ECG Guru - Instructor Resources - IWMI https://www.ecgguru.com/ecg/iwmi en Inferior Posterior M.I. https://www.ecgguru.com/ecg/inferior-posterior-mi-1 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-posterior-mi-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/111222%20IWMI%20Ed%20ON%20GURU.jpg" width="1291" height="620" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This is a "classic" ECG of very good quality for you to use in a classroom setting.</p><p><strong>The Patient:</strong>&nbsp; A 57-year-old man who complains of a sudden onset of "sharp" chest pain while on a long bike ride.&nbsp; The pain does not radiate, and nothing makes it worse or better.&nbsp; He is pale, cool, and diaphoretic.&nbsp; His medical history is unknown.</p><p><strong>The ECG:</strong>&nbsp; This ECG could be considered "classic" for an inferior wall ST elevation M.I. caused by occlusion of the right coronary artery.&nbsp; ECG findings include:</p><p>*&nbsp; &nbsp;Normal sinus rhythm</p><p>*&nbsp; &nbsp;Marked ST elevation in Leads II, III, and aVF.&nbsp; The elevation is higher in Lead III than in Lead II, a reliable sign of RCA occlusion.</p><p>*&nbsp; &nbsp;Reciprocal depression in Leads aVL and I.&nbsp; ST depression in the setting of acute transmural ischemia (STEMI) is almost ALWAYS due to&nbsp; reciprocal change. The fact that this STD is localized to leads that are reciprocal to the inferior wall is proof of the nature of the STD.</p><p>*&nbsp; &nbsp;Reciprocal depression in V1 - V3.&nbsp; More localized depression.&nbsp; What wall is reciprocal to the anterior-septal wall?&nbsp; The posterior (postero-lateral).&nbsp; Since the inferior wall is really the lower part of the posterior wall, inferior wall M.I. is often accompanied by posterior wall M.I.</p><p>An additional lead, V4R, is helpful in this situation, since the right ventricle is often affected in RCA occlusions.&nbsp; The EMS crew reports that V4R was negative for ST elevation, but we do not have a copy.</p><p>Small q waves have formed in Lead III, and we would watch for progression of this sign, as it can indicate necrosis.</p><p><strong>Outcome:</strong>&nbsp; The patient went to the cath lab, but we have no further followup.</p><p>&nbsp;</p><p>Our thanks to Ashley Terrana for donating this tracing.</p><p>&nbsp;</p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/618/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Posterior M.I. 1/5</option><option value="40">Give Inferior Posterior M.I. 2/5</option><option value="60">Give Inferior Posterior M.I. 3/5</option><option value="80" selected="selected">Give Inferior Posterior M.I. 4/5</option><option value="100">Give Inferior Posterior M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-TGj5nDhDXlK4tKTaa4awaZQ7hsy2cn2C9PwBVe_ayEo" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div><div class="field-item odd"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/inferior-posterior-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-posterior M.I.</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-posterior-mi-1&amp;title=Inferior%20Posterior%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Mon, 24 Jul 2023 20:41:39 +0000 Dawn 850 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-posterior-mi-1#comments Large Anterior Wall M.I. and Effect of Lead Reversal https://www.ecgguru.com/ecg/large-anterior-wall-mi-and-effect-lead-reversal <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/large-anterior-wall-mi-and-effect-lead-reversal"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Prox%20LAD%20MI%201%20edit.jpg" width="2227" height="1287" alt="" /></a></div><div class="field-item odd"><a href="/ecg/large-anterior-wall-mi-and-effect-lead-reversal"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Prox%20LAD%20MI%202_0.jpg" width="1860" height="1230" alt="" /></a></div><div class="field-item even"><a href="/ecg/large-anterior-wall-mi-and-effect-lead-reversal"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Cath%20lab%20photos%20before%20and%20after_0.jpg" width="1601" height="738" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong>EDIT: Please refer to the comments below this text. The second ECG in this series shows unexpected QRS and ST-T morphology changes, which I tried to explain by way of the patient's long anterior descending coronary artery. However, Dave Richley, who is a very well-known cardiac physiologist and ECG Guru took the time to analyze these morphologies and realize they can be explained by an inadvertent ECG LEAD MISPLACEMENT. This patient does have a proximal lesion of the LAD, proven and repaired in the cath lab. But the inferior wall does not have the injury it appears to have in this second ECG. Thanks to Dave for reminding us to slow down and look closely when things don't look "right".</strong></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">These two ECGs, taken 26 minutes apart, were obtained from a 50-year-old man who complained of sudden onset of chest pain.