ECG Guru - Instructor Resources - Type 2 M.I. https://www.ecgguru.com/ecg/type-2-mi en Shark Fin Pattern https://www.ecgguru.com/ecg/shark-fin-pattern <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/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1025%20initial%20RS.jpg" width="1000" height="153" alt="" /></a></div><div class="field-item odd"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%20jpg.jpg" width="1800" height="596" alt="" /></a></div><div class="field-item even"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20Lead%20with%20J%20points%20and%20P%20waves%20marked.jpg" width="1800" height="596" alt="" /></a></div><div class="field-item odd"><a href="/ecg/shark-fin-pattern"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/1041%20Rhythm%20Strip%20e.jpg" width="1000" height="255" 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><span style="color: #009999;">The Patient:</span></strong><span style="mso-spacerun: yes;">&nbsp; </span>This ECG is from a 59-year-old woman who was found by the EMS crew to be unresponsive, with agonal respirations at about 6 breaths per minute. Her pulse was thready at the carotid, and absent peripherally. Her skin was pale, cool, and mottled.<span style="mso-spacerun: yes;">&nbsp; </span>Her BP via the monitor is 81/40, peripheral pulses not being palpable.<span style="mso-spacerun: yes;">&nbsp; </span>An <strong>initial rhythm strip</strong> showed sinus rhythm at 75 bpm with right bundle branch block and ST elevation.</p><p class="MsoNormal">The patient’s husband gave a history of “difficulty breathing” since sometime this morning, alcohol dependence, hypertension, tobacco use, and insomnia. He said she had been drinking heavily for several weeks.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">She was immediately ventilated and intubated, and an intraosseous infusion line established.<span style="mso-spacerun: yes;">&nbsp; </span>A<strong>12-lead ECG</strong> was done, and it showed a dramatic change in the rhythm and ST segments over the initial strip. She was transported to a nearby hospital with CPR support. She <span style="color: #0d0d0d; mso-themecolor: text1; mso-themetint: 242; mso-style-textfill-fill-color: #0D0D0D; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=95000 lumo=5000';">achieved return of spontaneous circulation (ROSC) at the Emergency Department, after having three doses of epinephrine.<span style="mso-spacerun: yes;">&nbsp; </span>Follow up with the ED physician revealed that the patient had suffered a massive gastrointestinal bleed.<span style="mso-spacerun: yes;">&nbsp; </span></span>This patient, due to loss of a critical amount of blood, had low blood pressure and very poor perfusion, which resulted in damage to her heart (and possibly other organs as well). <span style="color: #0d0d0d; mso-themecolor: text1; mso-themetint: 242; mso-style-textfill-fill-color: #0D0D0D; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=95000 lumo=5000';">I do not have further follow up, but will update this if I receive more information.</span>&nbsp;</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><strong><span style="color: #009999;">The ECG:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="color: #0d0d0d; mso-themecolor: text1; mso-themetint: 242; mso-style-textfill-fill-color: #0D0D0D; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=95000 lumo=5000';">The 12-Lead ECG done several minutes into the call is very different from the original rhythm strip.</span> The P waves are slightly irregular, with an average rate of about 47 bpm. (Marked with blue arrows on the labeled ECG).<span style="mso-spacerun: yes;">&nbsp;</span>The QRS complexes are also slightly irregular, but not at all related to the P waves.<span style="mso-spacerun: yes;">&nbsp; </span>It appears to be a right bundle branch block pattern, with a pathological Q wave in V1. Because of the ST changes, it isn’t possible to discern a small S wave in Leads I and V6, as we would normally see in RBBB.<span style="mso-spacerun: yes;">&nbsp; </span>This appears to be a junctional rhythm that averages about 51 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>I would call this a complete heart block, even though complete heart block usually implies that the atrial rate will be faster than the escape rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>In this ECG, I see no signs of the P waves conducting, even when they have ample opportunity – that is, they have not fallen into a refractory period. In fact, a few minutes after the 12-lead ECG was done, there was a period recorded of about four seconds with P waves only.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">&nbsp;The most notable feature of this ECG is that there is <strong>extreme ST segment elevation</strong> in all leads except aVR and aVL.&nbsp; The J points are so high, it appears that the QRS complexes are extremely wide.&nbsp; A second view of this ECG is provided with the J points marked with red lines to help you see where the QRS ends and the ST segment begins.&nbsp; These types of ST segment elevations are often called <strong>“shark fin”</strong> pattern. Rather than wide QRS, this pattern represents a blending of the QRS and T wave. Shark fin pattern is often seen in “related leads”, leads that are oriented to one coronary artery.&nbsp; In this case, the ST elevations are very widespread.&nbsp; Without knowing this patient’s outcome, I can only make an educated guess, that this is a Type 2 M.I.