tag:blogger.com,1999:blog-21475255335766156602024-03-13T22:39:05.917-07:00 Academic Life in Emergency Medicine Collaborating, meeting, and sharing with inspiring people in the academic world of EMAnonymoushttp://www.blogger.com/profile/03280819544365226469noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-2147525533576615660.post-64131762821430237362015-01-02T14:10:00.001-08:002015-01-02T14:20:33.878-08:00ALiEM has moved<div class="separator" style="clear: both; text-align: center;">
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<br />Anonymoushttp://www.blogger.com/profile/03280819544365226469noreply@blogger.com0tag:blogger.com,1999:blog-2147525533576615660.post-41452877291919644592013-06-12T12:11:00.000-07:002015-10-21T19:54:37.610-07:00aVR: The Forgotten 12th Lead<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-3a4qCW6sLZM/UaOKW5ohW7I/AAAAAAAAAsU/ZzX1dpYmvtI/s1600/STE+in+aVR.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://4.bp.blogspot.com/-3a4qCW6sLZM/UaOKW5ohW7I/AAAAAAAAAsU/ZzX1dpYmvtI/s1600/STE+in+aVR.png" /></a></div>
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Image from <a href="http://www.ncbi.nlm.nih.gov/pubmed/22412103">PMID: 22412103</a></div>
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Augmented
leads (aVR, aVF, and aVL) were developed to derive more localized information
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from the right upper side of the heart.
Lead aVR also gives reciprocal information from the left lateral side of
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forgotten.<o:p></o:p></div>
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<b><span style="font-size: large;">What is the sensitivity and specificity of
lead aVR for left main coronary artery (LMCA) occlusion?</span><o:p></o:p></b></div>
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</div>
<ul>
<li>Yamaji
et al (2001): aVR ST segment elevation (>0.05 mV) greater than ST segment
elevation of V1 = sensitivity 81% and specificity of 80%</li>
<li>Rostoff
et al (2006): aVR ST segment elevation (>0.05 mV) = sensitivity 68.2% and
specificity 73.3%</li>
<li>Kosuge
et al (2011): aVR ST segment elevation (>0.05 mV) = sensitivity 91% and
specificity 79%</li>
<li>Kosuge
et al (2011): aVR ST segment elevation (>0.1 mV) = sensitivity 80% and
specificity 93%</li>
<li>Kosuge
et al (2011): aVR ST segment elevation (>0.15mV) = sensitivity 27% and
specificity 98%</li>
</ul>
<div>
<b>Conclusion: </b>ST elevation of >0.05 mV in aVR has a <b>SENSITIVITY 68.2% - 91%</b> and <b>SPECIFICITY 73.3% - 80%</b></div>
<b><o:p></o:p></b><br />
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<b><o:p></o:p></b></div>
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<b><o:p></o:p></b></div>
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<b><o:p></o:p></b></div>
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<b><o:p></o:p></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-size: large;">Does ST elevation in lead aVR predict
clinical outcome?</span><o:p></o:p></b></div>
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</div>
<ul>
<li>Yamaji
et al (2001): ST elevation of aVR (0.15 mV) predicts DEATH with 75% sensitivity
and 75% specificity</li>
<li>Barrabes
et al (2003): ST elevation of aVR (0.05 mV – 0.1mV) mortality 8.6% and ST
elevation of aVR (>0.1 mV) mortality 19.4% versus no ST elevation of aVR
mortality 1.3%</li>
<li>Abbase
et al (2006): MORTALITY in ST elevation of aVR (0.05 mV) 30.2% vs no ST
elevation in aVR 12.2%</li>
</ul>
<div>
<b>Conclusion:</b> ST elevation in lead aVR has <b>INCREASED MORTALITY</b> versus no ST elevation in lead aVR</div>
<o:p></o:p><br />
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<o:p></o:p></div>
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<br />
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<b><span style="font-size: large;">What is the best management of ST elevation
in lead aVR?</span></b></div>
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<li>Several
studies quote a 3-year mortality rate of 50% (1975 Study) for medical
management and 36% (1989 Study) for PCI, stating that surgery (CABG) is the
treatment of choice.</li>
<li>There
are several new studies now looking at drug eluding stents (DES) as an option:</li>
</ul>
