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Category Archives: Ischemic Chest Pain

Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (13)

Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (13)Conclusions
The review of recent studies dealing with the diagnostic and prognostic significance of the ECG in acute coronary syndromes indicate that the ECG remains an important initial test in patients with AMI or other coronary syndromes. It is of interest, however, that while the ECG is of limited value in the differentiation between transmural and nontransmural myocardial infarction, the different ECG manifestations of acute coronary syndromes are helpful in the assessment of prognosis, severity of coronary artery disease, and degree of myocardial impairment. As suggested by Spodick the ECG is “trying to tell us something” about the nature of AMI. In patients with QMI, the ECG confirms the diagnosis, while in patients with NQMI, the diagnosis of myocardial infarction is less certain and has to be confirmed by non-ECG methods. In addition, the degree of coronary artery disease is usually less severe in patients with ST segment elevation than in those with ST segment depression. buy antibiotics online

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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (12)

Fourth, patients with left ventricular hypertrophy and ischemic chest pain should be admitted into the coronary care unit because of higher likelihood of development of acute coronary syndromes and life-threatening complications.

Normal ECG or Nonspecific ST-T Wave Chances
Finally, in patients with ischemic chest pain, the initial ECG can show minor nonspecific ST-T wave changes or be normal. Among the possible causes of a normal initial ECG in AMI are delayed evolution of the ECG changes, lateral infarction due to occlusion of the left circumflex coronary artery, or small myocardial infarctions. buy prednisone
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (11)

Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (11)The majority of patients with ischemic chest pain and intraventricular conduction defect, with the exception of left anterior fascicular block, have advanced coronary artery disease, more impaired left ventricular function, and therefore, are of higher risk for life-threatening complications and should be monitored in the coronary care unit. Furthermore, the diagnosis of AMI has to be confirmed or excluded by non-ECG techniques. asthma inhalers
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (10)

The second question is localization of myocardial infarction. Patients with new right bundle branch block usually have an extensive anterior myocardial infarction in comparison to those with LBBB who can have either anterior or inferior one. The third question is whether the intraventricular conduction defect is new or old. According to Ross, in 20 to 50 percent of patients, this question remains unanswered.
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (9)

Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (9)Intraventricular Conduction Defects
Twenty percent of patients with AMI have intraventricular conduction defects. Patients with AMI and intraventricular conduction defect with exception of left anterior fascicular block, have higher mortality, more advanced coronary artery disease and more impaired left ventricular function. ventolin inhalers
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (8)

In the second group are patients with impending myocardial infarction who have minimal ST segment elevation and deep T wave inversion in leads V2 and V3 and less frequently in other chest leads. Cardiac enzymes are either normal or slightly elevated. According to de Zwaan et al, this ECG finding can be a manifestation of severe proximal stenosis of the LAD and presents an increased risk for the development of extensive anterior myocardial infarction. However, because the ECG does not accurately localize the site of LAD obstruction, these patients should undergo early coronary angiography.
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (7)

Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (7)In patients who underwent coronary bypass surgery, the incidence of AMI and mortality was similar in both groups. According to Granborg et al, the long-term prognosis of isolated ischemic T wave changes regardless of whether they represent NQMI or unstable angina is poor. During 31 month follow-up, 17 percent of patients developed AMI and 24 percent died.
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (6)

Unstable Angina
The ECG manifestations of unstable angina are transient ST segment depression, ST segment elevation and less frequently, T wave changes.” What is the role of the 12-lead ECG in patients with unstable angina? First, patients in whom episodes of chest pain is not associated with ECG changes seem to have less severe coronary artery disease than those with ECG changes. Second, according to some studies, patients with ST segment elevation have less extensive coronary artery disease in comparison to patients with ST segment depression. This finding could explain the higher mortality in the latter. Third, patients with ST segment elevation are more prone to coronary spasm and life-threatening arrhythmias than subjects with ST segment depression.* Fourth, the incidence of AMI during the initial hospitalization in patients with ST segment elevation and depression is 12 to 25 and 5 to 7 percent respectively.” The early survival rate is high in both groups (>95 percent). birth control pills
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (5)

Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (5)Second, the initial ECG plays an important role in coronary thrombolysis. An abnormal ECG is one of the criteria for thrombolytic therapy and helps to identify patients who will or will not benefit from coronary reperfusion. According to Bar et al, patients who benefited most from coronary thrombolysis were those with prominent ST segment elevation. In contrast, in patients with ST segment depression or previous myocardial infarction, coronary thrombolysis did not improve mortality. However, this finding has not been confirmed by some newer studies; ie, coronary thrombolysis improved mortality regardless of the ECG. It is possible that in the future, the ECG will play a less important role in candidates for coronary thrombolysis. buy flovent inhaler
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Initial Electrocardiogram in Patients with Suspected Ischemic Chest Pain (4)

ST depression in lead V,_4 can also be a manifestation of a posterior AMI. As reported by Boden et al, in 40 percent of patients with ischemic chest pain, ST segment depression in lead is due to posterior AMI. This localization of AMI should be suspected if the ST segment depression is horizontal and the T waves are positive. Occasionally, however, the T waves can be biphasic or negative. Patients with posterior MI have a higher CK-MB enzymes than those with anterior NQMI.
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