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Wednesday, 26 March 2014

Spring 5 - Severe Aortic Stenosis

Welcome to another weekly case on ECGclass. 
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Enjoy. :)

#ECGclass  Spring 5

A 49yr old man presents to his GP with a 6 month history of chest pain.

Sometimes this is triggered by exertion, but sometimes it occurs at rest. 
It can be prolonged, often lasting several hours and on occasions, all weekend.

He considers himself fit and active, so he light-heartedly dismisses his symptoms. 
His job involves heavy labour, but he 'works through' his mild discomfort, which is very localised in the left upper chest, without radiation. 

Other than this, he feels great. 
He only came to see you under duress, from his wife, and feels he is wasting your time, and is keen to get back to work. He is self-contracted and tells you "Time, is money" 

He has no arm pain, no dizziness, and no breathlessness.

He is a non smoker, with no risk factors for IHD, and is not on any medication. 
His BP is normal, as always. However, you do hear a systolic heart murmur at the left sternal edge.

You obtain the ECG below:

What now?

He's sitting in front of you, feeling 'great' and looking clinically well.  

At the time of his consultation/ECG, he is pain free, but he admits the pains can come and go several times a day.

How are you going to take this consultation forward?

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If you want to ask the patient any questions, or request any further information this can  be done by the live hashtag during the course of this evening.   

(Alternatively, if you are referring to this blog at a later date, please leave any comments below).

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Widespread T-wave inversion with chest pain at rest. 

On the basis of his resting pain, and ECG changes, it wouldn't be wrong to admit this man.  Given his dismissive nature, he may take some persuading, but with rest symptoms he is at risk.  You can't reassure him that nothing adverse will happen if he stays at home.

At very least, it should prompt an urgent referral to the RACPC. With this ECG and rest pains, it's quite likely he'll be admitted directly from RACPC anyway!

In the meantime he should be started on aspirin/beta-blocker and a statin and given GTN/999 advice. The referral should include his ECG and make note of the murmur. 
(Note: Not all RACPC are set up with ECHO facilities, so if this information is included in the referral, an "ECHO on arrival" request can be made by the clinician receiving the referral).

In this case, an ECHO confirmed severe Aortic stenosis. 
As such, an  ETT is contraindicated.
He needs same day admission for monitoring, and an in-patient work up for diagnostic cardiac catheterisation.

It's not uncommon to see marked LVH with prolonged severe Aortic stenosis. The above ECG shows no voltage criteria for LVH, and we know he is normotensive.

Below is another example of severe AS, this time, causing the typical 'strain' pattern seen with LVH:

Note the similarities in the two ECG's. 
However, in this second example, there is gross voltage criteria for LVH (fulfilled in Leads I, aVL, V1-6). 
There is widespread T-wave depression, and  (typical of LVH)  T-wave inversion in the leads which face the left ventricle (i.e. leads I, aVL, v4-6).

Here however, T-wave inversion is also seen in leads V2 and V3.  This is suggestive of other pathology, such as co-existing coronary disease.

Lesson of the week - Don't let the stoical nature of some patients disarm you!! Go with your instinct  and advise accordingly.  :-) 

Thank you. 

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