Peculiar association of pulmonary embolism with evolved inferior wall myocardial infarction

Inferior wall myocardial infarction (MI) is one of the common straightforward cardiac conditions in the emergency department (ED) but inferior wall MI masquerading pulmonary embolism (PE) is extremely rare and can be missed if not evaluated promptly in ED. Misdiagnosis of PE is associated with high mortality. Here, we report a case of a 67-year-old male who was admitted to the ED and has been diagnosed with evolved inferior wall MI based on his clinical presentation and electrocardiogram. Later, he developed syncope following which he was reassessed and evaluated for the other possible conditions. Bedside echocardiography findings raised suspicion for PE, which was further confirmed by computed tomography pulmonary angiogram (CTPA). The patient underwent successful thrombolysis and was scheduled for an elective coronary angiogram. This case report highlights the importance of clinical presentation and the benefits of bedside echocardiography that helped in suspecting the association of PE with evolved inferior wall MI

Type 2 myocardial infarction resulted from the left thoracic stomach

Abstract The universal definition of myocardial infarction (MI) provides five subtypes of acute myocardial infarction (AMI). We present an interesting case of a type 2 myocardial infarction caused by the dilation of the left thoracic stomach.

Preponderance of Inferior Wall Myocardial Infarction in Smokers with no other Cardiovascular Risk Factors

Introduction: Smoking is an independent risk factor forischemic heart disease and acute myocardial infarction.Smoking raise both heart rate and blood pressure, thusincreasing myocardial oxygen demand, moreover it alsodecreases the dimension of coronary vessel and coronaryblood flow. Inferior wall Myocardial Infarction is consequenceof disease in usually Right coronary artery, whereas anteriorwall Myocardial Infarction is usually disease in left coronaryartery. The aim of the study is to evaluate whether smokinginfluence the incidence of inferior wall MI (Right coronaryartery). Study objective was to find out whether there was anassociation between smoking and inferior wall MyocardialInfarction and an early association of atherosclerosis andischemic heart disease with smoking.Material and methods: 126 patients of ST ElevationMyocardial Infarction admitted from the outdoor patientdepartment/ emergency department/ Cardiology OPD inMMIMSR, Mullana, Ambala, considered for study. Thosewho are willing to participate and fulfilling the inclusion andexclusion criteria.Result: In our study there was a high proportion of smokerin patient with inferior wall MI than other location of MI.Smokers were prone to get myocardial infarction at a youngerage as compared to others. Mortality was higher in anteriorwall MI as compared to Inferior wall MI. Anterior wall MIpresented with more complications i.e. cardiogenic shock andarrhythmias.Conclusion: Smoking enhance the risk of inferior wall MImore than other MI. Smoking thus appear to adversely affectthe Right coronary artery to greater extent than left coronaryarterial circulation by mechanism yet to be explored. Smokingleads to ischemic heart disease at early age.

Clinical profiling of right ventricular infarction in patients with acute inferior wall myocardial infarction

Background: Incidence of Right Ventricular Myocardial Infarction (RVMI) associated with Inferior Wall Myocardial Infarction (IWMI) is reported to be quite high (30%-50%). To diagnose coexisting RVMI is important, since its early recognition and proper treatment reduces overall morbidity and mortality in IWMI. Author assessed the incidence and clinically profiled patients with right ventricular infarction in acute inferior wall myocardial infarction and analysed the effects of RVMI on clinical outcome of IWMI.Methods: A total of 150 patients of IWMI were evaluated in the present hospital based prospective observational study over duration of two years. They were evaluated for coronary risk factors like diabetes mellitus, hypertension, smoking, obesity, alcohol and dyslipidemia. Twelve-lead ECG, cardiac enzyme assay and echocardiography were undertaken in all the participants.Results: Of the total 150 patients, 45 (30%) patients had right ventricular myocardial infarction (RVMI). Complications were significantly lower in patients with isolated IWMI as compared to patients with IWMI and associated RVMI except pulmonary edema (p<0.05). Of the total 22 (14.67%) deaths in the present study, 18 (12%) had associated RVMI and 4 (2.66%) isolated IWMI, the difference being statistically significant.Conclusions: Involvement of right ventricle increases rate of complications as well as the mortality rate in patients with inferior wall myocardial infarction.