<span style="mso-spacerun: yes;">&nbsp; </span>He denied history of coronary artery disease. He was Covid-positive, and the rest of his medical history was unremarkable.</span></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">ECG No. 1:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 10.0pt; line-height: 107%;">This ECG was obtained by paramedics enroute to the hospital.<span style="mso-spacerun: yes;">&nbsp; </span>For your beginner-level students, it will be easy to demonstrate the large ST elevations in V3 through V6. The machine’s measurements at the bottom confirm that this ECG meets any field criteria for ST elevation M.I. “STEMI”.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">But there is so much more to see! Taking a methodical approach, and starting with rate and rhythm, we see <strong>sinus bradycardia </strong>at 57 bpm. Intervals and frontal plane axis are within normal limits. R wave progression in the chest leads is stalled in V1- V3 due to loss of initial r waves (narrow QS). The transition to positive deflections in V4 – V6 is abrupt.<span style="mso-spacerun: yes;">&nbsp; </span>These q waves in the V1 and V2 appear narrow, but V3 appears to have a Q wave that is almost wide enough to be considered pathological.<span style="mso-spacerun: yes;">&nbsp; </span>Narrow Q waves may be a transient sign of injury, while wide ones (&gt;40 ms) are an ECG sign of necrosis. </span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">A very visible finding on this ECG is the <strong><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500486/">hyperacute T waves</a></strong>. Hyperacute T waves are defined by comparison to the patient’s normal T waves, if possible. But a general description is broad-based, symmetrical T waves that are unusually tall in comparison to the QRS complex and to the patient’s previous T waves. In this tracing, we see hyperacute T waves in just about all leads.<span style="mso-spacerun: yes;">&nbsp; </span>Hyperacute T waves are a very early sign of subendocardial ischemia in a patient with coronary artery occlusion, and the sign doesn’t last long.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">This patient is already progressing to the next ECG stage of ischemia and injury:<span style="mso-spacerun: yes;">&nbsp; </span><strong>ST segment elevation</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>There is elevation in V2 through V6, I and aVL, and very slightly in Leads II and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>In addition to this J point elevation, many ST segments have a flat, horizontal shape, which is an abnormal sign, indicative of ischemia. Leads III and aVF are good examples of this abnormal ST segment shape.<span style="mso-spacerun: yes;">&nbsp;</span></span><span style="font-size: 10pt;">V1 has </span>an inverted T wave<span style="font-size: 10pt;">.</span><span style="mso-spacerun: yes;">&nbsp; V2 shows the T wave transition to upright.&nbsp;&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 13.3333px;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">ECG No. 2:</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">This ECG was taken in the Emergency Department, 26 minutes after the first one.<span style="mso-spacerun: yes;">&nbsp; </span>The rate and intervals have not changed much.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS duration has lengthened by .04 seconds, the QTc has prolonged by 26 ms.<span style="mso-spacerun: yes;">&nbsp; </span>The axis has shifted slightly to the left, but still within normal limits.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Leads II, III, and aVF (inferior wall) have lost voltage and gained quite noticeable ST segment elevation.<span style="mso-spacerun: yes;">&nbsp; </span>Lead III has a narrow Q wave and biphasic T wave, which are new developments.<span style="mso-spacerun: yes;">&nbsp; </span>Leads I and aVL are now so influenced by the STE in the inferior wall, they show ST depression, which is reciprocal to the elevation in the inferior leads.&nbsp;<span style="mso-spacerun: yes;">&nbsp;</span>It has obliterated the ST elevation in those leads, but we remember it is there!</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Lead V1 has developed concave-down elevation (the “frown”), and has a narrow Q wave.<span style="mso-spacerun: yes;">&nbsp; </span>V2 and V3 have enhanced ST elevation, and the Q waves in those leads have widened to greater than 40 ms. <span style="mso-spacerun: yes;">&nbsp;</span>Leads V5 and V6 have less ST elevation, possibly influenced by simultaneous reciprocal ST depression.<span style="mso-spacerun: yes;">&nbsp; </span>We can say that this M.I. has definitely progressed, and it is <strong>VERY large</strong>.