1/354. Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram.Criteria for reperfusion therapy in acute myocardial infarction require the presence of ST elevation in 2 contiguous leads. However, many patients with myocardial infarction do not show these changes on a routine 12-lead electrocardiogram and hence are denied reperfusion therapy. Posterior chest leads (V7 to V9) were recorded in 58 patients with clinically suspected myocardial infarction, but nondiagnostic routine electrocardiogram. ST elevation >0.1 mV or Q waves in > or =2 posterior chest leads were considered to be diagnostic of posterior myocardial infarction. Eighteen patients had these changes of posterior myocardial infarction. All 18 patients were confirmed to have myocardial infarction by creatine phosphokinase criteria or cardiac catheterization. Of the 17 patients who had cardiac catheterization, 16 had left circumflex as the culprit vessel. We conclude that posterior chest leads should be routinely recorded in patients with suspected myocardial infarction and nondiagnostic, routine electrocardiogram. This simple bedside technique may help proper treatment of some of these patients now classified as having unstable angina or non-Q-wave myocardial infarction.- - - - - - - - - - ranking = 1keywords = angina, stable (Clic here for more details about this article) |
2/354. Coronary dissection and myocardial infarction following blunt chest trauma.myocardial infarction (MI) following blunt chest trauma is rarely diagnosed because the ensuing cardiac pain is commonly attributed to contused myocardium or the traumatic injuries in the local chest wall. There are only scattered reports on the coronary pathology associated with MI secondary to blunt chest trauma. Because differentiation of the pathology is difficult but important, we report here three cases of acute anterior MI secondary to coronary dissection following blunt chest trauma. Coronary dissection was demonstrated by coronary angiography. Two of the patients had intimal tears at the proximal left anterior descending artery (LAD) with normal flow, and the other patient had nearly total occlusion of the LAD associated with filling defects probably caused by an intracoronary thrombus. All three patients received conservative treatment without major complications and remained free from angina or heart failure throughout a 5-year follow-up period. In order to exclude associated MI in cases of blunt chest trauma, electrocardiography is necessary, and coronary angiography may be indicated to demonstrate coronary arterial pathology. dissection of the coronary artery with subsequent thrombus formation is one of the possible pathophysiologic mechanisms of MI following blunt chest trauma.- - - - - - - - - - ranking = 0.99882113498213keywords = angina (Clic here for more details about this article) |
3/354. Ventricular rhythms in acute myocardial infarction.Ectopic ventricular activity in acute myocardial infarction is considered to be benign if it is slow and regular (accelerated idioventricular rhythm), but ominous when rapid (ventricular tachycardia). However, it has been observed in an increasing number of reports that these two types may coexist in the same patient, altering thereby the clinical significance of both. In the present study electrocardiograms were analyzed of 55 patients hospitalized for acute myocardial infarction, in whom idioventricular rhythm occurred. It was found that three major types of ventricular rhythms could be identified: a regular-stable rhythm, an irregularunstable one, and a third variant which was a combination of these two types. The stable ventricular rhythm was self limited and harmless. The unstable and combined types which were characterized by random coupling times and varying interbeat intervals, were frequently associated with re-entrant beats and fast ventricular rates and therefore a potentially ominous prognosis. It is suggested that the Ca dependent slow diastolic depolarization may be the mechanism responsible for the unstable ventricular rhythm, and the reasons for this assumption are discussed. A therapeutic approach based on the above considerations is described.- - - - - - - - - - ranking = 0.0058943250893681keywords = stable (Clic here for more details about this article) |
