ACLS Revision: Subtle ECG findings in ACS

acs

  • ST-segment elevation in lead aVR portends a worse prognosis in ACS and often predicts the need for CABG.
  • Hyperacute T-waves are not necessarily tall, and small T-waves can still be hyperacute when paired with a low-amplitude QRS complex.
  • The tall T-waves associated with hyperkalemia are sharp, pointy, symmetric, and have a narrow base.
  • When in doubt, get serial ECGs (every 15 minutes) and use adjunctive information.

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Where else is there evidence of STEMI?

Inferior STEMI

There is obvious inferior ST elevation, with reciprocal ST Depression in aVL (inferior STEMI). There is also ST Depression in lead I.  This is good evidence that the inferior STEMI is caused by an RCA occlusion. There is ST depression maximal in lead V2.  Thus, there is a posterior STEMI. There is also ST depression in V5 and V6.

Where else is there evidence of STEMI?

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Acute Heart Failure Management

Acute Heart Failure Management

  • Treatment of pulmonary edema should be focused on ‘fluid redistribution’ and not ‘fluid removal’.
  • First line: Nitroglycerin and NIV (start ASAP)
  • Second line: ACE-I (in addition or instead of NTG)
  • Third line: Diuretic like furosemide
  • Morphine has NO ROLE in modern management of cardiogenic pulmonary edema

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The Elevated Troponin

 

Causes of Elevated Troponin

Noncardiac Causes Cardiac Causes
Acute Noncardiac Critical Illness Acute and Chronic Heart Failure
Acute Pulmonary Edema Acute Inflammatory Myocarditis or Endocarditis/Pericarditis
Acute Pulmonary Embolism Aortic Dissection
Cardiotoxic Drugs Aortic Valve Disease
Stroke, Subarachnoid hemorrhage Apical Ballooning Syndrome
Chronic Obstructive Pulmonary Disease Bradyarrhythmia, Heart Block
Chronic renal failure Cardiac contusion from trauma
Extensive Burns Cardiac surgery, Post-percutaneous Coronary Intervention, Endomyocardial biopsy
Infiltrative Disease (Amyloidosis) Cardioversion
Rhabdomyolysis with Myocyte Necrosis Direct Myocardial Trauma
Sepsis Hypertrophic Cardiomyopathy
Sever Pulmonary Hypertension Tachycardia/Tachyarrhythmia, Bradyarrhythmia
Strenuous Exercise/Extreme Exertion  
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