</span></p><p class="MsoNormal"><strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">Follow Up:</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">The patient was taken very quickly to the cath lab, where it was found that he had a proximal LAD occlusion from a fresh clot.<span style="mso-spacerun: yes;">&nbsp; </span>The other arteries showed no signs of CAD.<span style="mso-spacerun: yes;">&nbsp; </span>You might be thinking, “that explains the changes in the chest leads (anterior wall), but how is the inferior wall involved in this M.I.?”<span style="mso-spacerun: yes;">&nbsp; </span>This patient is one of the many people (up to 79% of the population) who has a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528515/">wrap-around LAD</a>.<span style="mso-spacerun: yes;">&nbsp; </span>That is, it perfuses the apex of the left ventricle.<span style="mso-spacerun: yes;">&nbsp; </span>Approximately one fourth of the population has an LAD that wraps around <strong>more than one fourth</strong> of the inferior wall. This type of LAD predicts additional risk of adverse clinical outcomes for M.I. patients because of the large amount of territory covered by this wrap-around artery.<span style="mso-spacerun: yes;">&nbsp; </span>The patient arrived in the cath lab before his troponin levels went up, and had a successful procedure.<span style="mso-spacerun: yes;">&nbsp; </span>He is lost to follow up after that.<span style="mso-spacerun: yes;">&nbsp;&nbsp;</span></span></p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/618/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Large Anterior Wall M.I. and Effect of Lead Reversal 1/5</option><option value="40">Give Large Anterior Wall M.I. and Effect of Lead Reversal 2/5</option><option value="60">Give Large Anterior Wall M.I. and Effect of Lead Reversal 3/5</option><option value="80" selected="selected">Give Large Anterior Wall M.I. and Effect of Lead Reversal 4/5</option><option value="100">Give Large Anterior Wall M.I. and Effect of Lead Reversal 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.1</span></span> <span class="total-votes">(<span >67</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-Icqr0H2TZ71arRFPOxsd5NAubS3ovkRWcR7JKBLhiQw" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/lead-reversal" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Lead reversal</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/awmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">AWMI</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div><div class="field-item even"><a href="/ecg/lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Lateral M.I.</a></div><div class="field-item odd"><a href="/ecg/anterior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior M.I.</a></div><div class="field-item even"><a href="/ecg/proximal-occlusion-lad" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Proximal occlusion of LAD</a></div><div class="field-item odd"><a href="/ecg/hyperacute-t-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperacute T waves</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Flarge-anterior-wall-mi-and-effect-lead-reversal&amp;title=Large%20Anterior%20Wall%20M.I.%20and%20Effect%20of%20Lead%20Reversal%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 23 May 2022 21:52:02 +0000 Dawn 814 at https://www.ecgguru.com https://www.ecgguru.com/ecg/large-anterior-wall-mi-and-effect-lead-reversal#comments Inferior Wall M.I. With Wide QRS and Complete AV Block https://www.ecgguru.com/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%20LBBB%20101_0.jpg" width="1800" height="802" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWMI%20WC%20101%20Follow%20up%20post%20cath.jpg" width="453" height="132" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p><span style="font-size: 13.008px;">This ECG is from a 66-year-old woman who called 911 for a complaint of chest pain for the past four hours. She also complained of nausea, vomiting, and diarrhea for that time.</span><span style="font-size: 13.008px;">&nbsp;She was pale and diaphoretic, and her BP was 77/43 sitting up, improving to 90/54 reclining.&nbsp;</span><span style="font-size: 13.008px;">She denied “cardiac” history.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">Her medications included:</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">aspirin, an SSRI, cilostazol, amlodipine, umeclidinium and vilanterol inhaler, atorvastatin, levothyroid, and metoprolol. We don’t have a previous ECG.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">The EMS crew followed their chest pain protocol and delivered the patient to a facility with an interventional cath lab, but they did not designate a “STEMI Alert” because of the wide QRS.</span><span style="font-size: 13.008px;">&nbsp; </span><span style="font-size: 13.008px;">It is their protocol to use the term “STEMI Alert” only when no M.I. mimics, such as left bundle branch block, are present.