<o:p></o:p><br />
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<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-EnmMsMO2NLA/UaTeZI8rFCI/AAAAAAAAAs0/J0NTLSU6WUY/s1600/Screen+Shot+2013-05-28+at+11.29.27+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="295" src="http://1.bp.blogspot.com/-EnmMsMO2NLA/UaTeZI8rFCI/AAAAAAAAAs0/J0NTLSU6WUY/s400/Screen+Shot+2013-05-28+at+11.29.27+AM.png" width="400" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: justify;">
</div>
<ul>
<li>Currently the <a href="http://clinicaltrials.gov/show/NCT01205776">EXCEL</a> (Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial is underway and recruiting patients and can hopefully give us a more clear answer.</li>
</ul>
<br />
<b>Conclusion:</b> It is still not clear who would be best treated with PCI versus CABG in LMCA occlusion<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-pd8xhyAPsgo/UaTmb8ApkhI/AAAAAAAAAtE/n4wTi-getK0/s1600/Screen+Shot+2013-05-28+at+12.15.40+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="126" src="http://1.bp.blogspot.com/-pd8xhyAPsgo/UaTmb8ApkhI/AAAAAAAAAtE/n4wTi-getK0/s400/Screen+Shot+2013-05-28+at+12.15.40+PM.png" width="400" /></a></div>
<br />
<b>Final Thoughts:</b> Lead aVR is a forgotten but valuable lead that is highly predictive of LMCA occlusion and gives prognostic information. The best management of LMCA occlusion is still unclear (PCI vs CABG).<br />
<br />
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<a href="http://1.bp.blogspot.com/-BtwJFWH5o8I/UaAcpwBde_I/AAAAAAAAZw8/pZQM_jiClvg/s1600/rezaie.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-BtwJFWH5o8I/UaAcpwBde_I/AAAAAAAAZw8/pZQM_jiClvg/s1600/rezaie.jpg" /></a></div>
</td><td style="padding: 0in 5.4pt; width: 305.1pt;" valign="top" width="305"><div align="center" class="MsoNormal">
<b>Salim Rezaie, MD</b><br />
<span style="text-align: left;">(</span><a href="http://www.twitter.com/srrezaie" style="text-align: left;">@srrezaie</a><span style="text-align: left;">)</span><br />
Clinical Assistant Professor of EM and IM<br />
University of Texas Health Science Center at San Antonio<br />
<br />
<br /></div>
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<b>References:</b></div>
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<li><a href="http://www.iasj.net/iasj?func=fulltext&aId=32167" style="font-family: Cambria; font-size: 12pt;">Abbase AH et al. The Significance of ST Segment Elevation in Lead aVR in Acute Anterior Myocardial Infarction. Med J Babylon2011. 8 (4): 490 – 96.</a></li>
<li>Barrabes
JA et al. Prognostic Value of Lead aVR in Patients With a First Non-ST Segment
Elevation Acute Myocardial Infarction. Circ 2003; 108: 814 – 819.<a href="http://www.ncbi.nlm.nih.gov/pubmed/12885742"> PMID:12885742</a></li>
<li><span style="text-align: justify;">Chieffo
A et al. 5-Year Outcomes Following Percutaneous Coronary Intervention With
Drug-Eluting Stent Implantation Versus Coronary Artery Bypass Graft for
Unprotected Left Main Coronary Artery Lesions: The Milan Experience. JACC
Cardiovas Interv 2010 June; 3 (6): 595 – 601. </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/20630452" style="text-align: justify;">PMID: 20630452</a></li>
<li>Kosuge M et al. An Early and Simple Predictor of Severe Left Main and/or Three-Vessel
Disease in Patients With Non-ST Segment Elevation Acute Coronary Syndrome. Am J
Cardio 2011; 107: 495 – 500. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21184992">PMID: 21184992</a></li>
<li>Nakamura
K et al. Significance of ST-Segment Elevation in Lead aVR. Arch Intern Med 2012
Mar; 172 (5): 389. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22412103">PMID: 22412103</a></li>
<li>Rostoff P et al. ST Segment Elevation in Lead aVR and Coronary Artery Lesions in Patients
with acute Coronary Syndrome. Kardiol Pol 2006. 64: 8 – 14. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16444621">PMID: 16444621</a></li>
<li><span style="text-align: justify;">Yamaji H et al. Prediction of Acute left Main Coronary Artery Obstruction by 12-Lead
Electrocardiography. JACC 2001; 38 (5): 1348 – 1354. </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/11691506" style="text-align: justify;">PMID: 11691506</a></li>
