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Wellens Syndrome

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81. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non?ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Full Text available with Trip Pro

plaque disruption (eg, rupture, ulceration, erosion) with superimposed thrombus formation in a coronary artery, resulting in acute reduction in myocardial blood supply and/or distal embolization with subsequent myonecrosis. MI type 2 is myocardial injury caused by conditions other than coronary artery disease that results in an imbalance between myocardial oxygen supply and/or demand (eg, coronary artery embolism or spasm, tachyarrhythmias, anemia, respiratory failure, profound hypotension (...) and statements that would potentially impact the construct of the measures. The practice guidelines and statements that most directly contributed to the development of these measures are summarized in . Table 2. Associated Guidelines and Other Clinical Guidance Documents Clinical Practice Guidelines 1. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes 2. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction 3. AHA/ACCF Secondary

2017 American Heart Association

82. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope Full Text available with Trip Pro

of syncope and the acute reversibility of the underlying condition; long-term prognosis is related to the effectiveness of therapy and the severity and progression of underlying diseases, especially cardiac or terminal illnesses. Recommendations for Risk Assessment Although having precise definitions for high-, intermediate-, and low-risk patient groups after an episode of syncope would be useful for managing these patients, evidence from current clinical studies renders this proposal challenging because (...) 4.1.1. Bradycardia: Recommendation e79 4.1.2. Supraventricular Tachycardia: Recommendations e79 4.1.3. Ventricular Arrhythmia: Recommendation e80 4.2. Structural Conditions: Recommendations e80 4.2.1. Ischemic and Nonischemic Cardiomyopathy: Recommendation e80 4.2.2. Valvular Heart Disease: Recommendation e80 4.2.3. Hypertrophic Cardiomyopathy: Recommendation e80 4.2.4. Arrhythmogenic Right Ventricular Cardiomyopathy: Recommendations e81 4.2.5. Cardiac Sarcoidosis: Recommendations e81 4.3

2017 American Heart Association

83. Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Guideline For the Management of Patients With

Transplantation .. . e147 7.8. Neuromuscular Disorders. ... e148 7.9. Cardiac Channelopathies . ... e149 7.9.1. Speci?c Cardiac Channelopathy Syndromes .. .. e150 8.VA IN THE STRUCTURALLY NORMAL HEART .. . e160 8.1. Out?ow Tract and Atrioventricular Annular VA . e161 8.2. Papillary Muscle VA ... e162 8.3. Interfascicular Reentrant VT (Belhassen Tachycardia) ... e162 8.4. Idiopathic Polymorphic VT/VF ... ... e163 9.PVC-INDUCED CARDIOMYOPATHY ... . e164 10.VA AND SCD RELATED TO SPECIFIC POPULATIONS e165 10.1 (...) to ensure they do not have underlying conditions (e.g., ischemic heart disease, left ventricular [LV] dysfunction) that warrant further treatment to reduce risk. PVC and NSVTinpatientswithcardiovasculardiseasearecommon and have been associated with adverse outcomes (S2.2.2- 12,S2.2.2-13). In CAST (Cardiac Arrhythmia Suppression Trials), treatment of patients with post-myocardial infarction (MI) who took antiarrhythmic medications (e.g., ?ecainide, encainide, moricizine) increased the risk of death

2017 American College of Cardiology

84. Syncope: Guideline For Evaluation and Management of Patients With

. Ischemic and Nonischemic Cardiomyopathy: Recommendation .. ... e64 4.2.2. Valvular Heart Disease: Recommendation... ... e64 4.2.3. Hypertrophic Cardiomyopathy: Recommendation... ... e64 4.2.4. Arrhythmogenic Right Ventricular Cardiomyopathy: Recommendations . ... e65 4.2.5. Cardiac Sarcoidosis: Recommendations .. e65 4.3. Inheritable Arrhythmic Conditions: Recommendations .. .. e66 4.3.1. Brugada Syndrome: Recommendations .. e66 4.3.2. Short-QT Syndrome: Recommendation .. e67 4.3.3. Long-QT Syndrome (...) : Recommendations . e67 4.3.4. Catecholaminergic Polymorphic Ventricular Tachycardia: Recommendations .. ... e68 4.3.5. Early Repolarization Pattern: Recommendations .. ... e69 5.REFLEX CONDITIONS: RECOMMENDATIONS e70 5.1. Vasovagal Syncope: Recommendations .. e70 Shen et al. JACC VOL. 70, NO. 5, 2017 2017 ACC/AHA/HRS Syncope Guideline AUGUST 1, 2017:e39–110 e405.2. Pacemakers in Vasovagal Syncope: Recommendation . e72 5.3. Carotid Sinus Syndrome: Recommendations ... e72 5.4. Other Re?ex Conditions.. e73 6

