ECG Case

[Sublime]

Here's why I call the ECG chronic. There is no axis deviation. No LBBB or RBBB. Though there is ST elevation in V1, it is only in V1 and even then it is variable. No ST elevation in V4R. And variable ST depression in V8 & V9.

Are we looking at the same ECG? How do you not see gross ST-Depression in the inferior leads with mild depression in lateral and anterior leads as well? Do you not see the elevation in AVR?

 

[Sublime]

I just received an update from a member of the flight crew who dropped her off. I received the following information: She did have an MI, also has an infection which they are attempting to treat, they found out she had a UTI the previous week, and apparently her heart is damaged to an extent where there is nothing they can do. Did not get specifics such as troponin. I was told she was not sent to cath but was decided to be managed medically.

 

[MSDeltaFlt]

I just received an update from a member of the flight crew who dropped her off. I received the following information: She did have an MI, also has an infection which they are attempting to treat, they found out she had a UTI the previous week, and apparently her heart is damaged to an extent where there is nothing they can do. Did not get specifics such as troponin. I was told she was not sent to cath but was decided to be managed medically.

Chronic, not chronic. Regardless it wasn't acute. The damage had already been done.

 

[medicsb]

I just received an update from a member of the flight crew who dropped her off. I received the following information: She did have an MI, also has an infection which they are attempting to treat, they found out she had a UTI the previous week, and apparently her heart is damaged to an extent where there is nothing they can do. Did not get specifics such as troponin. I was told she was not sent to cath but was decided to be managed medically.

Good update. I think this is a good teaching case in many ways. First, a reminder to look at the whole clinical picture and not anchor on one finding. Two, from a prehospital perspective, this gives a glimpse into how decisions are made in hospital (e.g. MI =/= PCI). And it could also be used to discuss the complexity of disease and its sequelae.

I imagine that the root cause was infection and the MI was ultimately due to demand and not necessarilly an acute thrombus. I've seen this occur in severely ill patients (often sepsis, or patients undergoing major surgical procedures), who ultimately spill troponin and receive a NSTEMI diagnosis. In pretty much all cases that I've seen (which isn't a whole lot, to be honest), they were medically managed initially with coronary angiography performed at a later time to assess the degree of coronary disease and help guide management (stents vs. CABG vs. risk factor modification/prevention).