50 year old male with chest discomfort and excessive perspiration. P- 104/min BP - 90 systolic spo2 normal. No past history of any disease..

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Acute Coronary syndrome ( UA or NSTEMI ) Ecg shows ST depression in right and mid precordium probably subendocardial ischaemia A posterior wall infarct may be distinguished from a Sub endocardial ischemia by placing electrodes V 7 to V10 ( starting from left posterior axillary line backwards in a line till near spine ) If the Ecg Shows ST elevation in leads V7 to V10 it Signifies a posterior wall infarct but if it is a subendocardial isehaemia it will show only ST depression even ai those leads ( V7 to Vio) because the Subendocardium is always away from the electrodes wherever they are placed and always near to epicardium Management includes myocardial injury enzymes, repeated once again after 12 hours if the first one is found to be negative LMWH , Nitrates , Anti platelets , Beta blockers and statins though CAG and PTCA are ideal if facilities are available

your point is true Dr. dashan in case if it I. a posterior or right ventricular infarct but here without posterior electrode Ecg we cannot comment on posterior wall infarct and the likelihood of sub endocardial ischaemia is more and beta blocker should not be given in right ventricular infarct as the conduction pathways are already at risk due to rca involvement and even in acute anterior wall infarct I usually recommend beta blocker only with a word of caution that it may be used only if heart rate is more than 85 to 90 and blood pressure is more than 110/70 and regarding nitrates in RV infarct it may even initiate bezold jarisch reflex I recommend nitrates and beta blockers considering the likelihood of unstable angina / NSTEMI in this case and not posterior wall or right ventricular infarct

Acute Coronary syndrome ( UA or NSTEMI ) Ecg shows ST depression in right and mid precordium probably subendocardial ischaemia A posterior wall infarct may be distinguished from a Sub endocardial ischemia by placing electrodes V 7 to V10 ( starting from left posterior axillary line backwards in a line till near spine ) If the Ecg Shows ST elevation in leads V7 to V10 it Signifies a posterior wall infarct but if it is a subendocardial isehaemia it will show only ST depression even ai those leads ( V7 to Vio) because the Subendocardium is always away from the electrodes wherever they are placed and always near to epicardium Management includes LMWH , Nitrates , Anti platelets , Beta blockers and statins though CAG and PTCA are ideal if facilities are available

Nitrates are contraindicated in RVMI/IWMI. The guy needs fluids to maintain his RV Preload. I would refrain from giving Beta Blockers just as the patient is at a high risk of developing blocks and with an SBP of 90, on the verge of cardiogenic shock... He needs lysis of Cath.
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SBP 90 mm hg should be seen as cariogenic shock. drugs offered for ACS that lowers Bp , shall be reviewed accordingly. dobutamin can be offered in such case for hemodynamic stability.

Acute coronary syndrome -Posteriorwall MI

posterior wall mi

Tall R in V1,V2 with ST depression in V1V2 and upright T in V1 V2 are suggestive of Classical Acute Posterior wall Myocardial Infarction. Precordial 'Mirror image' sign. Right sided leads also should be obtained as Posterior is accompanied with RVMI. Nitrates are clearly contraindicated as Preload is to be maintained .He has borderline BP So, Beta blockers are not advisable. fluid challenge should be given if heart failure signs are absent (Basal crepts) Should recieve Loading Antiplatelet Thrombolysis,Low molecular weight Heparin,Statin and to be planned for Primary angiography( if presented early and is affording).

Sinus rhythm hyper acute t wave in Inferior leads with st depression in lead v1to v4 Probably inferoposterior mi.R/S ratio more than 1in lead v 1andv2.tocofirm post mi take v7to v9 . cardiac enzymes,Sr ECG, Echo,

Infero-Posterior STEMI. R/o RVMI (V4r). May progress to cardiogenic shock or already be in cardiogenic shock...

Anteriolateral wall infarction with old inferior wall infarction with pulmonary hypertension.

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