2017 American College of Cardiology

85. Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death Full Text available with Trip Pro

of evidence. c Reference(s) supporting recommendations. A standard resting 12-lead ECG may reveal signs of inherited disorders associated with VAs and SCD such as channelopathies (LQTS, SQTS, Brugada syndrome, CPVT) and cardiomyopathies (ARVC and HCM). Other ECG parameters suggesting underlying structural disease include bundle branch block, atrio-ventricular (AV) block, ventricular hypertrophy and Q waves consistent with ischaemic heart disease or infiltrative cardiomyopathy. Electrolyte disturbances (...) AVID Antiarrhythmic drugs Versus Implantable Defibrillator BrS Brugada Syndrome CAD coronary artery disease CARE-HF CArdiac REsynchronization – Heart Failure CASH Cardiac Arrest Study Hamburg CAST Cardiac Arrhythmia Suppression Trial CAT CArdiomyopathy Trial CHD congenital heart disease CI confidence interval CIDS Canadian Implantable Defibrillator Study CMR cardiac magnetic resonance COMPANION Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure CPG Committee for Practice

2015 European Society of Cardiology

86. Syncope and Chest Pressure, then an Unusual Bradycardia with Shock

Research, VOL.41 NO. 5, NOVEMBER 1977 3. Wit, Wellens, Josephson, Electrophysiological Foundations of Cardiac Arrhythmias, Cardiotext Publishing, 2017 4. I've also attached a coronary anatomy article whose reference I have lost. This case is from one of our fantastic 3rd year residents, Aaron Robinson. A woman in her 60s with Syncope A woman in her 60s presented to a facility with syncope. She had a history of CHF, pulmonary hypertension, CAD s/p CABG , and ESRD on hemodialysis. She had a dialysis run (...) of incomplete RBBB (albeit without an lateral chest lead terminal s wave). These findings are new compared to the 2nd ECG that was done (in which there was AV Wenckebach). I’m not quite sure what to make of this, given cath findings that the graft LAD & native circumflex were stented (no mention of RCA issues …), in this patient with established multivessel disease … But from an ECG-interpretation standpoint — I would have called, “incomplete RBBB/LPHB” for my interpretation of this post-cath tracing

2020 Dr Smith's ECG Blog

87. Diffuse T-wave inversions and a very long QT

to be acute MI. Here is the final ECG: ECG 4 (final chronologically) T-wave inversions still present but not as pronounced. The etiology of the T-wave inversions was not established. Perhaps a transient occurrence after a seizure? Or perhaps this was indeed Wellens' syndrome without a very elevated troponin. Only an angiogram would show for certain. =================================== MY Comment by K EN G RAUER, MD ( 6/22/2020 ): =================================== I LOVE this case presented by Dr. Smith (...) ’ Syndrome. WellensSyndrome is most probably not present in this case . While an acute ischemic coronary syndrome is a diagnostic possibility (ie, acute ischemia is included among the entities listed in Figure-2 ) — it is well to remember that there are other causes of the ST-T wave picture that we see in lead V2 of ECG #1. These include ( among others ) — LVH, cardiomyopathy, coronary reperfusion. In ECG #1 — I suspect the reason for the biphasic T wave in V2 is simply the reflection of the increased

