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• W4386585404 abstract "Figure: shoulder pain, ECG, NSTEMI, global ischemia, coronary artery disease, Aslanger, diabetes, vitiligoFigureA patient in his mid-60s with diabetes mellitus and vitiligo presented to the ED with constant bilateral shoulder pain that had started that morning. He also reported some associated generalized weakness, dyspnea, and sweating. He had no leg swelling, fever, cough, or other symptoms. His vital signs were normal, as was the physical exam except for the vitiligo. An ECG was done. The computer read it as a normal sinus rhythm of 78 bpm with premature atrial contractions (PACs), marked ST abnormality, and possible inferolateral subendocardial injury. What is the most likely cause of these ECG findings? Anxiety, blood clot or pulmonary embolism, cardiac ischemia, drug toxicity, or electrolyte issue? ECG Analysis I reviewed the ECG, which showed a sinus rhythm with multiple PACs and a scooped-out ST depression or a T-wave inversion in the lateral leads, the lateral precordial leads V4 to V6, and lead II (a total of six leads). There was also mild ST elevation in the right-sided leads (aVR and V1). These findings in a patient with ongoing pain are concerning for global ischemia from acute coronary syndrome, especially when the ST depression is maximal in leads V4 to V6 plus also lead II. I consulted Stephen W. Smith, MD, of Dr. Smith's ECG Blog (http://bit.ly/DrSmithsECGBlog), and he confirmed ST depression in leads II and V4 to V6 that, along with the slight ST elevation and hyperacute T-wave in lead III and the T-wave inversion in leads I and aVL, suggested Aslanger pattern. Aslanger indicates an acute inferior occlusion myocardial infarction (OMI) that is partially masked due to the simultaneous ST depression inferiorly, plus ST elevation in leads V1 and aVL, of global ischemia. The differential diagnosis includes inferior OMI and RVMI due to proximal right coronary artery occlusion; right ventricular OMI can result in STE in V1 and STD in V4 to V6. Anxiety should not cause ECG changes. PE and drug toxicity are not supported clinically. Hypokalemia related to electrolyte issues could cause some of the findings, but it's also not supported clinically. Cardiac ischemia is the correct answer. The patient's initial high-sensitivity troponin I about six hours after pain onset was 5000 ng/mL (99% URL; <55 ng/L for women, <80 ng/L for men: troponin I, Siemens). He had ongoing pain after heparin and nitroglycerin, so he was taken to the cath lab, which found 70 percent left main and critical left anterior descending artery and circumflex coronary artery disease. He was taken for an emergent coronary artery bypass graft (CABG). Repeat troponin before CABG but about 12 hours after pain onset was 19,000 ng/mL. Case Lessons Some NSTEMIs need to go to the cath lab emergently rather than urgently. The most common indications include pain refractory to heparin and nitrates or requiring opioids and electric or hemodynamic instability. Global ischemia from left main or three-vessel disease may cause only ST depression in the typical leads with reciprocal ST elevation only in aVR or V1. This may also be an indication for catheterization though it does not meet STEMI criteria. Aslanger pattern indicates a partially masked inferior MI due to simultaneous global ischemia. There will be little ST elevation in the inferior leads, usually just lead III, but there will be T-wave inversion in lead I or aVL. Dr. Pregersonis an emergency physician with Palomar and Tri-City medical centers in San Diego. He is the author of the Emergency Medicine 1-Minute Consult, the 8-in-1 Emergency Department Quick Reference, the A-to-Z Emergency Pharmacopoeia & Antibiotic Guide, and Think Twice: More Lessons from the ER. Follow him on Twitter@EM1MinuteGuru, and visit his websiteshttps://www.erpocketbooks.com/andhttps://em1minuteconsult.com. Read his past columns athttp://bit.ly/BradyCardiaEMN." @default.
• W4386585404 created "2023-09-11" @default.
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• W4386585404 date "2023-02-01" @default.
• W4386585404 modified "2023-09-29" @default.
• W4386585404 title "BradyCardia" @default.
• W4386585404 doi "https://doi.org/10.1097/01.eem.0000920084.51582.cf" @default.
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