Cases reported "Myocardial Infarction"

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1/281. 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.
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2/281. Primary percutaneous transluminal coronary angioplasty performed for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura.

    A 72-year-old female with idiopathic thrombocytopenic purpura (ITP) complained of severe chest pain. electrocardiography showed ST-segment depression and negative T wave in I, aVL and V4-6. Following a diagnosis of acute myocardial infarction (AMI), urgent coronary angiography revealed 99% organic stenosis with delayed flow in the proximal segment and 50% in the middle segment of the left anterior descending artery (LAD). Subsequently, percutaneous transluminal coronary angioplasty (PTCA) for the stenosis in the proximal LAD was performed. In the coronary care unit, her blood pressure dropped. Hematomas around the puncture sites were observed and the platelet count was 28,000/mm3. After transfusion, electrocardiography revealed ST-segment elevation in I, aVL and V1-6. Urgent recatheterization disclosed total occlusion in the middle segment of the LAD. Subsequently, PTCA was performed successfully. Then, intravenous immunoglobulin increased the platelet count and the bleeding tendency disappeared. A case of AMI with ITP is rare. The present case suggests that primary PTCA can be a useful therapeutic strategy, but careful attention must be paid to hemostasis and to managing the platelet count.
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3/281. The electrocardiographic diagnosis of acute myocardial infarction in patients with ventricular paced rhythms.

    The electrocardiographic diagnosis of ischemic heart disease is more difficult in the setting of ventricular-paced rhythms (VPR). ST segment/T wave configurations are changed by the altered intraventricular conduction associated with ventricular pacing. The anticipated, or expected, morphology in patients with VPR is one of QRS complex-ST segment/T wave discordance. An awareness of the anticipated ST segment morphologies of VPR is mandatory for the emergency physician. This knowledge is not dependent on additional diagnostic testing, medical records, or expertise in pacemaker function. Two cases are presented in which an analysis of the electrocardiogram in the setting of VPR assisted the treating physicians in establishing the correct diagnosis of acute myocardial infarction and arranging for urgent revascularization.
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4/281. Directional coronary atherectomy in acute myocardial infarction.

    To date, application of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI) has had limited reports. In eleven patients with AMI, DCA was applied. In three of these patients, DCA was used as a stand-alone procedure without use of thrombolytic agents. In each case a guidewire was placed across the stenosis, and in eight patients balloon angioplasty was utilized as a predilating modality prior to DCA. The thrombolytic agent urokinase was utilized in five of these eight patients, either before, during, or after angioplasty and/or DCA. DCA success (defined as ability to cross the lesion, reduction of less than or equal to 20% in stenosis and thrombolysis--when a thrombus is present) was achieved in 10 of 11 patients. One patient had persistent abrupt reclosure of an LAD lesion, accompanied by hemodynamic compromise, necessitating intra-aortic balloon pump insertion and subsequent emergent coronary artery bypass graft surgery. Final angiograms revealed residual stenoses less than or equal to 20%, and adequate thrombolysis. Significant cardiac events were limited to one emergent CABG, Q wave MI in four patients, and non-Q wave MI in two patients. Clinically all eleven patients improved, survived the AMI/CABG, and were discharged. This clinical experience demonstrates the feasibility and safety of DCA application in selected patients who experience acute myocardial infarction.
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5/281. The dynamic nature of ST-segment and T-wave changes during acute MI.

    Obtaining a prehospital 12-lead electrocardiogram (ECG) diagnostic of acute myocardial injury has been demonstrated to hasten the administration of thrombolytic agents in the emergency department. This case demonstrates that a prehospital electrocardiogram diagnostic of acute anterior wall infarction can become non-diagnostic following routine administration of oxygen, nitroglycerin, and morphine by paramedics. Although this phenomenon has been observed in the in-hospital setting, it has not been reported in patients with a prehospital ECG.
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6/281. myocardial infarction in a pre-menopausal woman with angiographically normal coronary arteries.