2020 Dr Smith's ECG Blog

88. CCS/CHRS 2016 Implantable Cardioverter-Defibrillator (ICD) Guidelines Full Text available with Trip Pro

the implementation of these guidelines, device programming, and management of common clinical conditions in patients with ICDs. Patient Selection Risk assessment of SCD Standard criteria for assessing the risk of ventricular tachycardia (VT)/ventricular fibrillation (VF) include left ventricular ejection fraction (LVEF) and the presence of reversible/treatable causes of VF or certain specific diseases (eg, hypertrophic cardiomyopathy, cardiac sarcoidosis); these are the cornerstones of indications for an ICD (...) ; MI, myocardial infarction; VF, ventricular fibrillation; VT, ventricular tachycardia. | | Significant structural heart disease pertains to conditions in which the risk of cardiac arrest in the presence of VT is high. These are conditions such as infiltrative cardiomyopathies or those associated with a reduced LVEF. This does not pertain to conditions in which the risk of cardiac arrest is low such as atrial septal defect, most valvulopathies, and atriopathies. Syncope of unknown origin

2016 Canadian Cardiovascular Society

89. Comprehensive geriatric care in hospitals: the role of inpatient geriatric consultation teams

or older, a share that will increase to 25.8% by 2060. 2 Although the majority of persons in the age group 65-74 years report to be in good health (i.e. 72% report the self-perceived health status as good), 3 there is also a growing burden of (multiple) conditions. 4 What’s more in the age group of 75 years and older, only 57% of the persons rate their health status as good. 3 This evolution will challenge our healthcare system: not only there will be an increasing number of older persons that need (...) health-care services but the healthcare services will also have to be re-designed to accommodate the needs of the persons with chronic conditions and multi-morbidity. 4 Ageing hospital population The proportion of patients older than 75 years hospitalised on non-geriatric acute care units a (non G-units) is already relatively high (i.e. 27.24% of the patients in 2011). In addition, this patient group accounts for 43% of all hospitalisation days on acute non geriatric units. The group aged =85 years

2015 Belgian Health Care Knowledge Centre

90. Drugs That May Cause or Exacerbate Heart Failure Full Text available with Trip Pro

that diabetes mellitus (31%), chronic obstructive pulmonary disease (26%), ocular disorders (24%), osteoarthritis (16%), and thyroid disorders (14%) predominated. As the burden of noncardiovascular comorbidities increases, the number of medications, medication costs, and complexity also may increase. In the general population, patients with ≥5 chronic conditions have an average of 14 physician visits per year compared with only 1.5 for those with no chronic conditions. Medicare beneficiaries with HF see 15 (...) and other comorbidities, as well as the increasing comorbidity burden in an aging population that may warrant an increasing number of specialist and provider visits. , The HF syndrome is accompanied by a broad spectrum of both cardiovascular and noncardiovascular comorbidities. Five or more cardiovascular and noncardiovascular chronic conditions are present in 40% of Medicare patients with HF. This estimate is much higher compared with the general Medicare population, in which only 7.6% have ≥3 chronic

2016 American Heart Association

91. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

to a spectrum of heterogeneous myocardial disorders that are characterized by ventricular dilation and depressed myocardial performance in the absence of hypertension, valvular, congenital, or ischemic heart disease. 5 In clinical practice, the pathogenesis of heart failure (HF) has often been placed into 2 categories: ischemic and nonischemic cardiomyopathy. The term nonisch- emic cardiomyopathy has been interchangeably used with DCM. Although this approach might be practical, it fails to recognize (...) confined to heart muscle. Secondary cardiomyopathies had myocardial involvement as part of a large number and variety of generalized systemic (multiorgan) disorders, including systemic diseases such as amyloidosis, hemochromatosis, sarcoidosis, autoimmune/collagen vascular diseases, toxins, cancer therapy, and endocrine disorders such as diabetes mel- litus. 6 The European Society of Cardiology (ESC) Work- ing Group on Myocardial and Pericardial Diseases took a different approach based on a clinically

2016 American Heart Association

92. Electrocardiographic Early Repolarization

define ER as “a normal variant commonly characterized by J-point elevation and rapidly upsloping or normal ST segment.” ERP was originally considered a normal variant with a benign outcome. , However, in the 1980s, abnormalities of the J point were associated with idiopathic VF and sudden death in isolated case reports. In 2000, Gussak and Antzelevitch published experimental models demonstrating that under conditions predisposing to ST-segment elevation, ERP resembled Brugada syndrome (...) ) that share a pathophysiological mechanism. A Brugada pattern, for example, refers to the electrocardiographic characteristic, whereas Brugada syndrome is the disease entity that requires the presence of a type I Brugada pattern and clinical signs such as syncope or ventricular arrhythmias. ERS: Defined as occurring in patients with ERP who have survived idiopathic VF with clinical evaluation unrevealing for other explanations. Familial cases have been described and associated with rare genetic variants