Characteristics of the inferior wall hypertrophy in hypertrophic cardiomyopathy patients with contrast echocardiography / 生物医学工程学杂志

We tried to explore the value of contrast echocardiography (CEcho) on evaluating hypertrophic cardiomyopathy (HCM) with the inferior wall hypertrophy. A total of 114 patients with HCM were investigated. All the patients received CEcho and routine echocardiography (Echo), and 45 of them received cardiac magnetic resonance (CMR) and 47 of them received Holter. The frequency and percentage of inferior wall hypertrophy were analyzed in HCM patients, as well as the structure and function. The results showed that: (1) Inferior wall hypertrophy was detected in 55 patients (48%) by Echo, while 68 patients (60%) by CEcho. (2) There was no significant difference between CMR and CEcho in the measurement of inferior wall at end-diastole and end-systole. Thickness of inferior wall by CEcho tended to be higher than CMR. However, the inferior wall thickness measured by Echo was obviously lower than that by CMR ( < 0.05) and CEcho ( < 0.05). (3) Bland-Altman plot suggested good consistency between CEcho and CMR in measuring inferior wall thickness. 95% CI of mean differences in inferior wall thickness between CEcho and CMR were smaller in HCM patients as compared with that between Echo and CMR. Unary linear regression analysis showed good degree of fitting between CEcho and CMR. (4) Holter showed that HCM patients with inferior wall hypertrophy were likely to have higher incidence of premature ventricular complexes (PVC) ≥ 500/24 h. We demonstrate that CEcho is rather sensitive in detecting inferior wall hypertrophy. Echo may underestimate the inferior wall thickness. The risk of ventricular premature beats may increase in HCM patients with inferior hypertrophy.

A case of resolution of inferior wall myocardial infarction and varying degrees of atrioventricular block: a case report.

Inferior wall myocardial infarction (IWMI) complicating with high degree atrioventricular (AV) block had been a subject of discussion for a long time. Also the transient nature of these AV blocks in the presence of IWMI is well known to us. However our case presented with IWMI with right ventricular MI (RVMI) and in complete heart block and subsequently post thrombolysis developed varying degrees of AV block and reverted back to sinus rhythm. We found it as an incidence not much reported and thus reporting the case herewith.

Mechanical Extraction of a Massive Intracoronary Thrombus from the Super-Dominant Right Coronary Artery in Thrombogenic Lung Cancer Patient

The congenital absence of the left circumflex artery and a compensatory super-dominant right coronary artery (RCA) is a very rare benign coronary anomaly in the clinic. The presence of a massive thrombus in the super-dominant RCA can lead to fatal results in cases of acute myocardial infarction, unless the thrombus is mechanically removed. Aspiration of the thrombus using a 6 Fr right Judkins guide catheter is useful to extract a massive thrombus and is both safe and effective. We report a case of complete revascularization of the super-dominant RCA after thrombus aspiration using a 6 Fr Judkins right catheter in a patient with acute inferior and inferolateral wall myocardial infarction.

Value of electrocardiogram (ECG) in identifying acute occlusion sites of right coronary artery / 中华全科医师杂志

Clinical data of 151 patients with acute occlusion of right coronary artery were retrospectively analyzed.Coronary angiography and electrocardiography (EEG) were performed in all 151 patients,angiography showed proximal-middle segment occlusion in 114 cases and distant segment occlusion in 37 cases.The correlation of ECG findings with coronary artery occlusion sites was analyzed.Results showed that EEG findings related to proximal-middle segment occlusion were:ST segment elevation in lead V4R ≥0.05 mV,Ⅲ degree atrioventricular block,ST segment depression in lead Ⅰ ＞0.1 mV,ST segment depression in lead AVL≥0.2 mV,ST segment elevation in lead l ≥0.25 mV,the total ST depression in lead V2,V3 and V4 ≥0.4 mV,the total ST depression in lead Ⅰ and aVL ≥0.25 mV;among which ST depression of Lead Ⅰ ＞0.1 mV,ST elevation of Lead V4R ≥0.05 mV and Ⅲ degree atrioventricular block were used to predict occlusion of proximal-middle segment of right coronary artery with 100％ specificity.ECG findings related to distal segment occlusion were:ST depression in lead Ⅰ ≤ 0.1 mV,ST segment depression in lead AVL ＜0.2 mV,ST elevation in lead Ⅲ ≤0.25 mV,the total ST depression in lead V2,V3 and V4 ＜ 0.4 mV,ST segment were not depression in lead V1-V5,the total ST depression in lead Ⅰ and aVL ＜ 0.25 mV.Based on a 4-step flow method,ECG might be adopted to identify the acute occlusion sites in proximal-middle segment and distal segment of right coronary.

