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Acute coronary syndrome in a patient with coexistent conduction abnormality.

Mugmon M - J Community Hosp Intern Med Perspect (2011)

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Union Memorial Hospital, Baltimore, MD, USA.

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There was a remote history of pyloric stenosis and abdominal hernia repair... He was a lifelong non-smoker and denied significant alcohol consumption or any drug use... ECG #1 (Fig. 1): Sinus rhythm with slightly increased QRS (112 msec) Incomplete right bundle branch block ST depression V3–V5 compatible with anterior ischemia ECG #2 (Fig. 2): ST depression is more pronounced in V3–V6 with ST depression becoming downsloping in V3 and V4 Given aspirin, heparin, integrilin, and sent to cardiac catheterization lab Cardiac catheterization revealed a 99% stenosis of the left anterior descending and total occlusion of the circumflex, with collaterals supplying the distal circumflex (Fig. 3)... The most important findings in the initial tracing would be horizontal ST depression in V3 and V4, and T-wave inversion in lead V3, indicative of anterior ischemia, and very suggestive of a left anterior descending lesion... This pattern is normally seen with right bundle branch block (RBBB), in which the QRS duration is typically 0.12 secs or greater... If the same pattern is seen with a QRS duration of <0.12 secs, then incomplete right bundle branch block is present... All of these ST-T abnormalities are due to changes in ventricular activation... In contradistinction to secondary ST-T abnormalities, primary ST-T changes are the result of processes that are independent of changes in ventricular activation... Possible causes include pharmacologic effects due to anti-arrhythmic agents, electrolyte disturbances, neurogenic effects (increased intracranial pressure due to hemorrhage), and myocardial ischemia or infarction... This patient had primary ST-T abnormalities in V3 through V6 (due to demonstrable anterior ischemia)... The electrocardiogram the next day showed improvement in the anterior ST depression, but the T inversion in V2 persisted... This case serves to illustrate how progressive coronary atherosclerosis can go undetected and can lead to minimal or no symptoms until the disease has progressed to a significant degree... However, when the left anterior descending stenosis became critical, he developed typical angina, and presented for treatment prior to suffering what would have likely been a large infarction, considering the relatively large amount of myocardium supplied by this vessel... Twenty to 25% of patients have potential coronary collateral channels in the absence of coronary stenosis, but in most they appear to be due to angiogenesis related to the development of ischemia.

No MeSH data available.


Electrocardiogram: ECG #1.
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Figure 0001: Electrocardiogram: ECG #1.

Mentions: A 46-year-old man had a 1-week history of exertional chest tightness and dyspnea. His symptoms became especially prominent while shoveling snow and he presented to the emergency department. He was free of pain at the time of initial presentation and denied any pain at rest (Fig. 1). One hour after reaching the emergency room his pain recurred and he became hypotensive and a second ECG was obtained (Fig. 2).


Acute coronary syndrome in a patient with coexistent conduction abnormality.

Mugmon M - J Community Hosp Intern Med Perspect (2011)

Electrocardiogram: ECG #1.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3714024&req=5

Figure 0001: Electrocardiogram: ECG #1.
Mentions: A 46-year-old man had a 1-week history of exertional chest tightness and dyspnea. His symptoms became especially prominent while shoveling snow and he presented to the emergency department. He was free of pain at the time of initial presentation and denied any pain at rest (Fig. 1). One hour after reaching the emergency room his pain recurred and he became hypotensive and a second ECG was obtained (Fig. 2).

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Union Memorial Hospital, Baltimore, MD, USA.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

There was a remote history of pyloric stenosis and abdominal hernia repair... He was a lifelong non-smoker and denied significant alcohol consumption or any drug use... ECG #1 (Fig. 1): Sinus rhythm with slightly increased QRS (112 msec) Incomplete right bundle branch block ST depression V3–V5 compatible with anterior ischemia ECG #2 (Fig. 2): ST depression is more pronounced in V3–V6 with ST depression becoming downsloping in V3 and V4 Given aspirin, heparin, integrilin, and sent to cardiac catheterization lab Cardiac catheterization revealed a 99% stenosis of the left anterior descending and total occlusion of the circumflex, with collaterals supplying the distal circumflex (Fig. 3)... The most important findings in the initial tracing would be horizontal ST depression in V3 and V4, and T-wave inversion in lead V3, indicative of anterior ischemia, and very suggestive of a left anterior descending lesion... This pattern is normally seen with right bundle branch block (RBBB), in which the QRS duration is typically 0.12 secs or greater... If the same pattern is seen with a QRS duration of <0.12 secs, then incomplete right bundle branch block is present... All of these ST-T abnormalities are due to changes in ventricular activation... In contradistinction to secondary ST-T abnormalities, primary ST-T changes are the result of processes that are independent of changes in ventricular activation... Possible causes include pharmacologic effects due to anti-arrhythmic agents, electrolyte disturbances, neurogenic effects (increased intracranial pressure due to hemorrhage), and myocardial ischemia or infarction... This patient had primary ST-T abnormalities in V3 through V6 (due to demonstrable anterior ischemia)... The electrocardiogram the next day showed improvement in the anterior ST depression, but the T inversion in V2 persisted... This case serves to illustrate how progressive coronary atherosclerosis can go undetected and can lead to minimal or no symptoms until the disease has progressed to a significant degree... However, when the left anterior descending stenosis became critical, he developed typical angina, and presented for treatment prior to suffering what would have likely been a large infarction, considering the relatively large amount of myocardium supplied by this vessel... Twenty to 25% of patients have potential coronary collateral channels in the absence of coronary stenosis, but in most they appear to be due to angiogenesis related to the development of ischemia.

No MeSH data available.