</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal"><strong>What does this ECG show? &nbsp;&nbsp;&nbsp;&nbsp;</strong>There is an underlying sinus rhythm at 75 bpm.&nbsp; There is AV dissociation, with regular, wide QRS complexes at a rate of 44 bpm.&nbsp; &nbsp;This meets the criteria for complete heart block (third-degree AV block).&nbsp; The morphology of the QRS complexes meets the criteria for left bundle branch block (wide, upright in Leads I and V6, negative in V1).&nbsp; At a rate of 44 bpm, several options for this escape rhythm are possible:&nbsp; 1)&nbsp; junctional escape with LBBB, 2) junctional escape with intraventricular conduction delay due to AMI,&nbsp; and 3) idioventricular escape rhythm.&nbsp; &nbsp;Also, in the presence of IWMI, AV node ischemia is very likely, resulting in AV blocks at the level of the AV node. &nbsp;CHB at the AV node would result in junctional escape rhythm, and CHB below that, in the fascicles of the bundle branches, would result in idioventricular escape. The issue for this patient, and ANY patient, is cardiac output, and we see several reasons for cardiac output to be lower:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Wide QRS</strong></p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Slow rate</strong></p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><strong>Lack of P waves preceding every QRS (loss of atrial kick).</strong></p><p class="MsoNormal">In the EMS setting, it really doesn’t matter if the escape rhythm is junctional with wide QRS or ventricular. &nbsp;The patient's hemodynamic status is the important consideration.</p><p class="MsoNormal"><strong>Even more alarming, </strong>this ECG shows signs of acute inferior wall M.I.&nbsp; It can be difficult to ascertain when STEMI is present in the presence of wide-complex rhythms.&nbsp; That is because most wide-complex rhythms have <em>discordant ST and T wave changes.</em>&nbsp; That is, whenever the wide QRS is positive, there is ST depression and T wave inversion, and whenever the wide QRS is negative, there is ST elevation and upright T waves.</p><p class="MsoNormal">This ECG shows excessively elevated discordant ST segments in the inferior leads (II, III, and aVF.)&nbsp; We also see <em>excessively discordant&nbsp;</em>ST elevation in V3, and V4. The change from ST depression to ST elevation between V2 and V3 is very abrupt, with the obvious ST depression in V1 and V2 indicating reciprocal views of ST elevation on the posterior wall. &nbsp;In LBBB without STEMI, there is normally ST elevation in V1 a V3.</p><p class="MsoNormal"><strong>Sgarbossa and Smith</strong>&nbsp;&nbsp;&nbsp; In 1996, Sgarbossa, et al proposed a univariate scoring system for determining acute M.I. in the presence of LBBB.&nbsp; <a href="https://lifeinthefastlane.com/ecg-library/basics/sgarbossa/">Sgarbossa’s Criteria</a> has been used for with some success both in the presence of LBBB and ventricular paced rhythms.&nbsp; These criteria were formulated before results could be confirmed with cath lab results.&nbsp; In this decade, Dr. Steven Smith and his colleagues have proposed some <a href="https://vimeo.com/34634434">modifications to Sgarbossa’s Criteria</a> which take into account the ratio of ST alteration to R wave. In Smith’s Modification, excessive discordance is measured as discordant ST elevation when the j point is &gt; 0.25, or 25% the depth of the S wave. &nbsp;His results have been, and continue to be, measured against cath lab findings, and are more accurate than the original criteria. &nbsp;For an excellent discussion of LBBB, Sgarbossa’s Criteria, and Smith’s modified Sgarbossa criteria, we recommend Tom’s Bouthillet’s excellent <a href="https://www.ecgmedicaltraining.com/making-sense-of-sgarbossas-criteria-chest-pain-and-left-bundle-branch-block-part-1/">three-part series</a> on the topic.</p><p class="MsoNormal">With the exception of right bundle branch block, most wide-QRS conditions are considered “mimics” of acute M.I., and can both disguise the presence of an M.I. and masquerade as M.I.&nbsp; Unfortunately, the mimics do not <em>prevent</em> the patient from having an M.I.</p><p class="MsoNormal"><strong>How did this patient do?&nbsp;&nbsp; </strong>The infero-lateral M.I. was recognized in the emergency department, and the patient’s hypotension was treated with pacing and fluids. She was sent immediately to the cath lab, where it was found that she had a single-vessel lesion in the proximal to mid right coronary artery. There was 100% occlusion with TIMI-0 flow. She underwent angioplasty and stent placement, with excellent TIMI-III results.&nbsp;<span style="font-size: 13.008px;">&nbsp;The RCA was dominant, and much larger than the LCA. The second ECG shows the excellent results of the angioplasty - QRS is narrow, the rhythm is sinus, and ST segments returning to normal. The tiny Q wave in Lead III eventually disappeared, probably because it was due to right ventricular M.I.