&nbsp; Type 2 M.I. is defined as an M.I. caused by a mismatch between cardiac supply and demand, rather than by thrombosis.&nbsp; Especially in coronary arteries that are narrowed by disease, a low-perfusion state can cause myocardial damage and elevated troponins.&nbsp;This patient has severe hypovolemia and anemia due to her G.I. bleed.&nbsp; Another possibility is an occlusion from a thrombus in a dominant artery. For example, one of the branches of the left coronary artery could wrap around and perfuse the inferior wall, which is usually the right coronary artery's territory. An occlusion in a markedly dominant artery can cause widespread ST changes.&nbsp; I would be very interested in hearing your thoughts on this.</p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;">For more information on shark fin pattern, and myocardial infarction in general, we highly recommend Dr. Steven Smith’s excellent blog.&nbsp; Dr. Smith is an authority on M.I. ECG changes, and the shark fin pattern.&nbsp; <a href="http://www.hqmeded-ecg.blogspot.com/">http://www.hqmeded-ecg.blogspot.com</a></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/755/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 Shark Fin Pattern 1/5</option><option value="40">Give Shark Fin Pattern 2/5</option><option value="60" selected="selected">Give Shark Fin Pattern 3/5</option><option value="80">Give Shark Fin Pattern 4/5</option><option value="100">Give Shark Fin Pattern 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3</span></span> <span class="total-votes">(<span >51</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-40liUJC_5-fvQYam5ZnTLg0JJKfXYEf-jDKkP8GqSUs" /> <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/sharks-fin-pattern" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sharks fin pattern</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/type-2-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Type 2 M.I.</a></div><div class="field-item odd"><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 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/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_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fshark-fin-pattern&amp;title=Shark%20Fin%20Pattern"><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> Tue, 28 Jan 2020 03:54:43 +0000 Dawn 781 at https://www.ecgguru.com https://www.ecgguru.com/ecg/shark-fin-pattern#comments Atrial fibrillation and Type 2 M.I. https://www.ecgguru.com/ecg/atrial-fibrillation-and-type-2-mi <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/atrial-fibrillation-and-type-2-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20channel%20page%20one.jpg" width="1800" height="1151" alt="" /></a></div><div class="field-item odd"><a href="/ecg/atrial-fibrillation-and-type-2-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20channel%20page%202.jpg" width="1800" height="1116" 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 style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span>This excellent teaching case was donated to the ECG Guru by our friend, Sebastian Garay (who is an ECG Guru himself).<span style="mso-spacerun: yes;">&nbsp; </span>It was taken from a 33-year-old man who was complaining of chest pain and palpitations. He reported a similar episode about six months prior, but failed to follow up with cardiology. Was told by his medical care provider that he had atrial fib.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">The ECG:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>We are able in this case to provide a 12-lead ECG with each lead recorded for the entire width of the paper. This has the advantage of producing twelve ten-second rhythm strips.<span style="mso-spacerun: yes;">&nbsp; </span>Page one contains the limb leads, and page two shows us the precordial leads.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;">The rhythm</strong> is atrial fibrillation, with a heart <strong style="mso-bidi-font-weight: normal;">rate</strong> of 133 bpm and an irregularly irregular rhythm. The <strong style="mso-bidi-font-weight: normal;">QRS axis</strong> is extreme left at about -75 degrees.<span style="mso-spacerun: yes;">&nbsp; </span>This has caused Leads II, III, and aVF to be negatively deflected, and aVR and aVL to be positive. Lead I is biphasic, low voltage, and mostly positive, indicating that the axis travels almost perpendicular to Lead I, but slightly toward it.</p><p class="MsoNormal">The machine mistakenly gives us a reading for PR interval and P wave axis, even though there are no P waves.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS is on the wide side without being abnormal at .10 seconds (100 ms). The QTc is within normal limits, although it might be considered “borderline”, with 431-450 usually considered borderline.</p><p class="MsoNormal">There appears to be very <strong style="mso-bidi-font-weight: normal;">slight ST elevation</strong> in the inferior leads with no coving of the ST segment.<span style="mso-spacerun: yes;">&nbsp; </span>We see the same ST appearance in Leads V3 through V6.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong style="mso-bidi-font-weight: normal;">axis in the vertical plane</strong>, as indicated by the chest, or precordial, leads, is also unusual.<span style="mso-spacerun: yes;">&nbsp; </span>It appeared the same in multiple ECGs run by different people, so lead placement is presumed to be correct.