateral leads....

Questions:

1)  What do you think is going on?  Or, what do you think is going on in my mind that I want cardiology to rule out?
2)  Aside from what I'm harping on with the previous question, what else do you notice with this EKG

Bonus Question:

3)  What do you think cardiology did?

Love, 

JMFK

[Bjs04f]

So looking at it, heres some badness.
1-you said shes new onset afib rvr, ie doing a self stress test, probably because she didnt want to pay for ours
2-during self stress she has ST elev in AVr and inferolateral depression...not good
So based on EKG and afib IM saying this lady became high risk (which is what stress test doe, ie risk stratification)and has acute contrast deficiency, fixable only in cath lab
Cardiology saw this on the other hand, and said "phew not a stemi, whelp thats that, thank god I dont have to go do work, lalallalalala"

[jmfkmd]

Preach it, son!

[kemple]

brando is on fire! I saw the same AvR elevation with lateral depressions, concerning.

[Bjs04f]

shit like this makes me miss colyer, dude wouldve been on this. HE was a proponent of everyone needs contrast or they get contrast deficiency, as well as self stressing is a thing

[Bjs04f]

Holy shit this looks really similar. And i quote "This is all academic because such a high risk ECG and case requires immediate cath lab activation if such an elderly patient is in favor of aggressive therapy to save her life." AKA we cant theorize as noone is dumb enough not to cath this lady.........except the cardiology group who shant be named
A Hybrid of de Winter’s T-waves and Diffuse Subendocardial Ischemia: Left Main Ischemia
hqmeded-ecg.blogspot.com/2014/10/a-hybrid-of-de-winters-t-waves-and.html

[jmfkmd]

Yes! I'm telling you (along with all the other cardiologists I've politely and maybe previously impolitely asked to come in and take this patient to Cath Lab) that we need to be on high alert with the classic AvR ST-Elevation with the classic inferior-lateral recip changes. What are we worried about? Lesions to the Left Main Artery OR Triple Vessel Coronary Disease!

So yeah, I know this lady is sitting there without any pain and looks happy as a clam, but dude, you don't go from a completely normal EKG 2 months ago to one like she had 2 days ago (above)... and to give me the whole, "I'm the cardiologist and I say she doesn't need a cath... and why are you admitting someone to my service because of some bogus AvR elevation?" speech just demonstrates either your apathy or stubbornness to believe EBM/academic medicine. Ugh... I only have one foot on my soapbox right now... but so close to fully standing on it and losing it. So frustrating.

Again, be on alert for possible Left Main Artery OR Triple-Vessel coronary disease! And be sure to tell your consult that you are worried about these 2 things based on the EKG findings despite what the patient looks like... remember old and DM people don't project pain complaints in the typical way... but be prepared to get A LOT of push back on the other end of the line. Don't relent...as Maximus from Gladiator says, HOLD THE LINE... you're likely to come out as victors in the end. Here I'll show you with some first hand examples...

Last year, PB and I had a patient with a very similar EKG like the one above and thank God the patient actually had typical chest pain convincing the interventionalist to at least send down his in house PA (God forbid he actually acknowledges that he's on CALL and does his job - slowing getting taller on my soapbox now...). Outcome: 100% Left Main Occlusion that was stented (sans apology or acknowledgement from cards that ER saved yet another near miss - cuz that'd be the day when Z-paks become proven to actually kill respiratory viruses).

So, to catch you up to speed and shut up my whiny rambling and wrap up my point... I took the pleasure of looking up this patient and alas, she got cathed yesterday. Here's the report:

LIMA graft to the mid LAD is widely patent
Saphenous Vein graft to the mid 2nd OM has a distal lesion of 70%, graft is aneurysm just after stenosis making PCI very difficult.
Saphenous Vein graft to the mid 1st OM is totally occluded 100%
Saphenous Vein graft to the mid PDA is totally occluded 100 %
LAD: has a proximal lesion of diffue 90-95 %
CIRC: has a proximal lesion of 100 %
1st OM: has a proximal lesion of diffuse 95 %, with TIMI II flow distally
RCA: has a proximal lesion of 100 %
LAD: has a mid lesion of 100 %
Left Main: is normal
(D) Multi-vessel Coronary Disease.

So, hmm, both of my experiences with this EKG pattern showed a Left Main Artery lesion AND a Triple(+some)-Vessel Disease, respectively. Now, I'm not saying this is a 100% absolute relationship because remember I'm only 2 for 2... but hey, I'm batting 1000 thus far and I like that average. If Amal was here right now, he'd be giving me a hi-five. But he's in Baltimore so I'll just raise my hand up in the air and take the hypothetical hi-five....There, that stung but it was awesome.... SVEEEEEET.

And final note, I used to get frustrated when cardiology never followed-up with us regarding these patients to tell us that we well, frankly, we were right. But that's way too selfish of me to ask for such a thing, so I'm okay with that. But how about a "hey doc, thanks for bringing that patients to our attention... we got her feeling better." They don't even have to acknowledge the cath at all... just a hook me up with some much deserved love....c'mon, please??? Lol. Next time i see those cardiologists, I'm just gonna go up to one and offer them the rock (my fist) without any preface. They may bump it and give me a weird look like I'm crazy, but I know what I'm doing.... Trust me. Just HOLD THE LINE, my friends!

[kemple]

Great post man.

[pbruss]

I am impressed with the resident driven cases. I ENCOURAGE EVERYONE TO POST A CASE!!!! There is no better way to retain knowledge then look at one of your cases and think about how to present it as a question, I guaren-damn-tee it.