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Dan's Soapbox 1 - What's Hot in EM

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Dan's Soapbox 1 - What's Hot in EM

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Dan's Soapbox 1 - What's Hot in EM

  1. 1. Dan’s Soapbox 1 What’s hot in EM?
  2. 2. Dr Smith’s ECG Blog
  3. 3. 58 year old man, intermittent chest pain for 2 weeks
  4. 4. Pain settled spontaneously. Serial Troponins negative
  5. 5. ST elevation Vs early repolarisation • Benign early repolarisation – Widespread concave ST elevation ST – Most commonly V2 – V5 – Notching is common at J point – Rare > 50 years – ST elevation is usually less than 2mm in precordial leads, but can be more – < 0.5mm in limb leads – No reciprical ST segment changes – Normal R wave progression – Changes are relatively stable
  6. 6. Repeat ECG 12 hours later!!!
  7. 7. How good is it? • Retrospective review • Subtle anterior STEMI admitted to cardiology with proven LAD occlusion Vs ED coded non cardiac chest pain with BER • Mathematical formula comparing: – Height of ST elevation – QTc interval – R wave progression • Actual calculation – (1.196 x ST-segment elevation 60 ms after the J point in lead V3 in mm) + (0.059 x QTc in ms) - (0.326 x R-wave amplitude in lead V4 in mm)
  8. 8. Seems Complicated? • The greater the ST elevation  more likely to be STEMI • The longer the QTC  more likely to be STEMI • Poor R wave progression (small R wave in V4)  more likely to be a STEMI – A value of >23.4 was found to predict STEMI – </= 23.4 predicted early repolarization • Sensitivity 86% • Specificity 91%
  9. 9. Learning Points • Significant LAD occlusion with dynamic ECG changes can still have negative high sensitivity troponins • Don’t wait 12 hours for repeat ECG if any concerns • Try to learn some features that suggest BEP: – Widespread concave ST elevation ST – Most commonly V2 – V5 – Notching is common at J point – Rare > 50 years – ST elevation is usually: • less than 2mm in precordial leads (but can be more!) • < 0.5mm in limb leads – No reciprical ST segment changes – Normal R wave progression – Changes are relatively stable • Download SubtleSTEMI and give it a try
  10. 10. PESIT TRIAL
  11. 11. PESIT • Cross sectional multi-centre study • All patients with 1st episode syncope admitted from ED • All then got D dimer testing and Wells score • Negative D dimer and PE unlikey wells score  testing stopped • +ve D dimer or PE likely Wells score  CTPA or Ventilation Perfusion Scan
  12. 12. PESIT • 2584 patients presented to ED with syncope • 717 (27.7%) patients admitted • Of these 157 excluded • 560 patients included in study • > 75% over 70 years old • 58.9% had PE ruled out on Well’s score / D dimer • 17.3% had diagnosed PE
  13. 13. Clot Burden – 41.7% Main Pulmonary artery – 25% Lobar Artery – 26.4% Segmental Artery – 6.9% Subsegmental Artery
  14. 14. Discussion
  15. 15. Discussion • 1/6 pick up rate of PE for syncope sounds high • Remember that lots of people were sent home – so actually < 4% of patients presenting with syncope to ED • PE was much more likely if: – Tachopnoea – Tachycardiac – Hypotensive – Clinical signs of DVT – Active cancer • You would hope we would expect PE in syncope ?cause if any of these features • Did finding the PE also find the cause of syncope? – 26% segmental, 7% subsegemental – Much debate about the relevance of diagnosing these • False +ve rate high • clinical significance of diagnosis uncertain
  16. 16. References • http://hqmeded-ecg.blogspot.com.au/2017/02/chest- pain-st-elevation-and-negative.html • http://lifeinthefastlane.com/ecg-library/benign-early- repolarisation/ • http://www.emdocs.net/ber-vs-anterior-stemi/ • http://www.annemergmed.com/article/S0196- 0644(12)00160-6/pdf • http://heart.bmj.com/content/94/12/1620.full • http://sinaiem.org/clot-or-not-what-are-we-going-to- do-about-pesit/

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