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<!--EndFragment-->Anonymoushttp://www.blogger.com/profile/17186040409746582066noreply@blogger.com0tag:blogger.com,1999:blog-2147525533576615660.post-74746727579604064092013-06-06T03:00:00.000-07:002015-10-21T19:54:37.620-07:00Must We Avoid Nitrofurantoin with Impaired Renal Function?<span style="font-family: inherit;">Acute uncomplicated cystitis is becoming more difficult to treat in the setting of increasing antimicrobial resistance. In the <a href="http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Uncomp%20UTI.pdf" target="_blank">2010 IDSA Guideline</a>, nitrofurantoin (Macrobid) is now listed as the first-line choice, surpassing ciprofloxacin and sulfamethoxazole/trimethoprim from the previous iteration.</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">For tested E. Coli strains at my institution in 2012, the susceptibility to common agents is as follows:</span><br />
<ul>
<li><span style="font-family: inherit;">Ciprofloxacin 61%</span></li>
<li><span style="font-family: inherit;">Levofloxacin 72%</span></li>
<li><span style="font-family: inherit;">Sulfamethoxazole/trimethoprim 69%</span></li>
<li><b><span style="font-family: inherit;">Nitrofurantoin 97%</span></b></li>
</ul>
<div>
<span style="font-family: inherit;">The reality of resistance hits close to home for me and may be similar in your institutions.</span></div>
<div>
<span style="font-family: inherit;"><br /></span></div>
<div>
<span style="font-family: inherit;">Why not just prescribe 5 days nitrofurantoin for all patients with acute uncomplicated cystitis?</span></div>
<div>
<ol>
<li><span style="font-family: inherit;">The <a href="http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf" target="_blank">American Geriatrics Society's Beers Criteria for Potentially Inappropriate Use in Older Adults</a> recommends against using nitrofurantoin in this age group.</span></li>
<li><span style="font-family: inherit;">Nitrofurantoin is contraindicated in patients with creatinine clearance < 60 mL/min.</span></li>
</ol>
Let's tackle each of these concerns.<br />
<div>
<br /></div>
<b>Inclusion in Beers Criteria</b></div>
<div>
Darrell Hulisz, PharmD explores the reason for nitrofurantoin's inclusion in the Beers Criteria in a recent <a href="http://www.medscape.com/viewarticle/803715?nlid=31277_745&src=wnl_edit_medp_phar&uac=191648SN&spon=30">Medscape article</a>. He concludes, "It is generally accepted that nitrofurantoin may be ineffective for UTIs in the elderly because age-related declines in renal function result in subtherapeutic concentrations in the urinary tract. However, the recommendation to avoid the drug in the elderly is not because it causes nephrotoxicity. Although not well-documented, it is plausible that the risk for other toxicities from nitrofurantoin, such as pulmonary fibrosis, would increase secondary to drug accumulation." </div>
<div>
<br /></div>
<div>
Who experiences adverse reactions and how common are they?</div>
<div>
<ol>
<li>Concern exists for an associated increased risk for serious adverse reactions in patients with renal impairment (possible older adults). </li>
<li>Pulmonary toxicity, hepatotoxicity, and hemolytic anemia are rather rare occurrences, and are often linked to prolonged treatments (6 months or longer). [1] </li>
<li>Published cases of peripheral neuropathy associated with nitrofurantoin in patients with renal insufficiency have occurred most often with treatments lasting beyond the 5-day period recommended by the IDSA. [1]</li>
</ol>
<u>Bottom Line</u>: Adverse effects tend to occur in those on therapy longer than 5 days.<br />
<br />
<b>Use with Reduced Renal Function</b><br />
Is it really true that nitrofurantoin is not effective when CrCl drops below 60 mL/min? </div>
<div>
<br /></div>
<div>
When nitrofurantoin was originally FDA-approved in 1988, the CrCl lower limit was 40 mL/min. It was changed to 60 mL/min in 2003 with little explanation. The contraindication seems to be based on a few studies from the 1950s and 1960s addressing urinary recovery of this drug in patients with various degrees of renal function. [2] These 40+ year-old studies had significant flaws, some not even listing clear methodologies or how many patients were included. They also didn't report clinical efficacy.<br />
<ul><ul>
</ul>
</ul>
<div>
