68M Of Acute Myocardial Infarction Telangana PaJR
This is an online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
PPM 1 - From the ward now:
68M with giddiness and this ECG at 4:00PM yesterday. 👆
PPM 1 - This is at 5:00 PM just before starting thrombolysis. 👆
PPM 2 - How was his blood pressure at this time sir? Clearly the RCA is gone!
PPM 1 - 👍
BP was barely recordable at 70mm Hg.
PPM 2 - Can somehow feel the locomotor brachii across continents!!
PPM 1 - 👍
PPM 2 - Just to add what I learned here - apparently Ticagrelor 180 vastly (read as marginally) outperforms Clopidogrel in loading doses.
And apparently Atorvastatin is not really a part of the loading regimen. A beta blocker is if left sided MI
Let's hope those T wave inversions start appearing in the right sided leads.
PPM 1 - Sharing what happened next.
ECG just after thrombolysis. Note involvement of newer arterial segments. Will share the echo video also that particularly shows a dyskinetic segment at this LAD territory, perhaps an acute dyskinesia as there's no myocardial thinning noticed.
PPM 2 - Finally TWI in inferior leads! The vessel wall has opened and possibly can be linked to subsiding giddiness?
PPM 1 - 👍
Here's the bedside clinical imageology for the patient 👇
01-02-2025
PaJR discussion update on 1/2/25
PPM 1 - Update Myocardial infarction Day 4, K2:
PPM 2 - Junctional rhythm with frequent sinus capture?
PPM 1 - Or the opposite with sinus arrest and junctional escapes?
PPM 1 - Today's ECG: @PPM3 @PPM4
Interesting changes in ECG since yesterday!
Can help with interpretation @PPM2 @PPM3 @PPM4.
The two ECGs above and below are a minute apart.
Today is Day 5, K2.
PPM 1 - His chest X-ray today.
His phenotype today.
👆The radiology suggests he could be in K3
Especially comparing with this chest X-ray during admission as attached here, where the cardiomegaly suggests a chronic CVD too.
PPM 3 - 👍
PPM 2 - Yes. How can we differentiate between the two?
01-02-2025
Feedback received from another group
RB - Will be grateful for your comments on the day 4 and 5 (today's) ECG of this patient of inferior wall myocardial infarction which are accessible here 👇.
ECG CME India - Thanks with regards 🙏🙏 for these series of ECGs
Ist ECG on the screen:
🔽 Junctional rhythm with Bradycardia ( please see the inferior leads with inverted p in these leads)
,associated Low voltage
🔽 evidence of Acute MI in inferior leads :ST elevation with tendency to have Q genesis
Plus
Anterior MI -as evident by mild ST elevation with the virtual loss of R > only visible as tiny r in most of Anterior leads
Comments
Acute MI with inferior as well, site of lesion most possibly proximal LAD, prior to its Diagonal branch.
I request you Sir to further rearrange the subsequent ECGs directly on the screen,so as to be visualised with more clarity.
My PRANAM SIR
🙏🙏
DR.K, ECG CME India: Proximal LAD with wrap art involvement
BKS CME India: Bradycardia HR approximate 48
Recent IWMI, ectopic atrial rhythm
Possible old AWMI
Possible hypokalemia
Possible SA node infarction or stunning leading to origin of ectopic atrial rhythm
Possible Site of origin of ectopic p wave superior to TA annulus
Site of occlusion prox RCA.
RB - Thanks sir.
RB - Thanks sir.
RB - Sir if you click on the ECGs their resolution improves and one can zoom in easily.
BKS CME India: Dr RB, there are many ECG on link you posted. I answered first ECG. It is very unfair to audience that they are reading our post without seeing ECG. Please take screenshot of all ECG and post it with chronological order with foot note of comments like day, point of pre/post thrombolysis etc. Me and Dr.K. sir will repost. Will be meaningful to our group members. Thanks.
DR.K. ECG CME India - Thanks Dr RB Sir and Dr S. sir.
My regards to both of you 🙏🙏
I would like to revise My opinion after seeing the entire series of ECGs, which I could not see earlier.
🔽 On the first ECG there is evidence of Acute inferior MI with more ST elevation in lead 111and simultaneous mild ST elevation in V1 as well, which should not be ignored and Rt sided chest leads would have been explored to assess it's true nature -
Now it is more suggestive of the involvement of RCA-Proximal, please see the presence of rhythm with P inversion in inferior leads with bradycardia - possible involvement due to the SA node leading to bradycardia and inverted p due to low ectopic p.
Initially by seeing the precordial leads this gave me the impression of the simultaneous involvement of anterior MI.
