68Y F K/c/o CAD - TVD(NSTEMI), Post PTCA - Stenting to LCX(2011), LV Apical Aneurysym with LV Clot, DMtype2, Systemic HTN now presented with Left sided chest pain radiating to left arm & upper back associated with sweating & palpitations since 1 day. Pt. is on Ecospirin, Clopidogrel, Metoprolol & Sorbitrate. Kindly give your valuable opinion on ECG & Management of this case.

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Pl rule out wrong lead placement else strong possibility of pulm embolism

I agree with Dr.mohan B

Rad ant wall mi resolving qs v2 v4 t inv v5 v6 but s wave prominent lead 1 t inv lead 3 r wave prominent v2v4 rvh pulmonsry emboli plz rule out echo ct chest angio or as per d dimer carry other test repeat ecg

avr in this +ve echo imp chest pain
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compare with old ecg adv tropt 2d echo check cag

imidiatly go for cabg and implant paste maker to patient but should be temporary single chamber then rule out cardiac threshold ,gap,pulmonary ambuligum. dispute all of this an lvef should be Mounters with two d echo cardio grafic shouldn't be less then 20% EF and immediate and endocrinologist intervention and necrologist intervention also should be their.

possibility of lead misplacement since avr is positive apart from that shows old asmi with st uptake which may be persistent due to LV apical aneurysm and lateral wall shows changes so how is his labs, echo can do cag and proceed look for myocardial viability to decide on benefit of revascularisation .If LV dysfunction there then with LV clot and apical aneurysm she will benefit from anticoagulant in addition to DAPT.

First to note that there is an electrical lead switch giving appearance of dextrocardia He will need to be investigated further for aortic aneurysm in addition to routine work up for ongoing ischemia

Ecg suggestive of evolved awmi there is also lead misplaced manage as acs needs anticoagulation if ongoing chest pain needs revascularization

stent thrombosis ? angiography is advised

chest pain is there since last 24 hours. so there is no role of thrombolytic agents, ecg is showing anteroseptal myocardial infarction, manage with anti platelets and heparin, nitrates if required. repeat 2d echo again. if there is a presence of clot in LV then start patient with tablet warfarin 2.5 mg od on discharge and check is PT, INR After every 7 days, instead of warfarin, newer molecules like dabigatran or rivoraxaban can also be tried if patient is affordable

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