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Wellens Syndrome

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141. 8 year-old with report of "syncope and an abnormal ECG".

, as the ECGs in this cohort all had T-wave inversion in V3-V6) is by far most common in African American males. Smith has studied all the EKGs in his cohort and found that: 1. There is a relatively short QT interval (QTc less than 425ms). 2. The leads with T-wave inversion often have very distinct J-waves . 3. The T-wave inversion is usually in leads V3-V6 (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. II, III, and aVF also frequently have T-wave inversion. Case Continued With respect to this specific case, the history was more consistent with a seizure: while

2017 Dr Smith's ECG Blog

142. Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble.

exam and expert interpretation. 5. This case does not demonstrate it, but a wall motion abnormality may disappear after spontaneous reperfusion ( ). 6. Patients with transient occlusion may manifest only transient STEMI on ECG. Subsequent troponins may be all negative and subsequent formal echo may be normal. . Posted by Steve Smith at Labels: , , , , Reactions: 8 comments: Alswiss This confirms that the typical Wellens-morphology do happen "only" in 15-20% of the anterior riperfusion-cases (de (...) Zwaan 1981-1989): right ? merci dr Smith ! Al Al, That would only be confirmed if I were showing a next day ECG, which I did not do here and I don't have (but maybe could find). It often takes longer for the Wellens' waves to appear, and they are also dependent on the amount of infarct. If very small, there may be no T-wave inversion, though usually when Troponin I is > 1.0 ng/mL, Wellens' waves appear. Thanks! Steve Great as always. I would say that i see hypokinesis on the anterior septum

2017 Dr Smith's ECG Blog

143. Unusual ST Elevation in V1 and V2, and LVH, in a Patient with Chest Pain

Pseudo-Wellens' due to LVH. They are recognizable. They do not rule out coronary occlusion but they leave room for careful evaluation, especially with high quality echocardiography. Often, even if you suspect PseudoSTEMI, angiogram may be the only way to be certain there is no acute coronary occlusion. However, if you are unaware of all the pseudoSTEMI patterns, you will pull the trigger on the cath lab too soon too often. In the context of an angiogram showing no obstructive coronary disease (...) and elevated troponins, only evolution of the ECG, or its absence, can establish the etiology of ECG findings that are questionable for ischemia. Other LVH PseusoSTEMI cases: This very important case posted a few days ago: posted just last week: Here is an extensive discussion of the LVH pseudoSTEMI phenomenon: PseudoWellens' due to LVH Wellens' waves are NOT equivalent to Wellens' syndrome: Pseudo-Wellens' due to LVH and HTN Posted by Steve Smith at Reactions: 10 comments: I would have thought about stemi

2017 Dr Smith's ECG Blog

144. Is it important to recognize LVH Pseudo-infarction patterns?

about MI and asked to see me at the door to assess the ECG. What do you think? I looked at it and immediately said: "This is LVH. Not MI." And so we did not place the patient in the critical care area and did not activate the cath lab. What did I see? There is indeed ST elevation, but there is T-wave inversion also, and the TWI is in V4-V6. You might think it is Wellens', but Wellens' is a syndrome , not an ECG finding. It is a syndrome in which the pain has resolved (is gone). This patient's pain (...) was still present. Furthermore , a true Wellens' ECG has T-wave inversion in V2-V4, not just V4-V6. And it should not have high voltage. While Wellens' requires R-wave preservation in the affected leads, high voltage should make you think of what I call Pseudo- Wellens pattern due to LVH. Here is a true Wellens' case, showing evolution over time, in a patient whose pain had resolved: A. First ED ECG: T-wave inversion in V2 only, Pattern A (terminal T-wave inversion) B. At 2 hours, now V2-V4, Pattern

