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LITFL • Life in the Fast Lane Medical Blog

Emergency medicine and critical care medical education blog

| ECG Library | Myocardial Ischaemia

by Edward Burns , Last updated

This page covers the ECG signs of myocardial ischaemiaseen with non-ST-elevation acute coronary syndromes ( NSTEACS ). ST-elevation and Q-wave myocardial infarction patterns are covered elsewhere: ASOS Wide Fit Driving Shoes In Suede With Tie Front n6wa0gQ
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NSTEACS

Myocardial Ischaemia Background

Non-ST-elevation acute coronary syndrome ( NSTEACS ) encompasses two main entities:

Both produce the same spectrum of ECG changes and symptoms and are managed identically in the Emergency Department.

NSTEMI
Two main ECG patterns associated with NSTEACS:

While there are numerous conditions that may simulate myocardial ischaemia (e.g. left ventricular hypertrophy , digoxin effect ), dynamic ST segment and T wave changes (i.e. different from baseline ECG or changing over time) are strongly suggestive of myocardial ischaemia.

Other ECG patterns of ischaemia

Horizontal or downsloping ST depression ≥0.5 mm at the J-point in ≥ 2contiguous leads

Examples of ST segment morphology in myocardial ischaemia

ST depression due to myocardial ischaemia may be present in a variable number of leads and with variable morphology:
subendocardial ischaemia reciprocal change
T wave inversion may be considered to be evidence of myocardial ischaemia if:

There are two patterns of T-wave abnormality in Wellens’ syndrome:

critical stenosis of the left anterior descending artery

Wellens’ Type 1

Wellens’ Type 2

The following changes may occur with myocardial ischaemia but are relatively non-specific:

Example 1

Subendocardial ischaemia:

Example 2

Reciprocal change:

Example 3

Wellens’ Syndrome:

Example 4a

Dynamic ST depression in a patient with chest pain:

Example 4b

I highly recommend Fats that Heal, Fats that Kill (although it’s fairly technical) and The Cholesterol Myths — particularly the graphs in The Cholesterol Myths that show how the data were MANIPULATED to falsely portray saturated fats and cholesterol as contributors to heart disease. Always check your sources WELL. The US government continues to spout this same nonsense, and I’ve literally even seen them do it ON THE SAME PAGE with a chart of their own data that contradicts their claims. Lots of sources are quick to say “saturated fat is bad”; few, if any, have any corroborating evidence.

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Weston Price was not funded by any grants, as all studies today are, ie, no strings. He was funded by himself and had no preconcieved goals except to find out what was causing the sudden rise in health problems he was seeing. He spent 9 years traveling the world looking for the healthiest peoples and comparing them to their sickly neighbors. Saturated animal fats or palm and coconut oils took up 80% of the calories of the healthiest peoples he found. Tribe after tribe after tribe. Later, when cholesterol was able to be measured, in the 70’s I believe, another researcher went back to the massai, one of the cattle keeping people Price had chronicled, and found their total cholesterol was150 or below. This was a culture that lived largely on a gallon of full fat goat, cow and sheep milk a day per person. I would rather trust these studies than Harvard because all the universities get funding from drug companies to, ahem, support the drug industry. What it boils down to is how does YOUR body respond to these things? That may have to be something you personally do yourself. I found my body lowered cholesterol levels in the use of butter and more fats down to 150, hdl and ldl evenly divided at 75 each. So I know we are all different and need to find our demon foods and healthy foods and work with them accordingly. In fact, when I take pufas, I tend to get gallstones. I haven’t found that in any articles I’ve read today on pufas, ( researching for family) but if I plug in the search terms I bet I will find something on that.

Reply

The Harvard article fails completely at demonstrating saturated fats are unhealthy. It provides absolutely NO resources in the “saturated fat is bad” section. In fact the only reasoning they seem to have is that our bodies can produce saturated fat. That’s hardly an infallible argument. The Harvard link also fails to compare polyunsatured fat intake to saturated fat intake in any of its resources. It only compares higher unsaturated fat intake with high carbohydrate intake. In the Wikipedia link, the sources you mention (19-28) prove nothing. In fact, resource 19 demonstrates that saturated fatty acids raise HDL (good) cholesterol far more than LDL (bad) cholesterol! Most of the other resources involved studies on non-human primates, hamsters and mice–not humans. And the seven countries study? That study is heavily flawed. It did not examine a random selection of countries (only those Keys hand-picked) nor did it look at total mortality, longevity or any other factors other than fat intake.

Reply

As Dr. Keys warned Americans about the dangers of saturated fat, consumption of animal fats and butter declined.

The main component of animal fats is saturated fats. Omega 6 fat content is vanishingly low. Both butter as well as beef tallow are similar in composition.

Vegetable oils such as corn, by contrast have low level of saturated fats, but are very high in polyunsaturated fats, the majority of which is omega 6. There is virtually no omega 3 fats here.

Going back to the Seven Countries Study, the emphasis of modern nutrition until recently was to replace saturated fats with polyunsaturates. This at first led to the explosion of trans fats. Once that danger was recognized, it no longer appeared that saturated fats were dangerous at all.

Over the ensuing decades, the consumption of animal fat continued to fall. After remaining stable from 1900-1950, it began a relentless decline under government exhortations to reduce saturated fats.

The dialogue began to change beginning in the late 1990s due to popularity of higher fat diets such as the Atkins diet. Indeed, Dr. Atkins wrote in the “New Diet Revolution” that, “The thirty-year-long campaign against dietary fat is as misguided as it is futile”. True that, Dr. Atkins. True. That. As he pointed out on his website, all foods contain all three types of fat – saturated, monounsaturated and polyunsaturated. The proportions of the three do vary.