<u>Newer Data</u><br />
Two more recent studies evaluated clinical efficacy.<br />
<ul>
<li>A retrospective chart review of 356 patients (mostly older adults) was conducted in 2009 that assessed the efficacy and safety of nitrofurantoin in patients with renal impairment. The study concluded that nitrofurantoin cure rates for UTI and adverse events were similar between those with and those without renal impairment. [3] </li>
<li>In a cohort of 21,317 women, nitrofurantoin treatment was not associated with a higher risk of ineffectiveness in women with UTI and moderate renal impairment (30-50 ml/min/<span style="background-color: white; line-height: 17px;">1.73 m</span><sup style="background-color: white; line-height: 1.6363em; position: relative; top: -0.5em; vertical-align: baseline;">2</sup>). The authors did, however, find a significant association between renal impairment (<50 ml/min/<span style="background-color: white; line-height: 17px;">1.73 m</span><sup style="background-color: white; line-height: 1.6363em; position: relative; top: -0.5em; vertical-align: baseline;">2</sup>) and pulmonary adverse events leading to hospitalization (HR 4.1, 95% CI 1.31-13.09). AIn absolute terms, only 4 out of 187 (2.1%) patients had adverse effects in the group with poor renal function and it is unclear if patients with with the lowest CrCl had more adverse events. [4]</li>
</ul>
<div>
<b>Application to Clinical Care</b></div>
<div>
While both recent studies had some important limitations, they still suggest that patients with an estimated creatinine clearance >40 mL/min are probably ok to receive a 5-day course of nitrofurantoin. This is different from the current 60 mL/min mark stated in the Beers Criteria and Macrobid package insert. Cure rates and adverse reactions were generally similar to patients with normal renal function.</div>
<span style="font-family: inherit;"><b></b><br /></span>
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<b>Bryan Hayes, PharmD </b><br />
(<a href="http://www.twitter.com/PharmERToxGuy"><span style="color: windowtext; text-decoration: none; text-underline: none;">@PharmERToxGuy</span></a>)<br />
Clinical Assistant Professor, University of Maryland (UM) Clinical Pharmacy Specialist, EM and Toxicology</div>
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<b><span style="font-family: inherit;">References</span></b></div>
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<ol>
<li><span style="font-family: inherit; line-height: 18px;">Guay DR. An update on the role of nitrofurans in the management of urinary tract infections. <i>Drugs</i> 2001;61:353-64. [<a href="http://www.ncbi.nlm.nih.gov/pubmed/11293646" target="_blank">PMID 11293646</a>]</span></li>
<li><span style="font-family: inherit;">Oplinger M, et al. </span><span style="background-color: white; font-family: inherit; line-height: 1.125em;">Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence. <i>Ann Pharmacother</i> 2013;47(1):106-11. [<a href="http://www.ncbi.nlm.nih.gov/pubmed/23341159" target="_blank">PMID 23341159</a>]</span></li>
<li><span style="background-color: white; font-family: inherit;">Bains A, Buna D, Hoag NA. A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment. <i>Can Pharm J</i> 2009;142:248-52.</span></li>
<li><span style="background-color: white; font-family: inherit;">Geerts AF, et al. </span><span style="background-color: white; font-family: inherit; line-height: 1.125em;">Ineffectiveness and adverse events of </span><span class="highlight" style="background-color: white; font-family: inherit; line-height: 1.125em;">nitrofurantoin</span><span style="background-color: white; font-family: inherit; line-height: 1.125em;"> </span><span style="background-color: white; font-family: inherit; line-height: 1.125em;">in women with urinary tract infection and</span><span style="background-color: white; font-family: inherit; line-height: 1.125em;"> </span><span class="highlight" style="background-color: white; font-family: inherit; line-height: 1.125em;">renal</span><span style="background-color: white; font-family: inherit; line-height: 1.125em;"> </span><span style="background-color: white; font-family: inherit; line-height: 1.125em;">impairment in primary care. <i>Eur J Clin Pharmacol</i> 2013 May 10. [Epub ahead of print] [<a href="http://www.ncbi.nlm.nih.gov/pubmed/23660771" target="_blank">PMID 23660771</a>]</span></li>
