Comments or Questions? me:

Transcription

1 Comments or Questions? me: Interested in short video tutorials on electrocardiography? Check out Subscription fee < cost of a cup of coffee/week Covers every aspect of electrocardiography imaginable, focused on emergency medicine Subscription discounts for groups

2 Comments or Questions? me: Interested in more advanced ECG training? ECGs for the Emergency Physician, Volumes 1 and 2 (authors Amal Mattu and William Brady) Each with 200 intermediate-advanced ECG cases focused on emergency medicine with detailed interpretations, pearls, and pitfalls (no repeat cases between the two books) Available at amazon.com or ACEP bookstore

3

4 Electrocardiography of Cardiac Ischemia Classic, Confusing, and Confounding Patterns Amal Mattu, MD, NE Professor and Vice Chair Department of Emergency Medicine University of Maryland School of Medicine

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19 Electrocardiography of Cardiac Ischemia Classic, Confusing, and Confounding Patterns Amal Mattu, MD, NE Professor and Vice Chair Department of Emergency Medicine University of Maryland School of Medicine

20 Electrocardiography of Cardiac Ischemia Classic, Confusing, and Confounding Patterns NE = Nerdus electrocardiogramus

21 Electrocardiography of Cardiac Ischemia Classic, Confusing, and Confounding Patterns Amal Mattu, MD, NE Professor and Vice Chair Department of Emergency Medicine University of Maryland School of Medicine

22 A Few Points To Start Advanced content

23 A Few Points To Start Advanced content Courtesy Heidi Farinholt, MD

24 A Few Points To Start Workshop Questions? Writing PDF of slides: lectures.umem.org/essentials (will be available for 1 month only!)

25 Why is this important?

26 Why is this important? ACS is high-risk but high payoff! Very good outcome vs. very bad outcome

27 Why is this important? ACS is high-risk but high payoff! Very good outcome vs. very bad outcome Missed ACS 25-35% mortality In elderly 50% 3-day mortality

28 Why is this important?

29 Why is this important?

30 Why is this important?

31 Why is this important? Missed ACS accounts for 20% of malpractice dollars paid out in EM 25-50% of cases involve ECG misreads

32 Why is this important? Missed ACS accounts for 20% of malpractice dollars paid out in EM 25-50% of cases involve ECG misreads My experience: > 50% involve ECG misreads that are not arguable

33 Why is this important? In the U.S % of cath lab activations result in negative caths 10-15% of cath lab activations are cancelled upon cardiology arrival to the hospital

34 Bottom line You ve gotta know electrocardiography!

35 Cases

36 Case 1 50 yo man with chest pain Retrosternal CP with sweats History of htn..... Courtesy Dr. Lakshay Chanana(Vellore, India)

37 11:22 pm Courtesy Dr. Lakshay Chanana

38 11:22 pm Courtesy Dr. Lakshay Chanana

39 Is this a STEMI?? Courtesy Dr. Lakshay Chanana

40 Does lead III have significant STE??

41 11:46 pm Courtesy Dr. Lakshay Chanana

42 11:46 pm Courtesy Dr. Lakshay Chanana

43 Subsequent Course Courtesy Dr. Lakshay Chanana Cardiology consulted TN #1 positive: (normal < 14) Decision to give SK

44 Subsequent Course Courtesy Dr. Lakshay Chanana Cardiology consulted TN #1 positive: (normal < 14) Decision to give SK Good outcome at 9 month F/U ECHO without WMAs, EF 59%

45 Is there STE in ECG #1??

46 Where do you measure ST-segment elevation?

47 Is there STE?? Thygesen K, et al. ESC/ACCF/AHA/WHF expert consensus document: third universal definition of myocardial infarction. JACC and Circulation 2012.