2017 Dr Smith's ECG Blog

145. A 20-something with DKA and a regular wide complex tachycardia

ECG was recorded: Regular Wide complex tachycardia at a rate of 200. What do you think? If you're the medic, what would you do? Whenever there is a wide complex, especially in a patient with DKA, one should think of hyperkalemia (sinus rhythm, often with "invisible P-waves"). However , this rate is too fast for sinus tach and the morphology is not right for hyperkalemia. Still, calcium is harmless and it is harmless to give 3 grams of calcium gluconate. He arrived in the ED in the same condition (...) . sinus tachycardia with hidden P-waves. (With a rate this fast, and no inkling of P-waves, sinus is very unlikely but if you were not sure, you could record .) This ECG is almost certainly supraventricular tachycardia with aberrancy. Why? First: pretest probability The patient is young and without heart disease Good LV function makes VT less likely (except for ) Second: the ECG itself: 1. There is an inferior axis . The impulse originates cranially and propagates caudally. In contrast, VT, because

2017 Dr Smith's ECG Blog

146. Subtle Dynamic T-waves, Followed by LAD Occlusion and Arrest

, less than 0.010 ng/mL) She ended up doing fine and in the next few days was discharged home in good condition. Smith comment: T-wave inversion such as seen in the first ECG can be seen with active non-transmural ischemia. We usually see this sort of T-wave inversion AFTER chest pain has resolved and, in that case, it is called "Wellens' syndrome," and implies that when the patient had pain the LAD was occluded, but that it spontaneously reperfused and resulted in "reperfusion" T-wave inversion (...) the patient had only just become pain free, it would be better to get one 20 minutes later to see how the ECG changes. Thanks Although subtle — the history and clearly biphasic T waves in V2-thru-V4 of the initial ECG in this case should strongly suggest WellensSyndrome until proven otherwise. The clinical importance of WellensSyndrome is the very high correlation this type of ECG finding has with a tight LAD lesion. As emphasized by Dr. Smith — specific conditions should be established before

2017 Dr Smith's ECG Blog

147. ST-Elevation Myocardial Infarction: Guideline For the Management of

to Promote Care Coordination .e116 12. Unresolved Issues and Future Research Directions .e116 12.1. Patient Awareness .e117 12.2. Regional Systems of Care .e117 12.3. Transfer and Management of Non–High- Risk Patients After Administration of Fibrinolytic Therapy .e117 12.4. Antithrombotic Therapy .e117 12.5. Reperfusion Injury .e117 12.6. Approach to Noninfarct Artery Disease. . . .e117 12.7. Prevention of SCD .e117 12.8. Prevention of HF .e117 References .e118 Appendix 1. Author Relationships (...) With Industry and Other Entities (Relevant) .e135 Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) .e138 Appendix 3. Abbreviation List .e140 Preamble The medical profession should play a central role in evalu- ating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the bene?ts and risks of these therapies and procedures can improve the quality of care

2012 American College of Cardiology

148. Third Universal Definition of Myocardial Infarction Full Text available with Trip Pro

in clinical trials, observational studies and quality assurance programmes. These studies and programmes require a precise and consistent definition of MI. In the past, a general consensus existed for the clinical syndrome designated as MI. In studies of disease prevalence, the World Health Organization (WHO) defined MI from symptoms, ECG abnormalities and cardiac enzymes. However, the development of ever more sensitive and myocardial tissue-specific cardiac biomarkers and more sensitive imaging (...) by diaphoresis, nausea or syncope. However, these symptoms are not specific for myocardial ischaemia. Accordingly, they may be misdiagnosed and attributed to gastrointestinal, neurological, pulmonary or musculoskeletal disorders. MI may occur with atypical symptoms—such as palpitations or cardiac arrest—or even without symptoms; for example in women, the elderly, diabetics, or post-operative and critically ill patients. Careful evaluation of these patients is advised, especially when there is a rising