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Bryan D. Hayes, PharmDhttp://www.blogger.com/profile/18241720670877743026noreply@blogger.com0tag:blogger.com,1999:blog-2147525533576615660.post-43489310449233732092013-06-05T03:00:00.000-07:002015-10-21T19:54:37.615-07:00Wellens' Syndrome: Is it on your radar?<div class="separator" style="clear: both; text-align: center;">
<a href="http://3.bp.blogspot.com/-3mHN3c4Wigk/UaAhp9X2IqI/AAAAAAAAAr0/be5D8rbBJPE/s1600/Screen+Shot+2013-05-24+at+9.26.10+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" height="216" src="http://3.bp.blogspot.com/-3mHN3c4Wigk/UaAhp9X2IqI/AAAAAAAAAr0/be5D8rbBJPE/s320/Screen+Shot+2013-05-24+at+9.26.10+PM.png" width="320" /></span></a></div>
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<span style="font-family: inherit;">Wellen’s Syndrome was first described in 1982 in which 75% of patients with t wave inversions in V2-V4 went on to have an acute myocardial infarction (MI). This was again repeated in 1989, and showed that all patients with this morphology had >50% LAD stenosis. The incidence in the United States is about 10-15%. </span><br />
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<b><span style="color: #990000; font-family: inherit;">What is Wellens' Syndrome?</span></b><br />
This is a preinfarction stage of coronary artery disease, also referred to as LAD coronary T-wave syndrome. The syndrome criteria include the following:<br />
<ul>
<li>History of angina + T wave inversion or biphasic t waves in V2–V4 </li>
<li>Normal or minimally elevated cardiac enzymes </li>
<li>No pathologic precordial q waves or loss of precordial R wave progression </li>
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<b><span style="color: #990000;">What are the types of Wellens' Syndrome?</span></b><br />
There are two types: Type 1 (75% of cases) and Type 2 (25% of cases)<br />
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<a href="http://2.bp.blogspot.com/-akr1YCkkPyM/UaG_weys33I/AAAAAAAAZxg/McGBGr-zlrI/s1600/Screen+Shot+2013-05-25+at+3.35.14+AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" src="http://2.bp.blogspot.com/-akr1YCkkPyM/UaG_weys33I/AAAAAAAAZxg/McGBGr-zlrI/s1600/Screen+Shot+2013-05-25+at+3.35.14+AM.png" /></span></a></div>
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<b><span style="color: #990000;">Why does Wellens' Syndrome matter?</span></b><br />
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It signifies a critical high grade proximal LAD stenosis.<br />
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<li><span style="font-family: inherit;">Acute MI occurs within a mean of <b>6 - 8.5 days after admission</b></span></li>
<li><span style="font-family: inherit;">Acute MI occurs within a mean of <b>21.4 days after symptoms</b></span></li>
<li><span style="font-family: inherit;">Note: Exercise stress testing can be fatal due to severe stenosis (case reports)</span></li>
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<b><span style="color: #990000; font-family: inherit;">What is the specificity of inverted T waves (V1–V4) on EKG for proximal LAD stenosis? </span></b><br />
<span style="font-family: inherit;"><a href="http://crc.sums.ac.ir/icarusplus/export/sites/crc/article-pdf/Electrocardiographic-predictors-of-proximal-left-anterior-descending-coronary-artery-occlusion.pdf">Kojuri et al</a> took 130 patients with known proximal LAD >70% stenosis on angiography and retrospectively went back to look at the most specific EKG findings associated with this anatomic lesion. The <b>MOST SPECIFIC </b>predictor of a proximal LAD lesion was, inverted or biphasic T waves in leads V1 - V4 at <b>91.6%</b> (sens 70.8%, PPV 70.5%).</span><br />
<span style="font-family: inherit;"><br />
</span> <b><span style="color: #990000; font-family: inherit;">How do you treat Wellens' Syndrome?</span></b><br />
<span style="font-family: inherit;">Early revascularization is superior to medical management.</span></div>
<div class="MsoNormal">
<ul>
<li><span style="font-family: inherit;">26.7% of patients treated medically die from cardiovascular cause</span></li>
<li><span style="font-family: inherit;">0.7% of patients treated with revascularization die from cardiovascular cause</span></li>