48 Is there STE?? Thygesen K, et al. ESC/ACCF/AHA/WHF third universal definition of myocardial infarction. JACC and Circulation Use the J-point, 2 contiguous leads

49 Is there STE in 2 contiguous leads?

50 Is there STE?? Thygesen K, et al. ESC/ACCF/AHA/WHF third universal definition of myocardial infarction. JACC and Circulation Use the J-point, 2 contiguous leads

51 Is there STE?? Thygesen K, et al. ESC/ACCF/AHA/WHF third universal definition of myocardial infarction. JACC and Circulation Use the J-point, 2 contiguous leads Men > 40yo: 2 mm in V2-V3 and 1 mm in all other leads Men < 40yo: 2.5 mm in V2-V3 Women: 1.5 mm in V2-V3 and 1 mm in all other leads

52 Is there STE?? Diagnosing STEMI is not always simple! Is there anything that improves our yield?

53 Is there STE?? Serial ECGs Look for reciprocal changes! Look at the ST segment morphologies! (More on this coming up )

54 11:22 pm Courtesy Dr. Lakshay Chanana Reciprocal change may initially be more obvious than the STE

55 11:22 pm Lead III Beware straightening of the initial portion of the T-wave (& R-T sign)

56 11:22 pm Lead III Normal T-waves Beware straightening of the initial portion of the T-wave (& R-T sign)

57 11:22 pm When any concerns, get serial ECGs!

58 11:46 pm Lead III

59 Takehome Points STE is complicated! Pay attention to ST-T morphology More to follow Pay attention to potential reciprocal changes More to follow Consult cardiology for joint decision-making

60

61

62

63 Case 2 48 yo M presents with atypical CP Arrives via 911 Placed in hallway Initial ECG Courtesy Sean Fox, MD (Carolinas Medical Ctr)

64 Case 2 (with pain) Courtesy Sean Fox, MD

65 2:35 pm (with pain) Courtesy Sean Fox, MD

66 2:49 pm (cont. pain) Courtesy Sean Fox, MD

67 2:51 pm (cont. pain) Courtesy Sean Fox, MD

68 For comparison 2:35 pm 2:51 pm

69 For comparison 2:35 pm 2:51 pm

70 For comparison 2:35 pm 2:51 pm What s are these??

71 Terminal T-wave inversion is subtle or early Wellens

72 3:35 pm Courtesy Sean Fox, MD

73 Short time later en route to cath Courtesy Sean Fox, MD

74 Cath 95% LAD lesion Courtesy Sean Fox, MD

75 Case 2 Takehome point beware straightening of the initial part of the T-wave This is often an early finding in ischemia Get serial ECGs to evaluate this!

76 Traditional teaching: Hyperacute Ts

77 Note the morphology, not just the height

78 69 yo woman with vague SOB and LH (triage)

79 69 yo woman with vague SOB and LH (triage) Note the straightening of the Ts

80 69 yo woman with vague SOB and LH (triage) Repeated for better baseline

81 69 yo woman with vague SOB and LH (triage) Repeated for better baseline Note the reciprocal ST change

82 69 yo woman with vague SOB and LH (triage) Baseline ECG (not obtained initially)

83 69 yo woman with vague SOB and LH (triage) Next ECG few hours later positive TN, taken emergently for PCI LAD

84 44 yo man with CP

85 Baseline

86 later anterior STEMI, LAD stenosis

87 45 yo man with CP

88 45 yo man with CP V3 with T-wave straightening (and R-T sign )

89 later anterior STEMI

90 few minutes later

91 60 yo man with CP

92 52 yo woman with CP

93 Baseline ECG

94 52 yo woman with CP

95 52 yo woman with CP Inferior leads with + STE (computer not calling it) but note straightening of T- waves and terminal inversion of T-waves

96 later inferior (and impending anterior?) STEMI

97 69 yo man with CP

98 Baseline

99 Comparison Baseline Chest pain

100 Comparison Baseline Chest pain

101

102 later anterior MI

103 Takehome Points Beware straightening of the initial part of the T-wave This is often an early finding in ischemia Get serial ECGs to evaluate this!

104

105

106 Courtesy Dr. Alon Duby (U.K.)

107 Case 3 86 yo W with nausea, vomiting, epigastric pain Abdomen minimally tender Get an ECG??? Courtesy Dr. Peter Hammarlund (Sweden)

108 Case 3 Courtesy Dr. Peter Hammarlund

109 Case 3 Note speed of tracing Courtesy Dr. Peter Hammarlund

110 Baseline Courtesy Dr. Peter Hammarlund

111 Comparison Courtesy Dr. Peter Hammarlund Baseline Symptomatic

112 New TWI in avl (and I) is this a reciprocal change? Courtesy Dr. Peter Hammarlund Baseline Symptomatic

113 Case 3 (08:22) Courtesy Dr. Peter Hammarlund

114 Repeat ECG (09:08) Courtesy Dr. Peter Hammarlund

115 Case 3 Takehome point reciprocal changes can often precede the STE of a STEMI Especially common to see this in avl in the setting of an inferior STEMI (described by Marriott and others decades ago)