2012 American Heart Association

149. Management of Atrial Fibrillation

(Figure 1), especially when AF-related symptoms are also considered. > 1.3 AF NATURAL TIME COURSE AF is a naturally progressive disease except for a small proportion of patients (2- 3%), who are free of AF-promoting conditions (see section 2.1.1, page 5), may remain in paroxysmal AF over several decades. 1 AF progresses from short rare episodes, to longer and more frequent attacks (See Figure 2). With time, often years, many patients will develop sustained forms of AF. Paroxysm of AF episodes also (...) for clinical management of AF patients (Figure 1), especially when AF-related symptoms are also considered. > 1.3 AF NATURAL TIME COURSE AF is a naturally progressive disease except for a small proportion of patients (2- 3%), who are free of AF-promoting conditions (see section 2.1.1, page 5), may remain in paroxysmal AF over several decades. 1 AF progresses from short rare episodes, to longer and more frequent attacks (See Figure 2). With time, often years, many patients will develop sustained forms of AF

2012 Ministry of Health, Malaysia

150. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Full Text available with Trip Pro

and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation. The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care (...) Issues and Future Research Directions e401 12.1. Patient Awareness e401 12.2. Regional Systems of Care e401 12.3. Transfer and Management of Non–High-Risk Patients After Administration of Fibrinolytic Therapy e401 12.4. Antithrombotic Therapy e401 12.5. Reperfusion Injury e401 12.6. Approach to Noninfarct Artery Disease e401 12.7. Prevention of SCD e402 12.8. Prevention of HF e402 References e402 . Author Relationships With Industry and Other Entities (Relevant) e419 . Reviewer Relationships

2012 American Heart Association

151. 2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Full Text available with Trip Pro

for Specific Conditions e296 2.2.1. Cardiac Transplantation e297 2.2.2. Neuromuscular Diseases e297 2.2.3. Sleep Apnea Syndrome e297 2.2.4. Cardiac Sarcoidosis e297 2.3. Prevention and Termination of Arrhythmias by Pacing e298 2.3.1. Pacing to Prevent Atrial Arrhythmias e298 2.3.2. Long-QT Syndrome e298 2.3.3. Atrial Fibrillation (Dual-Site, Dual-Chamber, Alternative Pacing Sites) e299 2.4. Pacing for Hemodynamic Indications e299 2.4.1. Cardiac Resynchronization Therapy( UPDATED ) e299 2.4.2. Obstructive (...) Therapy for Secondary Prevention of Cardiac Arrest and Sustained Ventricular Tachycardia e313 3.1.2. Specific Disease States and Secondary Prevention of Cardiac Arrest or Sustained Ventricular Tachycardia e314 3.1.3. Coronary Artery Disease e314 3.1.4. Nonischemic Dilated Cardiomyopathy e314 3.1.5. Hypertrophic Cardiomyopathy e314 3.1.6. Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy e315 3.1.7. Genetic Arrhythmia Syndromes e315 3.1.8. Syncope With Inducible Sustained Ventricular

2012 American Heart Association

152. Obesity 2.0: More Than Just the Extra Weight

(1):E146-E150. Epub 2010 Nov 3. 15. Wascher TC, Lindeman JH, Sourij H, Kooistra T, Pacini G, Roden M. Chronic TNF-α neutralization does not improve insulin resistance or endothelial function in “healthy” men with metabolic syndrome. Mol Med. 2011;17(3-4):189-93. 16. Emerging Risk Factors Collaboration, Kaptoge S, Di Angelantonio E, Lowe G, et al. C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis. Lancet. 2010;375 (...) ] Of course, there is more to the problem than just expanding waistlines. Most people are also familiar with some of the major health problems associated with obesity: diabetes, cardiovascular disease, and cancer.[4] Add to those heavy hitters the sleep apnea, liver and gallbladder disease, osteoarthritis, stroke, and gynecological dysfunction, and we have a disease that affects every organ, spreading across the globe. That obesity contributes to this plethora of disease is well known, but how? What