2016 American Heart Association

93. A young woman with altered mental status and hypotension

blockers Here is a followup ECG: The patient had an initial troponin of 0.100 ng/mL, which could easily have been mistaken for acute coronary syndrome, but a D dimer was measured and was 2000. CTPA confirmed pulmonary emboli. The patient was NOT on a beta blocker. Learning Points: Learn the morphology of acute right heart strain vs. Wellens' T-wave inversions here: Use point of care ultrasound to confirm ECG findings of PE, OMI, etc. Posted by Pendell at Labels: , Reactions: 4 comments: excellent (...) , Pendell. thank you. when I first saw the ecg, I wondered if this might be Arrythmogenic right ventricular cardiomyopathy with the deep T waves anteriorly, and what I thought was an epsilon wave in V1. but of course I was wrong. but then I wondered : is the effect similar; i.e., a stressed, "ill" , unhappy right ventricle (stretched, strained , ischemic in the case of a pulmonary embolus. diseased myocardium in the right ventricle in ARVC. and is that why the pattern of the ECG's are similar

2019 Dr Smith's ECG Blog

94. A 40-something healthy male with transient chest squeezing

showed no WMA. First troponin was 0.042 ng/mL (elevated above 99th %-ile URL of 0.030 ng/mL). 1.5 hours later, this ECG was recorded: Still normal Several more were recorded, with no change. This was recorded at 8 hours: There is the beginning of terminal T-wave inversion in V2 . This is Wellens' syndrome, but, in Wellens', you don't always get an ECG recorded during pain as we do here. This shows that a patient with Wellens' had OMI at the time of their pain and that the T-wave inversion of Wellens (...) is identical between A and B. The artifact affects WCT and thus the changes seen in the chest leads in A are likely also artifactual, including the finding of TQRSD. It is interesting that no T wave inversion is present after NTG when the patient is pain free, considering Wellens syndrome, which is beautifully shown in the later ECGs. /Thomas @ Thomas Lindow — THANK YOU for your excellent comments! I expand upon determining which lead is most likely the source of artifact in the very next Blog post (from

2019 Dr Smith's ECG Blog

95. Do you understand these T-wave inversions?

involved in Wellens syndrome, which is simply the name given to reperfusion of anterior wall OMI when the patient is in the pain free state of reperfusion and has not yet lost the anterior wall (requires persistent R-waves to be classic Wellens syndrome). This pattern occurs in any wall of the heart, whichever wall is currently reperfused from a prior occlusion. On this note, "type A" and "type B" Wellens are useless distinctions that arose before we realized that reperfusion is a progression (...) of findings starting with terminal T-wave inversions ("type A") and progressing to full T-wave inversions ("type B"). My analogy for this misunderstanding of Wellens syndrome that I tell my residents is this: "Imagine you were an alien looking through a microscope and you discovered Earth. You zoom in to a city and look at a single street and you see humans, which happens to be a woman walking with her small child. You watch them for a few hours and then report your findings to your fellow aliens: you

2019 Dr Smith's ECG Blog

96. 15 yo AAM with ST Elevation and T-wave Inversion. Hypertrophic Cardiomyopathy or Normal ("Variant")?