4/354. Treatment of acute myocardial infarction with prolonged intracoronary urokinase delivery through intracoronary infusion catheter.Severe acute myocardial infarction in young patients is plagued by high mortality. We report the case of a 25-year-old man, with a family history of ischemic heart disease, who was treated with acute and prolonged intracoronary urokinase infused through a miniaturized catheter engaged in a large thrombus occluding the left anterior descending artery. Rapid and stable recanalization was achieved with complete lysis of thrombotic material.- - - - - - - - - - ranking = 0.0011788650178736keywords = stable (Clic here for more details about this article) |
5/354. Marked ST elevation after successful PTCA for acute myocardial infarction.Prompt reperfusion of acutely ischemic myocardium appears to be the rational way of reversing ischemic injury and limiting the extent of eventual necrosis. Recent advances in emergency coronary bypass surgery, percutaneous transluminal coronary angioplasty (PTCA) and thrombolytic therapy have provided methods for effective treatment of acute myocardial infarction. However, several observations indicate this issue is more complex. Although blood flow must be restored to ischemic myocardium if it is to survive, animal experiments suggest potential deleterious effects associated with this reperfusion. These deleterious effects may be associated with unstable ST segments reported early after acute infarct thrombolysis. Though recurrent coronary occlusion cannot be excluded, reperfusion injury in this setting of coronary artery patency must be considered. This case illustrates this proposed reperfusion injury reflected as "tombstone" ST segment elevation in a patient following successful acute infarct PTCA.- - - - - - - - - - ranking = 0.0011788650178736keywords = stable (Clic here for more details about this article) |
6/354. Wide QRS complex tachycardia: ECG differential diagnosis.Wide QRS complex tachycardias (WCT) present significant diagnostic and therapeutic challenges to the emergency physician. WCT may represent a supraventricular tachycardia with aberrant ventricular conduction; alternatively, such a rhythm presentation may be caused by ventricular tachycardia. Other clinical syndromes may also demonstrate WCT, such as tricyclic antidepressant toxicity and hyperkalemia. Patient age and history may assist in rhythm diagnosis, especially when coupled with electrocardiographic (ECG) evidence. Numerous ECG features have been suggested as potential clues to origin of the WCT, including ventricular rate, frontal axis, QRS complex width, and QRS morphology, as well as the presence of other characteristics such as atrioventricular dissociation and fusion/capture beats. Differentiation between ventricular tachycardia and supraventricular tachycardia with aberrant conduction frequently is difficult despite this clinical and electrocardiographic information, particularly in the early stages of evaluation with an unstable patient. When the rhythm diagnosis is in question, resuscitative therapy should be directed toward ventricular tachycardia.- - - - - - - - - - ranking = 0.0011788650178736keywords = stable (Clic here for more details about this article) |
7/354. The nondiagnostic ECG in the chest pain patient: normal and nonspecific initial ECG presentations of acute MI.The 12-lead electrocardiogram (ECG) is a powerful clinical tool used in the evaluation of chest pain patients, assisting in the selection of the proper therapy. Unfortunately, the ECG is diagnostic of acute myocardial infarction (AMI) in only one-half of such patients at initial hospital evaluation. In the remaining group of patients with the nondiagnostic 12-lead electrocardiogram, the ECG may be entirely normal, show nonspecific sinus tachycardia (ST) segment-T wave abnormalities, or obvious ischemic changes. In adult chest pain patients treated in the emergency department (ED), 1% to 4% of such patients with an absolutely normal ECG had a final hospital diagnosis of AMI; furthermore, patients with nonspecific electrocardiographic abnormalities experienced AMI in 4% of cases. These findings reinforce the teaching point that the history is the most important tool used in the evaluation of chest pain patients. Furthermore, overreliance on a normal or nonspecifically abnormal ECG in a patient with a classic description of anginal chest pain is dangerous.- - - - - - - - - - ranking = 0.99882113498213keywords = angina (Clic here for more details about this article) |