116 Acute Inferior Wall MI

117 Normal ECG

118 Case 3a Courtesy Dr. Thomas Cheung (London, Ontario)

119 Case 3a 79 yo woman with chest pain Pain at rest Radiating to left arm and jaw Courtesy Dr. Thomas Cheung History of Htn, hyperlipidemia, breast CA with radiation tx, GERD

120 Case 3a 79 yo woman with chest pain Pain at rest Radiating to left arm and jaw Courtesy Dr. Thomas Cheung History of Htn, hyperlipidemia, breast CA with radiation tx, GERD Symptoms identical to 1 week earlier admitted and ruled out by TNs, dx d with radiation pneumonitis

121 Initial ECG Courtesy Dr. Thomas Cheung

122 1 wk ago (asymptomatic)

123 One week ago (asymptomatic) Now (symptomatic)

124 One week ago (asymptomatic) Now (symptomatic)

125 13 min later Courtesy Dr. Thomas Cheung

126 13 min later Courtesy Dr. Thomas Cheung

127 Case 3a Courtesy Dr. Thomas Cheung Outcome 99% prox/mid-rca occlusion Successful stents (2) Discharged doing well

128 Case 3b Courtesy Dr. Anver Sethwala (intern) and Dr. Asim Cheema (consultant) Northwest Regional Hospital, Tasmania, Aus.

129 Case 3b 57 yo M presents with central CP (ongoing) and diaphoresis ECG 9:26 pm with 7/10 CP

130 Case 3b

131 Case 3b NTG and morphine given Pain persists Repeat ECG 9:36 pm

132 Case 3b

133 Case 3b Ongoing pain Short time later

134 Case 3b

135 Case 3c Courtesy Dr. Joe Young (Baylor Carrollton MC, TX)

136 Case 3c Courtesy Dr. Joe Young 75 yo woman presents with atypical burning CP

137 Case 3c Courtesy Dr. Joe Young

138 Case 3c Courtesy Dr. Joe Young No old ECGs TN normal Plan for admission for unstable angina, ready to go upstairs

139 Case 3c: ECG #2 Courtesy Dr. Joe Young

140 Case 3c: ECG #3 Courtesy Dr. Joe Young

141 Case 3c: ECG #4 Courtesy Dr. Joe Young

142 Case 3c Courtesy Dr. Joe Young Serial ECGs were done over the course of ~ 40 minutes inferior STEMI Patient sent for cath 100% RCA occlusion

143 Case 3d Courtesy Anna Marie Allen, MD Nashville VA Hospital 27 yo M with chest pain

144 Case 3d Courtesy Anna Marie Allen, MD Started yesterday, intermittent Retrosternal sharp pain 30 episodes in past 24 hours Radiates to both arms No SOB, sweats, N/V, recent illness Not like his usual reflux

145 Case 3d Courtesy Anna Marie Allen, MD Hx of htn, smokes ½ ppd, FHx early CAD (father MI in 40s) History of GERD No cocaine Mild htn (148/102), normal exam

146 1/10 chest pain 17:33 Courtesy Anna Marie Allen, MD

147 27 yo man 1/10 chest pain 17:33 Courtesy Anna Marie Allen, MD

148 27 yo man 1/10 chest pain 17:33 Courtesy Anna Marie Allen, MD

149 1/10 chest pain 17:33 Courtesy Anna Marie Allen, MD

150 Increasing chest pain 18:07 Courtesy Anna Marie Allen, MD

151 8/10 chest pain 18:50 Courtesy Anna Marie Allen, MD

152 Case 3d Courtesy Anna Marie Allen, MD 27 yo M then went for cath/pci: 80% OM1 stenosis 90% left circumflex stenosis 40% RCA stenosis Mild diffuse LAD disease

153 55 yo woman with atpical CP (triage ECG)

154 55 yo woman with atpical CP (during evaluation)

155 later in the day, cath 100% RCA

156 TWIs in avl: Normal variants LBBB LVH

157 Left Bundle Branch Block

158 Left Ventricular Hypertrophy

159 Takehome Points Reciprocal changes can be the first manifestation of an impending STEMI Especially in avl inferior STEMI When you see ST or T-wave changes in a symptomatic patient, get serial ECGs! Respect the T-wave!

160

161