Application of pulse-indicated continuous cardiac output in patients with acute inferior wall myocardial infarction / 心血管康复医学杂志

Objective: To explore the guiding significance of transpulmonary thermodilution pulse-indicated continuous cardiac output (PiCCO) in treatment for patients with acute inferior wall myocardial infarction (AIMI). Methods: A total of 26 AIMI patients in intensive care unit of cardiology department in our hospital from Jul 2012 to Jan 2014 received PiCCO and ultrasonic cardiography (UCG) to monitor cardiac output (CO) and cardiac index (CI), and their correlation analysis. Results: When PiCCO placement and after placement 72h， PiCCO monitoring CI were （2.77±0.77）L•min-1•m-2, (3.17±0.39) L•min-1•m-2 respectively, there was significant difference（P＜0.01）, UCG measured CI were (2.49±0.64）L•min-1•m-2, (2.63±0.24) L•min-1•m-2, there was no significant difference（P＞0.05）; PiCCO monitoring CO were（4.78±1.06）L/min, (5.08±1.53) L/min respectively, there was significant difference（P＜0.05）, UCG measured CO were（4.51± 0.86）L/min, (4.57±0.91) L/min, there was no significant difference（P＞0.05）; and CI，CO measured by PiCCO were significantly higher than those of UCG group (P＜0.01 both) after PiCCO placement 72h. Conclusion: Pulse-indicated continuous cardiac output can offer more sensitive hemodynamic indexes compared with UCG, which possesses important treatment guiding significance in patients with acute inferior wall myocardial infarction and unstable hemodynamics.

Role of cardiac MRI in acute myocardial infarction.

Mortality in patients with acute myocardial infarction (AMI) has decreased significantly and appears to be the result of current reperfusion therapeutic strategies. Reperfusion itself may develop into reperfusion injury. Therefore, management of these patients poses several challenges, such as diagnosing and managing heart failure, identifying persistent or inducible ischaemia, estimating the need for anticoagulation, and assessing overall cardiovascular risk. This case presentation will demonstrate the impact of cardiac magnetic resonance imaging (MRI) in the assessment of the pathophysiology of AMI in the current reperfusion era. Cardiac MRI can provide a wide range of clinically useful information which will help clinicians to manage and choose specific therapeutic strategies for AMI patients.

Study of Operative Approach of Temporary Cardiac Pacing Therapy in Patients with Acute Inferior Wall Myocardial Infarction Complicated by High Degree Atrioventricular Block / 昆明医科大学学报

Objective This study was purposed to analyze and summarize the vein temporary cardiac pacing therapy in patients with acute inferior wall myocardial infarction complicated by high degree atrioventricular block (AVB) . Methods One hundred and twelve patients with acute inferior wall myocardial infarction complicated by high degree AVB were selected as observation and research subjects, and they were treated by vein temporary cardiac pacing therapy. The safety, availability of different kinds of this surgical methods and the relationship between these surgical methods and complication were observed. Results Three out of 60 patients who were treated by ordinary temporary pacing electrode catheter were suffering from cardiac tamponade. No serious complications occurred when 52 patients were treated by floating temporary pacing electrode catheter. Conclusion Floating temporary pacing electrode catheter have already proved safe and effective in the treatment of acute inferior wall myocardial infarction complicated by AVB, and it could decrease the incidence of serious complications such as myocardial perforation.

Significance of terminal QRS distortion on the electrocardiogram in acute inferior myocardial infarction / 中国医师进修杂志

Objective To investigate whether terminal QRS distortion on the electrocardiogram in acute inferior myocardial infarction could be as a standard for the infarct-related artery,through comparing to coronary angiography.Methods Fifty-seven patients with acute inferior myocardial infarction were enrolled,among which,the right coronary artery (RCA) occlusion (RCA occlusion group) was present in 29 cases,and left circumflex coronary artery (LCX) occlusion (LCX occlusion group) was in 28 cases.The changes of electrocardiogram was analyzed in 12 hours after the acute episode.Results The incidence of terminal QRS distortion in leads Ⅱ,Ⅲ,aVF in RCA occlusion group was 44.8％(13/29) and 39.3％(11/28)in LCX occlusion group,and there was no significant difference (P ＞ 0.05).The incidence of terminal QRS distortion in leads V4R-V5R in RCA occlusion group was 17.2％(5/29) and 7.1％(2/28) in LCX occlusion group,and there was no significant difference (P ＞ 0.05).The incidence of terminal QRS distortion in leads V7-V9 in RCA occlusion group was 6.9％(2/29),which was lower than that in LCX occlusion group[53.6％(15/28)],and there was significant difference (P ＜ 0.05).For identifying LCX as the infarct-related artery of acute inferior myocardial infarction,the sensitivity,specificity,positive and negative value in terminal QRS distortion in leads V7-V9 were 53.6％ (15/28),93.1％ (27/29),88.2％ (15/17),67.5％ (27/40).The area under curve of terminal QRS distortion in leads V7-V9 in identifying LCX as the infarct-related artery of acute inferior myocardial infarction was 0.733 (95％ CI 0.599-0.868).Conclusion Terminal QRS distortion in leads V7-V9 may be of diagnostic value in identifying the infarct-related artery in acute inferior myocardial infarction.