<span style="mso-spacerun: yes;">&nbsp; </span>V1 and V2 are more upright than negative, which is not normal. The most common cause of upright QRS in V1 is right bundle branch block, which is not present here. Another common cause of a dominant R wave in V1 and V2 is <strong style="mso-bidi-font-weight: normal;">right ventricular enlargement.</strong><span style="mso-spacerun: yes;">&nbsp; </span>V3, V4, V5, and V6 all look very much alike, with no R wave progression, also a sign of right ventricular enlargement.<span style="mso-spacerun: yes;">&nbsp; </span>First glance appears to show pathological Q waves in many leads, but on closer inspection, there are small “r” waves.<span style="mso-spacerun: yes;">&nbsp; </span>Other signs of right ventricular enlargement, such as the “strain pattern” (ST depression and T wave inversion in right-sided leads), are not evident here.</p><p class="MsoNormal">So, to recap, this young and symptomatic man has had intermittent bouts of atrial fibrillation and chest pain.<span style="mso-spacerun: yes;">&nbsp; </span>We do not know of other symptoms, but the ECG is abnormal in many ways, especially for a young person. His symptoms also point to serious heart disease.</p><p class="MsoNormal">The Hospital Course:<span style="mso-spacerun: yes;">&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span>The patient presented to the Emergency Department in atrial fib with a rapid ventricular response at 140/min.<span style="mso-spacerun: yes;">&nbsp; </span>His troponin levels were all critically high at 1.230, 1.30, 1.230, and 1.250. (Normal 0.00 – 0.40). Later that day, he converted to sinus rhythm with PACs. The next day, cardiac catheterization was performed.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">Cath Findings:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>Marked right heart pressure variations with respirations. Mild, non-obstructive coronary artery disease in a co-dominant system. Severe non-ischemic cardiomyopathy (NICM). The left ventriculogram showed global hypokinesis, with an ejection fraction of 20-25% (normal EF is 60% or greater).<span style="mso-spacerun: yes;">&nbsp; </span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">Diagnosis:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>Unspecified atrial fib and <strong style="mso-bidi-font-weight: normal;">Type 2 M.I.<span style="mso-spacerun: yes;">&nbsp; </span></strong>This is a term now being used for M.I. due to an underlying cause other than coronary artery plaque rupture and thrombosis.<span style="mso-spacerun: yes;">&nbsp; </span>In this case, loss of cardiac output due to atrial fib with RVR and NICM caused a defect in the supply-demand conditions in his heart.<span style="mso-spacerun: yes;">&nbsp; </span>Even with open coronary arteries, his heart could not keep up enough cardiac output to adequately supply the coronary arteries and the myocardium. The rapid rate increased the demand side of the equation, while not enhancing the supply side.</p><p class="MsoNormal">Patient Outcome:<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>The patient was discharged home with instructions to follow up with his primary care provider and cardiologist.<span style="mso-spacerun: yes;">&nbsp; </span>Even in the absence of heart failure symptoms, he was started on medications for failure, as well as medications for the atrial fibrillation.</p><p class="MsoNormal">&nbsp;</p><p class="MsoNormal">Our thanks to Sebastian Garay for sharing this great <strong style="mso-bidi-font-weight: normal;">non-STEMI</strong> example.<strong style="mso-bidi-font-weight: normal;"></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/755/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 Atrial fibrillation and Type 2 M.I. 1/5</option><option value="40">Give Atrial fibrillation and Type 2 M.I. 2/5</option><option value="60">Give Atrial fibrillation and Type 2 M.I. 3/5</option><option value="80" selected="selected">Give Atrial fibrillation and Type 2 M.I. 4/5</option><option value="100">Give Atrial fibrillation and Type 2 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 >9</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-RUfrWJBAU76FYT85m3sI8e84hz-D6-Jj0fH7hmmk_PA" /> <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/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div><div class="field-item odd"><a href="/ecg/fib" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">A Fib</a></div><div class="field-item even"><a href="/ecg/type-2-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Type 2 M.I.</a></div><div class="field-item odd"><a href="/ecg/mi-non-obstructive-coronary-arteries" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">M.I. with non-obstructive coronary arteries</a></div><div class="field-item even"><a href="/ecg/nstemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">NSTEMI</a></div><div class="field-item odd"><a href="/ecg/non-stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Non-STEMI</a></div><div class="field-item even"><a href="/ecg/right-ventricular-enlargement" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right ventricular enlargement</a></div><div class="field-item odd"><a href="/ecg/12-channel-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">12 channel ECG</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%2Fatrial-fibrillation-and-type-2-mi&amp;title=Atrial%20fibrillation%20and%20Type%202%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> Sat, 20 Jul 2019 19:41:02 +0000 Dawn 774 at https://www.ecgguru.com https://www.ecgguru.com/ecg/atrial-fibrillation-and-type-2-mi#comments