2012 Clinical Correlations

153. Feasibility of Outpatient Closed Loop Control With the Bionic Pancreas in Cystic Fibrosis Related Diabetes

of glycemia versus usual care for adults with cystic fibrosis related diabetes. Condition or disease Intervention/treatment Phase Cystic Fibrosis-related Diabetes Device: Bionic Pancreas Other: Usual Care Not Applicable Study Design Go to Layout table for study information Study Type : Interventional (Clinical Trial) Estimated Enrollment : 129 participants Allocation: Randomized Intervention Model: Crossover Assignment Masking: None (Open Label) Primary Purpose: Treatment Official Title: Feasibility (...) intervention, or enzymatic lysis of a presumed coronary occlusion) Abnormal EKG consistent with coronary artery disease or increased risk of malignant arrhythmia including, but not limited to, evidence of active ischemia, prior myocardial infarction, proximal LAD critical stenosis (Wellen's sign), prolonged QT interval (> 440 ms). Non-specific ST segment and T wave changes are not grounds for exclusion in the absence of symptoms or history of heart disease. A reassuring evaluation by a cardiologist after

2017 Clinical Trials

154. Individualizing Automated Closed Loop Glucose Control Through Pharmacokinetic Profiling in an Insulin-Only Bionic Pancreas

, subjects will use a different rapid acting insulin analog -- Humalog, Novolog, or BC222 insulin lispro -- in a randomized cross-over order. Condition or disease Intervention/treatment Phase Type 1 Diabetes Mellitus Drug: Humalog Drug: Novolog Drug: BC222 insulin lispro Device: Bionic Pancreas Not Applicable Detailed Description: The investigators hypothesize that differences in the PK characteristics of insulin analogs will lead to differences in glycemic outcomes when delivered by the insulin-only (...) of a presumed coronary occlusion) Abnormal EKG consistent with coronary artery disease or increased risk of malignant arrhythmia including, but not limited to, evidence of active ischemia, prior myocardial infarction, proximal LAD critical stenosis (Wellen's sign), prolonged QT interval (> 440 ms). Non-specific ST segment and T wave changes are not grounds for exclusion in the absence of symptoms or history of heart disease. A reassuring evaluation by a cardiologist after an abnormal EKG finding may allow

2017 Clinical Trials

155. Efficacy of Glucagon In the Prevention of Hypoglycemia During Mild Exercise

. Condition or disease Intervention/treatment Phase Type 1 Diabetes Mellitus Device: Bihormonal Bionic Pancreas Device: Insulin Only Bionic Pancreas Drug: Glucagon Drug: Placebo Not Applicable Detailed Description: Twenty subjects will participate in two experimental periods. Each will include a 24-96 hour outpatient run-in period prior to their exercise visit wearing the bi-hormonal bionic pancreas. This will allow the bionic pancreas to adapt to their diabetes management needs. After the run-in period (...) coronary occlusion) Abnormal EKG consistent with coronary artery disease or increased risk of malignant arrhythmia including, but not limited to, evidence of active ischemia, prior myocardial infarction, proximal LAD critical stenosis (Wellen's sign), prolonged QT interval (> 440 ms). Non-specific ST segment and T wave changes are not grounds for exclusion in the absence of symptoms or history of heart disease. A reassuring evaluation by a cardiologist after an abnormal EKG finding may allow

2017 Clinical Trials

156. ECG Quiz – Answer

waves are possibly originating from the left atrium ( left atrial rhythm ). In addition there prolongation of the QT interval (note the wide and splayed T wave in aVR) and biphasic T waves in anterior leads giving a suggestion of Wellens syndrome. Wellens syndrome is indicative of tight stenosis of proximal left anterior descending coronary artery. Lateral leads show Q waves. QRS axis is a bit leftward, suggesting left anterior hemiblock. Share this: Related Related Posts | Apr 23, 2012 | Dec 18 (...) ECG Quiz – Answer ECG Quiz – Answer – All About Cardiovascular System and Disorders Now Trending: | April 26, 2018 | , | ECG Quiz – Answer Important findings and diagnosis First beat in the rhythm strip is a sinus and so is the fourth beat as well as the last beat, with upright P waves and a normal PR interval. These are sinus beats. 2nd, 3rd, 5th, 6th and 7th beat have inverted P waves with a shorter PR interval. These beats have inverted P waves in other inferior leads as well V4-V6. These P

