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General Medical Emergencies
Published in Anthony FT Brown, Michael D Cadogan, Emergency Medicine, 2020
Anthony FT Brown, Michael D Cadogan
Electrocardiogram (ECG). Perform this within 10 min of patient arrival, and arrange for immediate review by a senior emergency department (ED) doctor. Look for ST elevation in two or more contiguous leads.The greater the number of leads affected and the higher the ST segments, the higher the mortality.Inferior myocardial infarction causes changes in leads II, III and aVF.Anterior myocardial infarction causes changes in I, aVL and V1–V3 (anteroseptal) or V4–V6 (anterolateral).True posterior myocardial infarction causes mirror-image changes of tall R waves and ST depression in leads V1–V4.Repeat the ECG after 5–10 min in symptomatic patients with an initial non-diagnostic ECG.
Cardiology
Published in Shibley Rahman, Avinash Sharma, MRCP Part 2 Best of Five Practice Questions, 2018
Shibley Rahman, Avinash Sharma
A 65-year-old man presents with severe central crushing chest pain. ECG demonstrates evidence of an inferior myocardial infarction. He receives TPA, heparin and aspirin. Four hours after presentation, he starts to feel dizzy and breathless, his pulse is 40 bpm regular, blood pressure is 80/50, heart sounds are soft, and chest is clear to auscultation. ECG demonstrates 2:1 block with T wave inversion inferiorly. Intravenous atropine is administered, to no effect. The next best management step is: i.v. dopaminei.v. isoprenalineinsertion of a permanent pacemakerinsertion of a temporary pacing wiremonitor conservatively
Selected Functional Foods That Combat Inflammation
Published in Robert Fried, Lynn Nezin, Evidence-Based Proactive Nutrition to Slow Cellular Aging, 2017
A Cautionary Note: Capsicum and paprika are generally recognized as safe for use in food by the US Food and Drug Administration (No authors listed 2007). However, a clinical report in the International Journal of Emergency Medicine, in 2012, concerned the case of a previously healthy young man who reported severe chest pain after using cayenne pepper pills for slimming. He was diagnosed with extensive inferior myocardial infarction which was confirmed by electrocardiography combined with a bedside echocardiogram. The patient denied using illicit substances and had no risk factors for coronary artery disease. His medication history revealed that he had recently started taking cayenne pepper pills for slimming. A subsequent coronary angiogram revealed normal coronary arteries, suggesting that the mechanism was vasospasm. The authors postulated that the patient developed acute coronary vasospasm and a myocardial infarction in the presence of stimulating compounds. This case highlights the unlikely but nevertheless possible danger of capsaicin, even when used by otherwise healthy individuals (Sogut et al. 2012).
Acute myocardial infarction following misoprostol treatment
Published in Journal of Obstetrics and Gynaecology, 2021
Gabriel Levin, Ahmad Badrieh, Alla Abu Khatab, Natali Schachter-Safrai, Rami Attari, Rani Haj Yahya
Approximately three days after administration, she complained of a sudden-onset retrosternal chest pain and nausea. On her admission to the emergency department, an electrocardiogram (ECG) showed a regular sinus rhythm at 82 beats/minute with a notable ST elevation in anterior wall leads (Figure 1(A)). The patient was diagnosed with acute inferior myocardial infarction. Fifteen minutes after her arrival, the patient had entered the catheterisation theatre after treatment with heparin, aspirin and prasugrel. Coronary angiography demonstrated total occlusion of the proximal left anterior descending (LAD) artery (Figure 1(B)). After balloon intraluminal inflation and aspiration of clots, a drug eluting stent was deployed (Figure 1(C)). Following the procedure, the patient’s chest pain had resolved and she was discharged home in a good condition after two days of hospitalisation. Evaluation of the events from misoprostol treatment until the onset of chest pain for risk stratification reveals no abnormal events that might cause myocardial or coronary insults.
Transcatheter Heart Valve Thrombosis-Induced Myocardial Infarction: A Rare Manifestation of Transcatheter Aortic Valve Thrombosis
Published in Structural Heart, 2019
Taiyo Tezuka, Ryosuke Higuchi, Mike Saji, Itaru Takamisawa, Tetsuya Tobaru, Morimasa Takayama
An 89-year-old female with severe aortic stenosis underwent transcatheter aortic valve replacement (TAVR) using a 23-mm SAPEIN3 valve (Edwards Lifesciences, Irvine, CA, USA), and had taken 100 mg/day of aspirin thereafter. Her mean transvalvular pressure gradient was slightly elevated at 15 mmHg on post-procedural echocardiography. Fourteen months later, she developed acute inferior myocardial infarction due to thrombotic occlusion of the distal right coronary artery (RCA) (Figure 1a,b; Supplemental Video 1 and 2). She did not have atrial fibrillation, or intracardiac thrombus. We performed MDCT searching for an embolic source, and it depicted hypo-attenuated leaflet thickening (Figure 1c). Exchanging aspirin for direct oral anticoagulant, the leaflet thickening had disappeared on MDCT one month later (Figure 1d).
Percutaneous pericardial access for electrophysiological studies in patients with prior cardiac surgery: approach and understanding the risks
Published in Expert Review of Cardiovascular Therapy, 2019
Ammar M. Killu, Samuel J. Asirvatham
Epicardial substrate is most commonly seen in patients with non-ischemic cardiomyopathy, primarily idiopathic dilated cardiomyopathy without prominent perimyocarditis. Of the numerous etiologies, several may predilect the patient to require cardiac surgery. This includes valvular heart disease and hypertrophic cardiomyopathy with apical aneurysm [13]. Ischemic cardiomyopathy is a less common reason for epicardial substrate; however, those with inferior myocardial infarction will have epicardial scar more frequently than those with infarcts in other regions [14]. As such, these patient cohorts may ultimately require epicardial mapping and ablation in the setting of recalcitrant ventricular arrhythmias and previous failed endocardial ablation. Prior cardiac surgery poses unique obstacles for percutaneous pericardial access, even for those with considerable experience [15]. The main issue relates to pericardial adhesions as a result of prior sternotomy. Given the location, the bulk of adhesions are typically over the right ventricular free wall. This may preclude the identification of a space that can be accessed by the entry needle, especially for an anterior approach. Therefore, an inferiorly directly approach may be more frequently utilized though this is still challenging. The valve annulus (especially inferior annulus) appears to be a rare site for adhesion formation (personal observation). We believe this to be due to the fact that it is difficult for pericardial adhesions to form in the absence of direct contact between the visceral and parietal layers of the pericardium.