9/1 Morning Report w/ Teresa: MI Mimic

An elderly male w/ CAD and prior MI, afib, CHB now paced, HTN presents with chest pain “that feels like my last MI”. He had a fairly negative workup and was treated briefly with heparin for MI vs PE, but this was ultimately stopped when LFTs showed transaminitis with a late-peaking bilirubin, most consistent with a passed stone.
How do I interpret signs of ischemia in someone who is ventricular-paced? (Hint – there’s no foolproof way…)
-Compare to prior EKGs and look for changes
-Most pacemakers pace from the RV yielding a LBBB pattern; hence, you can consider using Sgarbosa criteria but these are less specific for ischemia in RV pacing. Other criteria have been proposed (http://en.ecgpedia.org/index.php?title=MI_Diagnosis_in_LBBB_or_paced_rhythm ) but if you’re clinically worried about ACS, call cards!
-Look for ANY non-paced beats that conduct via the AV node (ie narrow QRS). All of these native beats are still interpretable for ischemia
The definition of hepatojugular reflux:
We discussed this often confusing physical exam maneuver. The most important thing is that you hold pressure for at least 10-20 seconds to see if the rise in JVP sustains – if it sustains that long, then the test is abnormal. Normal subjects will have a JVP that rises initially but returns to normal within seconds.

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