</span></p><p class="MsoNormal">This crew felt they were following their protocol in not calling this a “STEMI Alert”, but fortunately they were able to transport the patient to a full-service cardiac hospital, where she received angioplasty very quickly.&nbsp;<strong></strong></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/618/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 1/5</option><option value="40">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 2/5</option><option value="60">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 3/5</option><option value="80">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 4/5</option><option value="100" selected="selected">Give Inferior Wall M.I. With Wide QRS and Complete AV Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.2</span></span> <span class="total-votes">(<span >5</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-Y5kPgB4dojtyj96IviAAKHSu0JUwI3Y5t6MjHItHDUU" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior M.I.</a></div><div class="field-item odd"><a href="/ecg/intraventricular-conduction-delay" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Intraventricular conduction delay</a></div><div class="field-item even"><a href="/ecg/third-degree-av-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Third-degree AV block</a></div><div class="field-item odd"><a href="/ecg/complete-heart-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete heart block</a></div><div class="field-item even"><a href="/ecg/complete-av-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Complete AV block</a></div><div class="field-item odd"><a href="/ecg/inferior-lateral-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior-lateral M.I.</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-mi-wide-qrs-and-complete-av-block&amp;title=Inferior%20Wall%20M.I.%20With%20Wide%20QRS%20and%20Complete%20AV%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 28 Jun 2017 20:13:14 +0000 Dawn 733 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-wide-qrs-and-complete-av-block#comments Inferior Wall M.I. https://www.ecgguru.com/ecg/inferior-wall-mi-2 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-2"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW119.jpg" width="1800" height="883" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" align="left">This ECG shows a common manifestation with inferior wall M.I., BRADYCARDIA.&nbsp; We see the signs of acute inferior wall M.I. in the inferior leads:&nbsp; II, III, and aVF all have ST segment elevation.&nbsp; There almost appear to be pathological Q waves in Leads III and aVF.&nbsp; There are still VERY tiny r waves, and the downward deflections are not wide, but should full-blown Q waves develop in these leads, they would signify necrosis in the area.&nbsp; A repeat ECG would certainly be warranted.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">Another sign that there is an inferior wall STEMI is the ST segment depression in Leads I and aVL, which are reciprocal to Lead III.&nbsp; ST depression can have many meanings, but when it is <strong>localized</strong> in the leads which are opposite ST elevation, it is reciprocal.&nbsp; There is also ST depression in Leads V1 and V2.&nbsp; These leads are reciprocal to the POSTERIOR wall, otherwise known as the upper part of the inferior wall.&nbsp; If an inferior wall M.I. is large enough, it can produce ST elevation in the posterior leads (not performed in this case), and ST depression in the anterior leads, especially V1, V2, and V3.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">The rhythm is a marked sinus bradycardia, at just under 40 beats per minute.&nbsp; Sinus bradycardia is very common in inferior wall M.I., because the inferior wall and the sinus node are usually both supplied by the right coronary artery.&nbsp; AV blocks can also occur because the AV node is also supplied by the RCA in most people.<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p class="MsoNormal" align="left">It is important to remember that bradycardia does not always need to be treated.&nbsp; In patients with acute M.I., a well-tolerated bradycardia may actually be beneficial to the injured heart, reducing supply/demand ischemia.&nbsp; A well-tolerated bradycardia is a rate that does not produce low blood pressure and poor peripheral perfusion.&nbsp; Some people tolerate rates in the 40’s quite well.&nbsp; If the patient shows signs of poor perfusion: low BP, decreased mentation, pallor, shortness of breath, the rate should be cautiously increased with medication or electronic pacing.&nbsp;<span style="font-size: 13.008px; line-height: 1.538em;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal" align="left">Patients who present with acute inferior wall M.I. should be screened for right ventricular M.I.&nbsp; Right-sided chest leads, especially V3 through V6 can reliably detect right ventricular M.I.