</ul>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://2.bp.blogspot.com/-lW_sHFsOBLk/UZ_cAK7eLOI/AAAAAAAAArk/swLTkbhdAhk/s1600/Screen+Shot+2013-05-24+at+4.29.25+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" height="240" src="http://2.bp.blogspot.com/-lW_sHFsOBLk/UZ_cAK7eLOI/AAAAAAAAArk/swLTkbhdAhk/s320/Screen+Shot+2013-05-24+at+4.29.25+PM.png" width="320" /></span></a></div>
<span style="font-family: inherit;"><o:p></o:p><br />
</span> <br />
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<span style="font-family: inherit;"><o:p></o:p></span></div>
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<span style="font-family: inherit;">The T-wave changes of Wellens' Syndrome may be transient, may persist for months or might resolve with medical treatment. These patients are at extremely high risk of anterior wall MI.</span></div>
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</span> <b><span style="font-family: inherit; font-size: large;">Bottom Line: </span></b></div>
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<span style="font-family: inherit;">Wellens' Syndrome signifies a proximal LAD lesion that requires admission with early revascularization to prevent acute MI.<!--EndFragment--></span></div>
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<a href="http://1.bp.blogspot.com/-BtwJFWH5o8I/UaAcpwBde_I/AAAAAAAAZw8/pZQM_jiClvg/s1600/rezaie.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" src="http://1.bp.blogspot.com/-BtwJFWH5o8I/UaAcpwBde_I/AAAAAAAAZw8/pZQM_jiClvg/s1600/rezaie.jpg" /></span></a></div>
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<b><span style="font-family: inherit;">Salim Rezaie, MD</span></b><br />
<span style="font-family: inherit;"><span style="text-align: left;">(</span><a href="http://www.twitter.com/srrezaie" style="text-align: left;">@srrezaie</a><span style="text-align: left;">)</span></span><br />
<span style="font-family: inherit;">Clinical Assistant Professor of EM and IM</span><br />
<span style="font-family: inherit;">University of Texas Health Science Center at San Antonio</span></div>
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<span style="font-family: inherit;"><b>References</b><o:p></o:p></span></div>
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<ol>
<li><span style="font-family: inherit;">De Zwaan C et al. Angiographic and Clinical Characteristics of Patients with Unstable Angina Showing an ECG Pattern Indicating Critical Narrowing of the Proximal Coronary Artery. Am Heart J 1989 Mar; 117 (3): 657–65. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2784024">PMID: 2784024</a></span></li>
<li><span style="font-family: inherit;">De Zwaan C et al. Characteristic Electrocardiographic Pattern Indicating a Critical Stenosis High in Left Anterior Descending Coronary Artery in Patients Admitted Because of Impending Myocardial Infarction. Am Heart J 1982 Apr 102(4): 730–6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/6121481">PMID: 6121481</a> </span></li>
<li><span style="font-family: inherit;">Hanna EB et al. ST-Segment Depression and T-Wave Inversion: Classification, Differential diagnosis, and Caveats. Clev Clin J Med 2011 Jun; 78(6): 404–14. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21632912">PMID: 21632912</a> </span></li>
<li><a href="http://crc.sums.ac.ir/icarusplus/export/sites/crc/article-pdf/Electrocardiographic-predictors-of-proximal-left-anterior-descending-coronary-artery-occlusion.pdf"><span style="font-family: inherit;">Kojuri J et al. Electrocardiographic Predictors of Proximal Left Anterior DescendingCoronary Artery Occlusion. Cent Eur J Med 2009 Sept; 3 (3): 294 – 99. </span></a></li>
<li><span style="font-family: inherit;"> Mead NE et al. Wellen’s Syndrome: An Ominous EKG Pattern. J Emerg Trauma Shock. 2009; 2(3): 206–8. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776372/">PMC: 2776372</a></span></li>
<li><span style="font-family: inherit;">Simon K et al. The Natural History of Post Ischemic T-Wave Inversion: A Predictor of Poor Short-Term Prognosis? Coron Artery Dis 1994; 5: 937–42. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7719526">PMID: 7719526</a></span></li>
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