2018 Cardiophile MD blog

157. Management of recent-onset atrial fibrillation and flutter in the emergency department

, pulmonary embolism or other pulmonary diseases, hyperthyroidism, and other metabolic disorders. In such cases, successful treatment of the underlying condition may promote the resolution of AF. Routine chemistry and hematology are indicated as well as, in some cases, troponin and thyroid-stimulating hormone levels. Transesophageal echocardiography, if available, is useful to exclude the presence of left atrial clot in patients in whom the onset of arrhythmia is unclear and cardioversion is desired (...) control for stable patients with known onset of AF/AFL within 48 hours. Both approaches are presented here. The decision regarding the initial strategy of rate versus rhythm control depends upon multiple factors including patient and physician preference, clarity of the history of onset of symptoms, type and duration of AF, severity of symptoms, associated cardiovascular disease and medical conditions, and age. Figure 1 A management strategy for patients with recent-onset AF/AFL. | Recommendation We

2010 CPG Infobase

158. Early Repolarization: Not as Innocent as Once Thought!

, the practitioner should rule out all more commonly studied ischemic and non-ischemic causes, including, but not limited to, the long-QT syndrome, the short-QT syndrome, the Brugada syndrome, and arrhythmogenic right ventricular dysplasia (i). Once these conditions have been excluded, it can be implied that the inferolateral J point elevation which represents early repolarization in an area with increased current density is what predisposed to the event. As such, these studies presented above suggest (...) the prevalence of early repolarization and evaluate its potential relationship with any observed arrhythmias, as monitored by implantable defibrillators. In the study, early repolarization prevalence was compared between case subjects who had previously experienced an episode of IVF prior to the study and control subjects with no known heart disease. Early repolarization occurred statistically more frequently in the case subjects with IVF than the control subjects (31% vs. 5%, P<0.001). Furthermore

2011 Clinical Correlations

159. Right Precordial T-wave Inversion

must not be measured in V2 or V3. The QT as measured in other leads is about 420 ms, with a preceding RR of 1500ms, resulting in a Bazett corrected QT interval of 345 ms . This short QT at least makes ischemia all but impossible. ERP is, of course, associated with an increased long term risk of sudden death, but only marginally and only if in inferior or lateral locations : In addition, many readers of this Facebook post were worried about ischemia , including Wellen's syndrome ("What (...) that some have tried to restrict its use to the syndrome of J-waves and QRS slurring/notching which predicts a higher long term risk of sudden death. For the purposes of STEMI mimics, which is an entirly different context "early repolarization" remains in widespread usage. And indeed, patients with normal variant ST elevation in leads V2-V4 do have short QT intervals due to rapid repolarization! As for the QT interval, there are many correction formulas, none work very good, and the only way to actually

2016 Dr Smith's ECG Blog

160. Syncope Several Times, Complete Heart Block, And a Surprise ECG in the ED!

. Transient STEMI is usually due to brief thrombotic occlusion that then lyses. This occlusion happened several times. The first time it did not result in chest pain but did result in complete heart block. In Acute Coronary Syndrome, a thrombotic event, a culprit is not always found. And the coronary disease may be mild in such cases: the thrombosis just happens at a minimally stenotic, but vulnerable lesion. It is even possible to have thrombosis with a completely normal angiogram, though in less than 1 (...) to make that less likely." He thought it might be vasospasm of two different coronary arteries. ECG 7. At 0428 the burning persisted and this was recorded: Now they are inferior again!! 7 minutes later the burning was gone and this ECG was recorded at 0435: All STE has resolved again. The Cath Lab was activated. Here is the last ECG before he left for the cath lab at 0449: There are now inferior reperfusion T-waves (inferior Wellens' waves!) This supports some degree of infarction. The troponin

2016 Dr Smith's ECG Blog

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