Oxygen supply in STEMI patients

Do you supply oxygen rutine for all STEMI patients?

Oxygen is indicated in patients with hypoxaemia
(SaO2 < 90% or PaO2 < 60 mmHg).

Routine oxygen is not recommended in
patients with SaO2  > 90%.

Post CABG MI

We know that during the CABG the cardiomyocytes are getting damaged. So after CABG the Cardiac troponin could be positive. How we will know that is it infarction secondary to CABG or not?

ABNORMAL Q WAVE (IN ≥ 2 CONTIGUOUS LEADS)

Dont search Q wave in V1



V2-V3: 

QS or Q duration ≥ 20 ms

I-II-aVL-aVF
V4-V5-V6
V7-V8-V9

QS or
Q ≥ 30 ms and > 1 mm

Accessory pathways (AP)

• Some people are born with an extra piece of heart muscle tissue [1]
• That connects directly between the atria and the ventricles, bypassing the AV node altogether[1]
• This abnormal piece of muscle is referred to as a bypass tract or an accessory pathway [1]

1. Kent - WPW [ delta wave, PQ<0.12 ] [LA-RA or RA-RV]
2. James - LGL [ no delta wave, PQ<0.12 ] [ LA-Hiss ]
3. Mahaim - [ small delta wave ] [ Hiss - V ]

• Accessory pathways (AP) typical, atypical, non-evident. [3]
• Typical
• Left sided (Left atrium - left ventricle)
• ECG changes (PR < 0.12 and pre-excitated wide QRS) [3]
• delta wave - manifest
• Atypical 
• Right sided(right atrium - right ventricle)
• ECG changes (PR > 0.12 and normal or pre-excitated wide QRS) [3]
• Non-evident - ECG normal [3]
• interatrial conduction delays (enlarged or diseased atria) [3]
• accessory pathway conduction delay (Ebstein anomaly, atriofasicular track etc.) [3]
• anterograd directed conduction. ECG changes (normal PR and normal QRS) [3]
• no delta wave - concealed
• if there is delta wave then it called manifes, else concealed.
• WPW Type A
• 
• WPW Type B
• 

• 

References

1. Wolff-Parkinson-White Syndrome and Accessory Pathways James Kulig, Bruce A. Koplan. Circulation 2010
2. Basic of Pre-excitation syndrome, Leonardo Paskah. Slideshare
3. The Esc Textbook of cardiovascular medicine, 2nd edition. page 1061.

Myocardial infarction and complete heart block

• Inferior MI
• a block above the bifurcation [1]
• Complete Heart Block (III AV block) is transitory [1]
• dont require pacing [1]
• the patients had no Stokes-Adams attacks** [1]
• Pacemakers generally should not be implanted with inferior MI if the peri-infarctional AV block is expected to resolve or is not expected to negatively affect long-term prognosis [2]
• Anteroseptal myocardial infarction
• a bilateral bundle branch block (below the bifurcation) [1]
• severe Stokes-Adams attacks [1]
• require pacing [1]

**Stokes Adams attack: Sudden collapse into unconsciousness due to a disorder of heart rhythm

References

1. Can Med Assoc J. 1970 Apr 11; 102(7): 705–708. Myocardial Infarction and Complete Heart Block J. F. Lopez, M. Mori, and B. L. Baltzan
2. ACC/AHA/HR, Guidedline Device-Based Therapy of Cardiac Rhythm Abnormalities

Hiatal Hernia and Heart

• hiatal hernia occurs when the upper part of your stomach bulges through the large muscle separating your abdomen and chest (diaphragm) [1]
• Hiatus hernia can present as acute chest pain [3]
• In echocardiography Hiatal Hernia Masquerading as Left Atrial Mass [2]
• 
• after drinking carbonated solution echo-free space replaced the mass in left atrium [2]
• 
• Youtube video
• Another example image
•  [3]
•  [4]
• Discussion and recommendations: [4]
• various origin can impress the left atrium
• These structures generally grow slowly
• When a structure behind the left atrium is diagnosed using TTE
• additional CT scan can give a more comprehensive view

References

1. Mayo Clinic, Hiatal Hernia
2. Hiatal Hernia Masquerading as Left Atrial Mass, Circulation 1996
3. Echocardiographic manifestation of hiatus hernia simulating a left atrial mass: Case report. Cardiovasc Ultrasound. 2008; 
4. Left atrial impression: a sign of extra-cardiac pathology Johan M. van Rooijen Lambert F.M. van den Merkhof European Journal of Echocardiography, Volume 9, Issue 5, 1 September 2008, Pages 661–664

Lyme disease, Lyme cardit, Reversible complete heart block

• Lyme disease also known as "Lyme borreliosis" [1]
• Lyme disease is a systemic illness caused by the spirochete Borrelia burgdorferi [3]
• caused by bacteria of the Borrelia type which is spread by ticks [1]
• The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans [1]
  
• Blood test - Screening Lyme serology - positive [2]
• Lyme carditis is a complication of Lyme disease [3]
• The Lyme bacterium can infect all parts of the heart, including the conduction system around the atrioventricular node, the outer or inner membranes of the heart, the cardiac muscle [4]
• impairment of conduction system cause heart block [ 1st degree, 2nd degree and complete heart block]
• Ceftriaxone started after 24 hours rash is resolved [2]
• After 48 hours of observation, he underwent a temporary VVI (ventricular pacing and sensing mode) pacemaker insertion [2]
• On ceftriaxone, the AV block converted to first degree 2 days after starting antibiotics and then completely resolved by day 11, at which point the pacemaker was removed [2]
• He completed a total 21-day course of treatment with oral doxycycline [2]

References

1. Lyme disease - Wikipedia
2. Case of Reversible Complete Heart Block - The American Journal of Medicine, Vol 130, No 8, August 2017
3. Lyme carditis with complete heart block: management with an external pacemaker, Muhammad Ali Chaudhry. Pubmed
4. Lyme Disease and the Heart. - Peter J. Krause, Linda K. Bockenstedt. Circulation, 2013