(in contrast to Wellens' syndrome, in which they are V2-V4) 4. The T-wave inversion does not evolve and is generally stable over time (in contrast to Wellens', ). 5. The leads with T-wave inversion (left precordial) usually have some ST elevation 6. Right precordial leads often have ST elevation typical of classic early repolarization 7. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves 8. The T-wave inversion in leads V4-V6 is preceded by high R-wave amplitude 9. The QRS is not at all (...) adults, making it among the most common inherited cardiac disorders. It is the most common underlying cause of sudden cardiac death (SCD) in asymptomatic young individuals. The condition is easily ruled in or ruled out on echocardiography — so obtaining an Echo is clearly indicated whenever a screening ECG shows any findings potentially suggestive of HCM. That said — there will by many false positive ECGs that turn out not to be due to HCM ( increased cost of getting Echos on these subjects

2019 Dr Smith's ECG Blog

97. The Interventionalist Refuses Angiography, and even to speak to the Emergency Physician

inversion after resolution of pain (ECG 2). Looks like Wellens' in V1 only! This ECG is typical of the rare isolated right ventricular STEMI. There is also some very minimal inferior STE, with reciprocal STD in aVL, which is gone after reperfusion (ECG 2). The very narrow-based, peaked T-waves would be an unusual manifestation of MI. There is quite a bit of diffuse T-wave peaking. Hyperkalemia can result in ST elevation in V1 and V2, so one might wonder about hyperkalemia, although such ECGs really look (...) in spite of medical treatment who is having acute coronary syndrome should go emergently to the Cath Lab. This is by the recommendations of their own societies . ACC/AHA Guidelines for the management of Non ST Segment Elevation Myocardial Infarction. And this is regardless of the ECG findings ." "Moreover, in this case you have ST Elevation in V1. This is an RV infarct." I continued: "The European society of Cardiology recommends emergent and angiography for patients even with normal biomarkers if you

2019 Dr Smith's ECG Blog

98. A woman in her 70s with chest pain

of the image) of Wellens/reperfusion from Smith et al, Acute Coronary Syndromes, EM Clinics of North America 2006. The patient had an uncomplicated course after PCI and was discharged two days after the procedure. Teaching Points: In the presence of a normal QRS (in particular, in the absence of QRS abnormalities such as LBBB or LVH, t he combination of STE in V1 and STD in V5 and V6 is very specific for septal transmural ischemia. The value of repeat ECGs cannot be overstated. While the initial ECG (...) associated with ST depression in other precordial leads (in this case, V5 and V6) Anonymous Wellens syndrome? Indeed, but in this case, the occlusion EKG was recorded (the EKG during pain, with upright Ts). Subscribe to: Recommended Resources , . Dr. Stephen W. Smith is a faculty physician in the at Hennepin County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine at the . This work is licensed under a . Disclaimer Cases come from all over the world. Patient identifiers have

2019 Dr Smith's ECG Blog

99. COMPUS Expert Review Committee (CERC) – Warfarin

MSc in Health Economics at the University of York, United Kingdom. He holds a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research/ Alberta Innovates – Health Solutions. Dr. Klarenbach’s research interests are in health outcomes research and health economics research. He has conducted numerous economic evaluations and health technology assessments for both chronic and acute conditions, and has received operating grants from the Kidney Foundation of Canada (...) specializing in thrombosis. His clinical research is focused in venous thromboembolic disease and cancer, including cancer screening, prevention, and management. He holds a T2 Research Chair from the University of Ottawa on Cancer and Thrombosis. Dr. Carrier is receiving research funding from the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada. Agnes Y. Lee , MD, MSc Dr. Lee is the Director of the Thrombosis Program at the University of British Columbia

2015 CADTH - Optimal Use

100. Supraventricular Tachycardia: Guideline For the Management of Adult Patients With

. TABLE 1 Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* Page et al. JACC VOL. 67, NO. 13, 2016 2015 ACC/AHA/HRS SVT Guideline APRIL 5, 2016:e27–115 e30Individualizing Care in Patients With Associated Conditions and Comorbidities Managing patients with multiple conditions can be com- plex, especially when recommendations applicable to coexisting illnesses are discordant or interacting (8).The guidelines (...) VII) NHLBI 2003 (26) Statements Catheter ablation in children and patients with congenital heart disease PACES/HRS 2015 (in press) (27) Postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope HRS 2015 (28) Arrhythmias in adult congenital heart disease PACES/HRS 2014 (29) Catheter and surgical ablation of atrial ?brillation HRS/EHRA/ECAS 2012 (30) CPR and emergency cardiovascular care AHA 2010 (31)* *A revision to the current document is being prepared

2015 American College of Cardiology

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