A 45year old male presented with complaints of Dyspnea on exertion and pain in chest left side esp after heavy metals and exertion. T wave inversion are present in V3,V4,5,6,I,avl and ST depression in lead II I have started treatment for CAD and started on lipikind AS at bedtime. please give your valuable inputs about further workup and treatment.

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NSR Left Axis Deviation, LAHB Anterolateral wall ischemia Voltage criteria do not fit in with LVH . P wave is normal and there is no bifid P . X-ray is suggestive of LVH. ECHO is the best indicator of LVH. History is suggestive of effort angina / stable angina Suggest cardiac work up for risk factors and correct them . Anti anginsls, antiplatelets, Statins. If symptoms persist after maximising medical management, angio can be considered . Studies indicate that in stable angina, maximising medical treatment is as effective as PTCA

1 PAIN CHEST AFTTER EXERTION + HEAVY MEALS = SUGGESTIVE OF IHD EFFORT ANGINA 2 SOB AFTER EXERTION = IN THIS PT DUE TO IHD DIMINISHED CARDIAC RESERVE 3 CXR ,= LV TYPE CARDIOMEGALY 4ECG = LVH ( STRAIN PATTERN ) RECOMMANDATIONS 1 ECHOCARDIUM 2 STEESS ECHOCARDIUM 3 LUNG FUNCTION TEST 4 BLOOD SUGAR CREATININE TLC DLC HB RX PL CONTINUE MEDICINES

Adv colour Doppler study to evaluate for mitral valve pathology considering LA and LV dilatation. As ECG shows left axis deviation, and Echo CD confirm lv dilatation, possibility of hypertensive changes are high. Adv TMT Bp monitoring Betablokers. Diuretics would be helpful.till that time continue antiplatelets statins etc.

St-t depression in L1L2 avl v3v4v5v6 Suggest inferolateral ischimia

Thanx dr Dinesh Gupta
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Continue as u started but also needs to do Echo and biomarkers otherwise may land up in massive injury.

ECG shows inferolateral ischemia Adv:CPK MB, TroponinI Echocardiography

Inferolateral wall ishchemia with mild LVH Investigate : ECho CPK MB , TROPONIN I Treatment is ok

Sinus rhythm, LVH with strain, also inferolateral ischemia is possible particularly given pts symptoms Management depends on time frame of pts symptoms If pt. coming with active chest pain, then needs to be managed as unstable angina. Also chest pain is of less than 2 weeks duration should be managed as unstable angina. In both scenarios pt. will need to be admitted and managed with DAPT (dual antiplatelets), high dose statin, control of BPand beta blockers Anticoagulation with unfractionated heparin or LMWH or Fondaparinaux should be given if active chest pain at rest After this needs CAG and intervention ( PCI OR CABG) However no active chest pain now only history and duration of chest pain more than 2 weeks then can be managed as stable angina Again maybe single anti platelet, statins, anti hypertensives and antianginals should be used Stress ECG alone is poor choice as pt. has baseline ST-T changes and any further change on stressing the pt. will not be reliable so if at all stress test is selected then should be thallium or echo imaging The other reliable test in stable angina is CT calcium scoring which correlates well with underlying CAD if score is more than 400. It is cheap and can be done without contrast CAG can be done if any of the above modality is positive for ischemia but decision for intervention depends on what CAG is showing If pt. has left main or severe 3VCAD then CABG should be done However if these 2 scenarios are not there on angio then stable angina pts with lesser disease severity can be managed medically as was shown in multiple studies like COURAGE, BARI 2D and just in 2019 ISCHEMIA trials which all showed medical treatment is equivalent to intervention However discussion should be done with the patient and his preference should be respected

T wave inversion in I, AVL,V3-V6..... suggest Ischaemia... Advise to Angiography

Definitely anterolateral ischemia do 2 decho tropi & t then decide angiography

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