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Signature ✍️
- This pages describes the “chest pain” syndromes that may present with ECG changes (“ECG ⊕”)
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DDx 🏳️🌈
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Culprit ⚡
Primary Cardiac
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- Occlusion Myocardial Infarction
- Hyperacute T-waves
- Wellens’ syndrome
- Terminal QRS Distorsion
- STD(max) V1-V4 …
- Precordial Swirl
- MINOCA
- IVUS ⊕ Plaque Rupture
- Coronary Vasospasm/Embolism
- Microvascular Disease
- SCAD
- Myocarditis
- Benign
- Diffuse > Segmental TWI/STE
- ⊕/⊖ Pericarditis findings ("myopericarditis")
- Malignant
- ↓ Voltage (Tamponade vs. Cellular infiltration)
- ↓ AV conduction (High-degree AV Block)
- QT prolongation → TdP
- NSVT → Incessant VT vs. VT Storm
- Takotsubo
- Early STE (”Shark fin sign”) → TWIs in V1-V6, I/II/aVL
- QT prolongation (”Spiked helmet sign”)
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- Stage 1
- Widespread STE ⊕ PR depression (Mirrored in aVR)
- Stage 2
- ST segment normalization ⊕ T-wave flattening
- Stage 3
- TWIs
- Stage 4
- Normalization
- OMI Red Flags (”You Diagnose Pericarditis at Your Peril”)
- STD in any lead other than aVR
- Convex ↑ (”tombstone”) vs. horizontal STE
- STE in III > II
- Consequential
- ↓ voltages (tamponade)
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- Infective endocarditis (e.g. AVB)
Secondary Cardiac
- Aortic dissection → OMI
- Pulmonary Embolism
Supply-Demand Mismatch (i.e. “stress test ⊕”)
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- STE in aVR ⊕ Diffuse STDs (”diffuse subendocardial ischemia”)
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- Territorial, reperfusion-like STDs & TWIs of type 2 MI (Wellens’-like)
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Bystander ⚡
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Principles❗️
Culprit vs. Bystander ⚡
- “Culprit” ⚡: refers to ECG findings of chest pain resulting from a primary cardiac issue of the myocardium (many) or pericardium (pericarditis), secondary cardiac issue related to strain (PE), & diffuse vs. focal supply-demand mismatch. In supply-demand mismatch, ischemic chest pain is being driven by an uncontrolled extra-cardiac issue (e.g. severe anemia, hypoxia, acute pulmonary hypertension) rather than a cardiac issue, & tachycardia is often a strong clue. Supply-demand ECG changes can be thought of as those that would be seen in a ⊕ stress test, because they quite literally account for ischemic chest pain related to supply-demand mismatch: they are simply being caught out “in the wild” rather than in a cardiologist’s stress lab
- “Bystander” ⚡: refers to ECG findings completely unrelated to symptoms, with the ECG findings being related to baseline repolarization issues vs. artifact
“Can’t Miss,” Initial Work-Up 🚨
- ECG: intent is to catch OMIs, but there are 2 important caveats. First, ECG ⊖ OMIs should be considered if the story is very compelling for unrelenting ischemia (i.e. consider electrocardiographically silent posterior wall OMI). Second, the ECG may shed light on another “ECG ⊕ chest pain” syndrome (see DDx). CXR: pneumothorax. CT chest w/ IV contrast: pulmonary embolism → infarction, aortic dissection, pneumonia. Echocardiogram: partly for further OMI work-up, partly for pericardium assessment, & partly for evaluation of evolving endocarditis
Role of Stress Testing 💨
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