Pseudo-infarct in ECG in A Case of Asymmetric Septal Hypertrophy.

A 68-year-old male with a history of type 2 diabetes and hypertension presented for a routine check-up. His routine ECG revealed recent inferior infarct. He was admitted and later echocardiography showed it to as asymmetric septal hypertrophy. The ECG findings of the disease and various causes of pseudo-infarct are discussed.

The value of differential diagnosis of the configuration of QRS complex in lead aVR in patients with inferior wall myocardial infarction / 中国综合临床

Objective To investigate the value of differential diagnosis of the configuration of QRS complex in lead aVR in patients with inferior wall myocardial infarction. Methods The configuration of QRS in 52 patients with pathological Q-wave both in lead Ⅲ and aVF were analyzed and the result of selective coronary arteriography was compared. Results 13 patients with the configuration of QRS in lead aVR appeared rS ( s), while 10 patients appeared QS(qs) and 29 Q(q)r,correlated with 12,4 and 0 patients with coronary arteriography showed stenosis or occlusion lesion in fight coronary artery or left circumflex artery (χ2 = 35.56, P = 0.000). Conclusions The con-figuration of QRS in lead aVR is helpful to differential diagnosis of the patients with pathological Q-wave both in lead Ⅲ and aVF. Patients with the configuration of QRS in lead aVR appear rS(s) could be diagnosed as old myocardial infarction,but excluded from old myocardial infarction while appearing Q(q)r.

Right ventricular myocardial infarction: echocardiographic evidence among patients with inferior wall myocardial infarction.

Right ventricular myocardial infarction (RVMI) predominantly a complication of inferior wall myocardial infarction is a distinct clinical entity in which major hemodynamic disturbance may occur. Bedside hemodynamic measurement, electrocardiography, gated blood pool radionuclide angiography and echocardiography are used to identify right ventricular involvement in setting of inferior wall infarction. RVMI as assessed by various diagnostic methods accompanies 30 to 50% of inferior wall infarction. We studied 37 consecutive patients of acute inferior wall infarction (by non invasive method) to determine echocardiographic evidence of RVMI and compared its sensitivity to electrocardiography and clinical criteria. On echocardiography 12 out of 37 patients (32%) had right ventricular involvement. Kussmaul’s signs was present in 27% of the patients and it had sensitivity of 50%, specificity of 88% and predictive accuracy of 70%. Right sided precordial leads (V3R – V4R) on electrocardiography showed evidence of RVMI in 30% of patients with sensitivity, specificity and predictive accuracy of 67%, 88% and 73% respectively. Echocardiographic features included enlargement of right ventricle and hypokinesia or akinesia of right ventricular wall. Right ventricular dilatation and dysfunction is gained from relative right and left ventricular dimension on echocardiography. It is more sensitive and specific than clinical signs and ECG.

ST Segment Depression in Lateral Leads in Inferior Wall Acute Myocardial Infarction

