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• W2920137048 abstract "Scenario: This electrocardiogram (ECG) is from a 74-year-old man, a “direct” admission to the cardiac telemetry unit to rule out acute coronary syndrome after being seen by his primary care provider Monday morning. The patient described having experienced increased weakness and shortness of breath for the past week. He reported having had chest pain on Friday night, but waited to seek care because it resolved and he was “going to see [his] doctor on Monday.” His medical history includes coronary artery disease, a stent 6 years earlier in the right coronary artery, hypertension, diabetes, and glaucoma. He takes the following medications: aspirin, metoprolol, lisinopril, atorvastatin, and latanoprost eye drops. His vital signs are within normal limits and he is free of chest pain but states that he is still short of breath. A prior 12-lead ECG is not currently available.Sinus rhythm, first-degree atrioventricular block, intraventricular conduction delay, and premature atrial contraction. Suspect acute myocardial infarction (MI) of inferior wall from leads III and aVF. Anterolateral ischemia versus reciprocal ST-T changes (V2 to V6, I, and aVL). Inferior wall infarct (QS pattern in III, aVF). Despite left ventricular hypertrophy not being evident according to suggested criteria (S wave in V1 + R wave in V5 > 35 mm), suspicion for left ventricular hypertrophy is high because R wave in aVL (8 mm) + S wave in V3 (27 mm) > 25 mm. Left-axis deviation.Although both left ventricular hypertrophy and left bundle branch block (LBBB; intraventricular conduction delay in this patient) can confound the diagnosis of acute MI because of the ST-T changes associated with these conditions, given this patient’s symptoms in the past week, his cardiac history, associated ST-segment elevation, and widespread ST-T changes, suspicion of acute MI is high. Patients with ischemic symptoms and new LBBB have higher rates of adverse events and mortality. Although a prior 12-lead ECG would help determine whether this LBBB is new, treatment of acute ST-elevation MI (STEMI) should not be delayed while awaiting verification.Delay in seeking treatment is a significant barrier to timely reperfusion therapies. This patient waited to seek care despite having symptoms suggestive of MI for a week. Patient factors associated with prehospital delay can include symptoms differing from a prior event, history of angina, misperception that symptoms are not serious because they go away, and not understanding the importance of seeking prompt medical attention in order to limit heart damage. Importantly, outcomes are worse for MI patients who delay seeking care.Guideline-based treatment for STEMI should be initiated. Troponin blood tests should be done immediately. Provide supplemental oxygen if oxygen saturation is less than 90%. Routine medical therapies includè-blockers, angiotensin-converting enzyme inhibitors, statins, antiplatelets, and anticoagulants. Primary percutaneous coronary intervention is a class I recommendation in patients with STEMI. Before angiography, the patient’s troponin I level was 0.046 (reference > 0.040) ng/mL. A prior 12-lead ECG was very similar. This patient ultimately had angiography because of his symptoms and prior stent; no significant coronary occlusions were found, and the stent was patent. His symptoms were most likely due to heart failure, as confirmed with echocardiography, ejection fraction of 40%, and elevated levels of brain natriuretic peptide (1200 ng/L). Furosemide 40 mg/d and potassium were prescribed. Providing education regarding worsening heart failure and recurrent signs and symptoms of MI with an emphasis on seeking prompt medical care should be emphasized. Set a cardiology appointment before discharge to ensure appropriate follow-up care." @default.
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• W2920137048 date "2019-03-01" @default.
• W2920137048 modified "2023-10-18" @default.
• W2920137048 title "Importance of Evaluating Prior Electrocardiograms" @default.
• W2920137048 doi "https://doi.org/10.4037/ajcc2019226" @default.
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