    A young pre-menopausal non-drug-addict woman without risk factors for coronary artery disease suffered from a non-Q-wave acute myocardial infarction. She presented with epigastric pain and vomiting. diagnosis of acute myocardial infarction was not suspected at first because of her young age and lack of risk factors. She was treated for gastritis but worsening of epigastric pain and its radiation to chest warranted the diagnosis of acute myocardial infarction, which was confirmed by serial serum cardiac enzymes. Subsequent coronary angiogram revealed normal coronary arteries.
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7/281. Histopathologic effects of radiofrequency catheter ablation in previously infarcted human myocardium.

    INTRODUCTION: The use of catheter-based radiofrequency (RF) ablation for the treatment of ventricular tachyarrhythmias due to previous myocardial infarction has been steadily increasing. The histopathologic changes caused by this technique are not well described in humans. methods AND RESULTS: Three patients with hemodynamically tolerated ventricular tachycardias (VTs) due to previous myocardial infarction underwent endocardial mapping and catheter based RF ablation. All patients received between 5 and 11 RF lesions each of 60-second duration. One patient underwent myocardial resection of a left ventricular aneurysm 1 day following RF ablation, one expired 7 days after RF ablation, and one expired 9 months after RF ablation. None of the deaths occurred as a result of RF ablation. Pathologic specimens obtained early after RF ablation revealed areas of focal acute inflammation and fibrin deposition. Later specimens revealed several focal areas of fibrosis and granulation tissue. Specimens obtained late after RF ablation revealed a dense band of fibrosis, measuring 17 x 17 x 5 mm (1,250 mm3). CONCLUSION: Catheter-based RF ablation of ischemic VT in humans causes lesions that initially resemble coagulation necrosis. This is followed by the development of an inflammatory infiltrate and, finally, the development of fibrosis. Repeated application of RF ablation may result in much larger lesions than have been previously reported.
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8/281. Electrocardiographic manifestations: benign early repolarization.

    Early repolarization, also known as benign early repolarization (BER) or normal variant, is noted in approximately 1% of the population and in up to 48% of patients seen in the Emergency Department with chest pain. BER represents a benign variant of the normal electrocardiogram and is one of several syndromes producing electrocardiographic ST segment elevation (STE). The electrocardiogram (EKG) findings of BER include diffuse or widespread ST segment elevation, upward concavity of the initial portion of the ST segment, notching or slurring of the terminal QRS complex, and concordant T waves of large amplitude. This article focuses on BER and includes the electrocardiographic findings useful in making the diagnosis as well as distinguishing BER from other STE syndromes.
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9/281. Psychosocial influences on heart rhythm in the coronary-care unit.

    This report is an extension of previous studies which have shown that significant heart rate and rhythm changes can occur in coronary-care patients during a variety of socio-clinical interactions. Results of continuous day-long observations and concurrent monitoring of one such coronary-care patient disclosed that twice as many ectopic beats occurred during routine nursing interactions compared to resting periods, even though such interactions accounted for less than half of the total observation period. These results are similar to previous studies that have shown that the frequency of ectopic beats can be significantly altered in coronary-care patients by such routine interactions as pulse palpation. Combined with other clinical and animal studies, these data suggest that psycho-social interactions can have major effects on cardiac functioning.
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10/281. Massive T wave changes following a combined kidney and liver transplant in a young female with cirrhosis.

    We report the case of a young female with PSC-associated cirrhosis and chronic renal failure who developed clinical and electrocardiographic signs consistent with acute myocardial infarction after a combined kidney and liver transplant. Cardiac investigations at that time were negative and she is currently asymptomatic one year post-transplant with resolution of most of her ECG abnormalities. Although the cause of her symptoms and ECG abnormalities is not immediately apparent, this case illustrates the difficulties in interpreting abnormal cardiac investigations in transplanted patients with liver cirrhosis who may have a background of subclinical cardiac disease.
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