BACKGROUND: The electrocardiogram may provide valuable information regarding the identity of the culprit coronary artery and the location of obstructing lesion within the artery, which may be of guidance in selecting the therapeutic modality. Previous studies have concluded that changes in lateral leads (I, aVL, V5, V6) are predictive of left circumflex coronary artery obstruction in inferior wall acute myocardial infarction. Elect-rocardiographic criteria for determining the location of the obstructing lesion, however, have not been well established. The purpose of this study is to investigate the patterns of ST segment depression in lateral leads in inferior wall acute myocardial infarction and the obstruction site of culprit artery according to ST segment depression in lateral leads. METHODS: We examined 78 patients with inferior wall acute myocardial infarction analizing their electrocardiogram and coronary angiography which performed during acute hospitalization. RESULTS: Of the fifty-five patients in which the culprit artery could be determined, 1)in 41 the culprit artery was the right coronary artery (19 proximal to the right ventricular branch and 22 distal), and in 14 the left circumflex coronary artery (7 proximal to the first obtuse marginal branch or involving a high first obtuse marginal branch, and 7 with distal obstruction). 2)Significant ST depression (ST< or =1 mm) in leads I and aVL was more common in right coronary artery obstruction (p<0.05 and p=0.01 respectively) than left circumflex artery. 3)It was difficult to define the location of obstruction with ST segment change of lateral precordial leads (V5, V6). CONCLUSIONS: In acute inferior wall myocardial infarction, ST segment depression in lateral limb leads (I, aVL) can be indicative of the right coronary artery obstruction and the ST segment depression pattern in lateral precordial leads was not indicative of the site of obstruction.

Clinical Study of Orbital Wall Fracture

The authors studied 229 patients (236 eyes) diagnosed with orbital wall fracture from April 1991 to December 1995 at Severance hospital with retrospective reviewing of the charts and orbital computed tomographs. Orbital wall fracture occurred most frequently between the ages of 20 and 29 years (mean age 25.7 years). It was more common in male (81.7%) than female (18.3%), about 4.5 times. Most patients were seen for management within 7 days after injury (66.4%). The causes of orbital wall fractures were violence (54.1%), traffic accidents (14.8%), falling down (7.9%) and others in order. Most common coexisting intraocular disease was hyphema (13.5%) and extraocular disease was eyelid laceration (15.3%). The difference between two eyes in initial exophthalmometry was 1.4 mm on average, and the patients with 1mm or less difference between two eyes allowed for the largst proportion of patients (57.2%). The number of patients with the presentation of binocular diplopia was 181 (79.0%), and the most of the complained of mild binocular diplopia (46.3%). As to the location of fracture, inferior wall fractures were most common, followed by fractures of medial (21.6%), inferior and medial (18.6%) and others in order. The number of patients operated for orbital wall fracture was 107 (47.0%), and the most common indication for surgical intervention was binocular diplopia caused by limitation of extraocular motor movement (49 cases, 45.8% of operated case).

Large Aneurysm Arising from the Inferior Wall of the Segment of the Posterior Communicating Artery

Seven patients with large aneurysm of the inferior wall of the internal carotid artery were treated during a recent six-year period; this report presents the findings. In this type of aneurysm, the neck arises from the ventral surface of the internal carotid artery at the level of the segment of the posterior communicating artery(PComA). As is the case with the ventral paracliniod type, the treatment of the this aneurysms presents the surgeon with technical problems involving safe exposure and clipping. The incidence of female patients was high, and aneurysms were large; in all cases, the clinical presentation was subarachnoid hemorrhage. In three cases, clipping was incomplete. During surgery, the neck of the aneurysms was hidden by the segment of PComA, and the dome adhered to the PComA and to the anterior choroidal artery. The outcome was considered good in five patients; one, however, was moderately disabled, and one died. We classified these aneurysms as separate from those of the internal carotid artery-PComA junction, and described their surgical treatment and related problems.

Significance of three electrocardiographic indexes in predicting the myocardial infarct-related artery in inferior wall of acute myocardial infarction / 中国介入心脏病学杂志

Objective To investigate the significance of three electrocardiographic indexes in predicting the myocardial infarct related artery (IRA) in inferior wall of acute myocardial infarction (IAMI) Methods One hundred and twenty patients with IAMI were studied Results (1) IRA was related to right coronary artery (RCA) in 98 (81 7%) case, left circumflex branch (LCX) in 22 (18 3%) cases (2) ST segment depression in lead Ⅰ identified RCA occlusion with a sensitivity of 77 6%, specificity of 90 9% in patient with IAMI, but isoelectric or elevated ST segment in lead Ⅰ identified LCX occlusion with a sensitivity of 90 9%, specificity of 77 6% (3) About QRS wave of lead aVL, S/R≥1/3 identified RCA occlusion with a higher sensitivity of 93 9% and a lower specificity of 63 6% (4) When IRA was RCA, ST segment elevated amplitude Ⅲ≥Ⅱ identified as a diagnostic index no matter the location of occlusion Conclusion Three electrocardiographic indexes have significant value in predicting the infarct related artery in inferior wall acute myocardial infarction