&nbsp; Other signs which may or may not be present, and have less accuracy, are:&nbsp; Lead III with higher ST elevation than Lead II, aVL with ST depression of 1 mm or more, and ST elevation in V1 on the 12-Lead ECG. &nbsp;For more about the prognostic implications and treatment of RVMI, we refer you to <a href="http://www.consultant360.com/content/inferior-myocardial-infarction-right-ventricular-involvement">Drs. Wang and Poponick.</a></p><p class="MsoNormal" align="left">For a more detailed look at this ECG, and a thorough discussion of inferior wall M.I. ECG changes, please refer to the comment below from our Consulting Expert, Dr. Ken Grauer, MD.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/618/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Wall M.I. 1/5</option><option value="40">Give Inferior Wall M.I. 2/5</option><option value="60">Give Inferior Wall M.I. 3/5</option><option value="80" selected="selected">Give Inferior Wall M.I. 4/5</option><option value="100">Give Inferior Wall M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.6</span></span> <span class="total-votes">(<span >5</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-SIe61PvBbm4uHP1kJPe3VWVAyzXdwpPubd5ZOIE0ZkE" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div><div class="field-item even"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/sinus-bradycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus bradycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-mi-2&amp;title=Inferior%20Wall%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Tue, 17 Nov 2015 20:38:04 +0000 Dawn 677 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-2#comments Inferior Wall M.I. and Right Bundle Branch Block https://www.ecgguru.com/ecg/inferior-wall-mi-and-right-bundle-branch-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-and-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWRBBB%20100.jpg" width="1800" height="1406" alt="" /></a></div><div class="field-item odd"><a href="/ecg/inferior-wall-mi-and-right-bundle-branch-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IWRBBB%20100%20detail.jpg" width="200" height="225" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This ECG shows two obvious abnormalities, right bundle branch block AND inferior wall M.I. &nbsp;It is also a good teaching example of how the terminal wave of RBBB can be mistaken for the ST elevation of M.I.</p><p>First, check this ECG to see if it meets the criteria for right bundle branch block:</p><p>1) &nbsp;<strong>The QRS will be wide. That is, it will be greater than or equal to .12 seconds (120 ms).</strong> &nbsp;In this case, the QRS is 134 ms.</p><p>2) &nbsp;<strong>The rhythm will be supraventricular.</strong> &nbsp;Supraventricular rhythms originate from above the ventricles. &nbsp;This ECG has P waves before each QRS. &nbsp;Even though the rhythm is irregular, slowing down during this recorded period, it is a sinus rhythm.</p><p>3) &nbsp;<strong>The QRS will have a terminal wave after the "normal" part of the QRS.</strong> &nbsp;This represents the right ventricle depolarizing late. &nbsp;It is very easily seen in<strong> V1</strong>, which normally has an rS pattern, and with RBBB has an rSR' pattern, making it appear upright. &nbsp;<strong>V6</strong> and<strong> Lead I</strong> will show this terminal wave as a wide little s wave.</p><p>As mentioned, there is also an <strong>acute inferior wall M.I.</strong> here. &nbsp;The ST segment elevation in Leads II, III, and aVF are actually quite subtle. &nbsp;The flat top of the ST segments gives them away as abnormal, along with the associated ST elevations in V5 and V6, and the reciprocal ST depressions in V1 through V3. &nbsp;Normally, in IWMI, there will be reciprocal ST depressions in Leads I and aVL, but the elevations they are reflecting are very subtle, and so, therefore, are the depressions.&nbsp;</p><p>The tricky thing about this ECG is that you must look carefully at the inferior wall leads to see the true ST elevation, which, as mentioned, is subtle. &nbsp;The RBBB terminal wave of the QRS complexes in Leads III and aVF is upright, and is often mistaken for ST elevation. &nbsp;Remember, ST segments are smooth from the end of the QRS to the peak of the T wave. &nbsp;See the detail illustration.</p><p>This ECG is suitable for your classes from beginner level (rate variation in sinus rhythm) through advanced (clinical significance of RBBB in acute M.I.). &nbsp;It also offers an example of reciprocal ST changes, and of a situation where the inferior leads II, III, and aVF are related to the low lateral leads V5 and V6 by a shared blood supply.