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Teaching Cases

Case #1: ECG in early AMI may fail to meet specific STEMI defining criteria. Become familiar with other early diagnostic clues.
Case #2: Incomplete and Inappropriate ECG lead placement may affect machine interpretation and STEMI recognition.
Case #3: High Lateral AMI may present with subtle STE, not uncommonly without involving two contiguos leads. The presence of inferior reciprocal changes should confirm the diagnosis. The presence of the anterior ST segment depression with the above lateral STE, should favor a concomitant posterior STEMI.
Case #4: Importance in recognizing Wellen's ECG patterns.
These patterns may represent spontaneous STEMI reperfusion and/or high risk ACS with residual ischemic  myocardium. Patients with these ECG findings benefit from more aggressive therapy and prompt coronary angiography.

72 y/o male with history of DM, HTN and former smoker. He presented to a Local Health Center with on & off chest pain of 6-8 hours of evolutio. He was treated with NTG sl, aspirin, clopidogrel and LMWH with resolution of CP. Serial CE's mildly elevated for AMI. 

ECG 12 hours after transfer to our ER. Patient arrived free of chest pain. 

Case #5: Reperfusion Assessment.
According to the ACC/AHA guidelines, it is reasonable & pertinent to monitor the pattern of STE, cardiac rhythm, and clinical symptoms during the 60 to 90 minutes after the initiation of fibrinolytic or PCI therapy. Non-invasive findings suggestive of a successful reperfusion include relief of symptoms, maintenance or restoration of hemodynamic and electrical stability, particular arrhythmias (slow VT or idioventricular rhythm) and a reduction of at least 50% in the initial max STE.
Case #6: Importance of recognizing occult AMI's on an initial 12-lead ECGs.

In patients who present with clinic very suggestive of AMI and a non-diagnostic initial ECG, it is recommended to use supplemental leads such as V4R to V6R (to assess right ventricle free wall) and V7 to V9 (to assess the inferobasal or posterior wall). It is also recommended to repeat ECGs every 15-30 minutes while the patient has ongoing CP. 

Clinical Case

82 y/o male with hx. of HTN, CAD, old MI and past CABG X3 1998. Presenting with a severe retrosternal oppressive CP of 5 hours of evolution. Treated with nitrates in ER, but persists w CP. Labs: Cardiac enzymes: Trop=I=2.6 and CK-MB=53.

ECG Findings: NSR, with chronic RBBB and common precordial ST and T waves changes discordant to the QRS from V1-V3. 

Cath Findings: Obtuse marginal (OM) from the circumflex artery filling from a saphenous vein graft (SVG). This is a thrombotic occlusion of the SVG at the anastomosis with the OM. Post-PCI with correction of flow and vessel diameter.

Case #7: Importance of recognizing diffuse ST segment depressions (>6 leads) and ST segment elevation limited to aVR, as severe subendocardial ischemia suggestive of LM ACS or equivalent LM stenosis or severe 3 vessel disease.

ACS patients with ST depression (> 1 mm) in six or more leads, maximal in leads V4 to V6, especially when associated with inverted T waves and ST elevation in lead aVR (> 1 mm; not indicative of STEMI, but more like reciprocal changes to the subendocardial ischemia), should have high priority for urgent invasive evaluation because of high probability of severe angiographic CAD. The probability for severe CAD is higher if the patient’s baseline ECG is normal and the changes are dynamic. Avoidance of the ADP receptor antagonist should also be consider in case emergent surgical revascularization is needed.

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