8/354. Inadvertent stenting of left main coronary artery complicated by later in-stent restenosis.Stenting of both the protected and unprotected left main coronary artery has been described. This case presents a patient who had inadvertent left main stent deployment. A 47-year-old female presented with a non-Q-wave infarction and subsequent angina leading to angiography and angioplasty of her proximal ramus intermedius artery. Recurrent angina and ECG changes necessitated repeat coronary angiography and angioplasty on the same day with Wiktor stent deployment to treat a resultant dissection. Poststent deployment pictures revealed that the stent had been partially deployed in the left main coronary artery. Additional balloon dilatations were performed at the ostia of the left anterior descending and circumflex arteries through the stent. Three months later the patient presented with progressive angina and was discovered to have severe distal left main stenosis. In a case such as this, stent removal may be preferable to leaving an unnecessary stent within the left main coronary artery. Cathet. Cardiovasc. Intervent. 48:194-197, 1999.- - - - - - - - - - ranking = 2.9964634049464keywords = angina (Clic here for more details about this article) |
9/354. Beware of the heart: the multiple picture of cardiac involvement in myositis.A 42-yr-old woman with dermatomyositis had two myocardial infarctions, episodes of acute chest pain and an acute lung oedema. These events were initially misinterpreted as atherosclerotic ischaemic heart disease accompanying the autoimmune disease. The lack of improvement of cardiac symptoms with anti-ischaemic and immunosuppressive drugs indicated other mechanisms. Intracoronary drug provocation as well as myocardial biopsy revealed a coincidence of small-vessel disease and vasospastic angina as a cause for the severe cardiac symptoms. After initiating therapy with high doses of calcium channel blockers, marked improvement of cardiac symptoms occurred. In the pathogenesis of cardiac involvement in dermatomyositis, two different mechanisms should be considered: inflammatory processes due to dermatomyositis and vasoconstriction caused by an impaired regulation of vascular tone, such as abnormal vessel reactivity or disturbed neuropeptide release. Signs of this generalized vasopathy are Raynaud's phenomenon, Prinzmetal's angina and small-vessel disease, which can coincide. In patients with severe cardiac symptoms and autoimmune diseases, Prinzmetal's angina should be excluded by intracoronary drug provocation using acetylcholine.- - - - - - - - - - ranking = 2.9964634049464keywords = angina (Clic here for more details about this article) |
10/354. Results of saphenous vein graft stent implantation: single center results from use of oversized balloon catheters.The results and complications of a single-center experience of stent implantation in old saphenous vein grafts (SVGs) need to be defined. The authors studied their initial consecutive 92 patients (125 stents, 1.4 stents/per patient) with a mean age of 67 /-9 years. The patients' mean saphenous vein graft (SVG) age was 10 /-4 years, and the mean left ventricular ejection fraction was 46% /-15. Patient population included unstable angina (65%), stable angina (10%), myocardial infarction (21%), and silent ischemia (4%). The authors implanted 122 Palmaz-Schatz/biliary and three Gianturco-Roubin stents. They aimed at a balloon-artery ratio of 1.1/1.0. Procedural success, defined as stent deployment with <50% stenosis without death/Q-wave myocardial infarction/coronary artery bypass grafting (MI/CABG) was 95%. The mean luminal diameter (MLD) increased from 0.6 /-0.5 to 3.3 /-0.8 mm (p<0.001) and mean SVG stenosis diameter was decreased from 80% /-14 to -10% /-11 (p<0.001). Angiographic SVG lesions exhibited thrombus (17%), ulceration (38%), and plaque rupture (28%). Sixty-two patients were treated with warfarin and aspirin and 30 with ticlid and aspirin. Complications included death in three patients (3.3%) who sustained subacute stent thrombosis, and two of three had Q-wave MI. Distal embolization occurred in seven patients (8%); six of seven sustained a non Q-wave acute myocardial infarction (AMI); and one of seven a Q-wave MI. Eight (9%) patients had major groin hematoma, two had pseudoaneurysm (2.2%), one had arteriovenous (A-V) fistula (1.1%), two had vascular surgery (2.2%), nine had blood transfusion (9.8%), and three had stent migration (3.3%). Single-center experience with stents in SVGs indicates a highly successful procedural and angiographic immediate result. However, it was complicated by significant risk of non Q-wave MI due to distal coronary embolization which may affect prognosis.- - - - - - - - - - ranking = 2keywords = angina, stable (Clic here for more details about this article) |
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