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/618/feed" method="post" id="fivestar-custom-widget--5" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--10" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Wall M.I. and Right Bundle Branch Block 1/5</option><option value="40">Give Inferior Wall M.I. and Right Bundle Branch Block 2/5</option><option value="60">Give Inferior Wall M.I. and Right Bundle Branch Block 3/5</option><option value="80">Give Inferior Wall M.I. and Right Bundle Branch Block 4/5</option><option value="100" selected="selected">Give Inferior Wall M.I. and Right Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.6</span></span> <span class="total-votes">(<span >9</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-kv_JVHUx9EfWWAgew9NlLQ-2QAZUH9Rn8tR6i66HYYE" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-mi-and-right-bundle-branch-block&amp;title=%20Inferior%20Wall%20M.I.%20and%20Right%20Bundle%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 24 Oct 2014 21:36:35 +0000 Dawn 603 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-and-right-bundle-branch-block#comments Inferior Wall MI With Artifact https://www.ecgguru.com/ecg/inferior-wall-mi-artifact <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-wall-mi-artifact"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/IW118.jpg" width="1800" height="1289" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This ECG is taken from a 66-year-old man who presented to the Emergency Dept. with a complaint of chest pain. &nbsp;The ECG shows clear signs of acute inferior wall MI: &nbsp;ST segment elevation in Leads II, III, and aVF and reciprocal ST depression in Leads I and aVL. &nbsp;In addition, there are reciprocal ST depressions in Leads V1, V2, and V3. &nbsp;These indicate that the MI extends up the inferior wall into the area called by most clinicians the posterior wall. &nbsp;When the injured area extends high enough from the inferior wall, it becomes visible to the anterior-septal leads as ST depression. &nbsp;There is also a small ST elevation in Leads V5 and V6, the low lateral wall, indicating a common blood supply for the inferior and low lateral walls (usually the right coronary artery). &nbsp;All of these findings make this a rather "typical" inferior wall MI.</p><p>Unfortunately, this ECG also has a significant amount of artifact. &nbsp;The second, sixth, and tenth "beats" &nbsp;appear to be &nbsp;premature beats in Leads I and II. &nbsp;However, it is important to remember that the four channels on this ECG are run simultaneously. &nbsp;That is, any complex of significant voltage should show up four times. &nbsp;The "premature" beats do not appear in Lead III, and do not affect the timing of the appearance of the next beat at all. &nbsp;They also appear during moments of baseline disruption, indicating that they are not heartbeats, but simply artifact.</p><p>Why is this important? &nbsp;Artifact makes the ECG hard to interpret accurately. &nbsp;The ECG machine even had a difficult time, completely ignoring obvious P waves, and calling the rhythm "atrial fibrillation". &nbsp;Every effort should be made to obtain the cleanest, most artifact-free ECG possible.</p><p>Additional note: &nbsp;it can be very informative to do a right-sided ECG on an IWMI patient, or at least a V4Rt. &nbsp;In fact, it is a protocol requirement in many EMS agencies. &nbsp;Right ventricular infarction can change the hemodynamics of your patient, causing a need for fluid resuscitation. In fact, a drop in BP, such as that caused by nitroglycerin, can cause circulatory collapse. &nbsp;Ntg should be given cautiously to RVMI patients. &nbsp;Fortunately, IV fluids will seldom cause left heart overload in these patients. &nbsp;A look at the right ventricle with V4Rt can be very helpful in deciding treatment options.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/618/feed" method="post" id="fivestar-custom-widget--6" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--12" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inferior Wall MI With Artifact 1/5</option><option value="40">Give Inferior Wall MI With Artifact 2/5</option><option value="60">Give Inferior Wall MI With Artifact 3/5</option><option value="80" selected="selected">Give Inferior Wall MI With Artifact 4/5</option><option value="100">Give Inferior Wall MI With Artifact 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >12</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-6gXiSddwKvkE6HK1d72rKmykO4LksWzppvZIl3arAqU" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/artifact" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Artifact</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/inferior-wall-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Inferior Wall M.I.</a></div><div class="field-item odd"><a href="/ecg/iwmi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IWMI</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finferior-wall-mi-artifact&amp;title=Inferior%20Wall%20MI%20With%20Artifact"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 17 Oct 2014 02:11:30 +0000 Dawn 602 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inferior-wall-mi-artifact#comments