Since on last ECG the precordial leads comes to normalcy through gradual steps this confirms.
✅ there is mainly involvement of Proximal RCA with involvement of SA node with resultant Bradycardia and inverted p in inferior leads might be due to low ectopic p
This is known fact that with RCA involvement the changes are transient. may last for a few days only.
✅ There was transient anterior myocardial ischemia as well over anterior leads ,possibly due to shunting of blood therein.
Thanks with Regards 🙏🙏
NB :This would be my request that all the ECGs must have been posted directly serial wise on the front to have direct visualisation by All and then this would be meaningful and appreciable to All the elite members of this group.. And interpretation would also be easier.
With Regards
🙏🙏
RB - Thanks Sir for the valuable inputs along with Dr @BKS CME India
We try to record most of our cases as whole case reports that contain clinical, radiological and electrophysiology of the patients and this case report keeps getting updated in real time as a life time health record with all clinical images, radiology and electrophysiology available in a serial manner as per patient's timeline. There are over 5000 such cases available through our dashboard and it keeps growing everyday. Our idea behind this is to create a case based reasoning engine toward supplementing what is currently labeled deep phenotypic data in age old precision medicine: https://pmc.ncbi.nlm.nih.gov/articles/PMC6163835/
Modern day AI driven LLMs make it easier for us to thematically analyse these case reports toward newer individual patient centred insights.
I can understand that it would be important to segregate just the serial ECGs for the audience here from the over-all patient data and I shall try to do this ASAP and share here again just that portion. 🙂🙏.
03-02-2025
PPM 1 - 
Yesterday's ECG update: The nodal dysfunction pattern appears to have vanished and the old inferior wall pattern as well as a fresh LBBB appears to have gotten consolidated. The patient appears to have been shifted out of the ward yesterday.
Dr.BKS - Nice out come well treated, 👌🏻👍
Dr K: Every step as per evolution on ECG has been well followed Sir till the patient appears well suitable ro be shifted out of the ward .
Thanks with Regards🙏🙏
Dr K: to be shifted.
Today's ECG update:
The patient had been shifted out from the critical ward to a step down ward and we located his ECG done today (attached) and here it again seems to have changed in terms of yesterday's LBBB! The patient is asymptomatic since two days.
Dr.K: Thanks Sir
The patient is asymptomatic and most possibly vitals being normal.No crepitations over the chest and the patient I think is otherwise positive signs free except this LBBB on ECG with minor change over lead 6
Again my speculation remains the same. We have to keep close observation over the further ECG changes. Better to have cardiac Echo as well to review the functional integrity.
Do not hesitate to have the second local opinion if needed.🙏🙏
RB: Thanks Sir
His cardiac echo on day 1 is available here 👇
It shows anteroseptal and infero septal dyskinesia.
Dr K: The recent most? Do you feel any need. for revascularization procedure?
RB: Not as per what current evidence would deem necessary. He missed the window for primary ptca and its currently not symptomatic enough for a rescue ptca.
PPM 1 - 
Today's ECG update:
The patient had been shifted out from the critical ward to a step down ward and we located his ECG done today (attached) and here it again seems to have changed in terms of yesterday's LBBB! The patient is asymptomatic since two days.
03-02-2025
Dr. K: EF?
RB: Given the dyskinetic segment, with albeit good lvpw contractility the overall visual EF in the above video appears to be 30%
Dr.K: I think we should consider to know the vascular patency with viability of the remaining myocardium .
Plus advise the patient to remain within his physical limitation.
BKS: Good enough,, MR, AR Normal MV ,AV, ,SO, Ischemic insult of RCA,. It should resolve gradually, LBBB should also resolve in couple of days.
LBBB has dual blood supply RCA &LAD. SO, here it should resolve.
Dr.K: Yes. There might be the impact of post ischemic stunning- this should get resolved within a few days.
Dr.BKS: Lvef is visible on scree of ECHO clip.
It is 43%
RB: Thanks Sir.
It's been our practice and we also teach that to our students, to rely more on the visual estimation of EF than go by the quantitative estimate of m mode which measures just an ice pick cross section using the uni-dimensional cursor, while our vision can work across the entire volume of the heart by eye balling and it's also supported by evidence 👇
BKS: 👌👍True
RB: Thanks Sir what appears intriguing though is the change from day before yesterday's ECG where the LBBB pattern is also visible in V6 while in yesterday's it has disappeared from V6!
Dr.K: Thanks Sir.
I have also marked this at v6 position and mentioned on my posting last day.Most likely this sort of clockwise rotation might be due to somewhat more wrong placing of the exploring electrode at V6.
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