The unintended consequence was that intake of omega 6 oils increased significantly. To be more precise, this was the intended consequence. It was unintentionally detrimental to human health.

Omega 6s are a family of polyunsaturated fats. These fatty acids are converted to eicosanoids such as prostaglandins and leukotrienes. These are highly inflammatory mediators. This is not good.

Atherosclerosis, or the buildup of plaque in the arteries was originally considered to be cholesterol sludge depositing in the arterial walls. This has long been known to be untrue at least since the time I was in medical school in the early 1990s. The pathophysiology of atherosclerosis is mainly dependent upon inflammation and thrombosis in the wall of the artery. The sludge deposits as a ‘response to injury’. Thus the plaque is the response to the inflammation. The real problem is the inflammation.

Increasing inflammatory molecules could conceivable contribute to worsening heart attack and strokes. Omega 3 fats tend to oppose the effects of Omega 6 fats and therefore increasing attention is being paid to the ratio of these fats. Vegetable oils have extremely high Omega 6:3 ratios.

It is estimated that humans evolved eating a diet that is close to equal in Omega 3s and 6s . However, the current Western diet is estimated to be closer to a 15:1 ratio. Either we are way under eating omega 3, way over eating omega 6s, or more likely, both.

Omega 3 fatty acids decreases thrombosis (blood clots) by its role in platelet aggregation, bleeding time and blood viscosity. Low rates of heart disease were originally described in the Inuit population, where, despite high intakes of fat, they had very low rates of heart disease. Subsequently, it was found that all major fish eating populations tended to have lower rates of heart disease. Additional studies seemed to confirm that addition of omega 3 to the diet could displace the omega 6 from cell walls. However, this will be very difficult if the ratio of Omega 6:3 is 30:1.

The massive increase in consumption of omega 6’s in the diet can be traced to technological advances in the 1900s that allowed modern methods of making vegetable oil. The invention of the continuous screw press (Expeller), steam-vacuum deodorization and solvent extraction techniques were critical to the production of vast quantities of vegetable oils.

Another culprit is the rise of the industrial farm and the feedlot cattle. Wild animals tend to be very lean, and contain high levels of polyunsaturated fats. Feedlot cattle, however, are fed grains at every turn. Indeed, there is nothing for the cattle to do all day, but eat. Cows, of course, are ruminants and designed to eat grass. Feeding them corn does wonders to fatten them, but increases omega 6 content of their meat significantly. So our grains, our meats, and our oils are omega 6 based. This all contributed to the massive imbalance in the Omega 6:3 ratio. The Canadian nutritional guidelines were the first in 1990 to recognize the difference and include specific recommendations for both types of fatty acids.

The other consequence of the scare about animal fats was that America increasingly reached for that tub of edible plastic – margarine. With large advertising budgets designed to play up its wholesome all-vegetable origins, trans fat laden margarine has always professed itself to be a healthier alternative to butter largely based on its low saturated fat.

Margarine has an interesting history. Designed by a French chemist in 1869 as a cheap butter alternative, it was originally made from beef tallow and skim milk. A Dutch company, eventually absorbed into Unilever bought the rights and proceeded to market the new substance. Margarine is actually an unappetizing white, but since it was designed as a butter alternative, it was dyed yellow. Butter manufacturers, though were not amused. Using taxes and laws against dying, margarine was a marginal product for decades. Its big break came with World War II and the ensuing butter shortage. Most of the taxes and laws against margarine were repealed since butter was scarcely available anyway.

This paved the way for the great margarine renaissance in the 1960s and 70s as the war on saturated fats gained ground. It is ironic that this ‘healthier’ alternative turned out to be chalk full of trans fats that were, actually killing people. Thankfully, most manufacturers no longer make margarine with trans fats and have tried to blend more healthful ingredients like olive oil in. Thus, where previous studies had linked margarine use to heart disease, it is questionable whether modern studies will still show this effect. However, it still doesn’t change the fact that butter just tastes way, way better.

It’s actually a minor miracle that vegetable oils were considered healthy at all. Consider the substantial amount of processing – pressing, solvent extraction, refining, degumming, bleaching and deodorization – that is required to squeeze the oil from a non-oily vegetable such as corn. There is virtually nothing natural about it.

It could only have become popular during an era where artificial was considered good. Artificial orange juices like Tang. Baby formula. Jello. Canned soups. This was a time we considered ourselves to be smarter than Mother Nature. Whatever she had made, we could make better. So out with all natural butter. In with industrially produced, artificially coloured trans fat laden margarine! Out with naturally produced lard from pigs. In with industrially processed, solvent extracted, bleached and deodorized vegetable oil! What could possibly go wrong?

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Start here with Calories I – How Do We Gain Weight?

See the entire lecture – The Aetiology of Obesity 6/6 – Fat Phobia

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Indeed, our work suggests that the management community may have badly underestimated the benefits of core management practices—as well as the investment needed to strengthen them—by relegating them to the domain of “easy to replicate.” Managers should certainly dedicate their time to fundamental strategic choices, but they should not suppose that fostering strong managerial practices is below their pay grade. Just as the ability to discern competitive shifts is important to firm performance, so too is the ability to make sure that operational effectiveness is truly part of the organization’s DNA.

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A version of this article appeared in the Diadora Equipe SW sneakers 0wzu7
issue (pp.120–127) of .

Raffaella Sadun is the Thomas S. Murphy Associate Professor of Business Administration at Harvard Business School, where she studies the economics of productivity, organization, management practices, and information technology.

Nicholas Bloom is the William Eberle Professor of economics at Stanford University and a codirector of the Productivity, Innovation and Entrepreneurship program at the National Bureau of Economic Research.

John Van Reenen is the Gordon Y. Billard Professor in the MIT’s department of economics and its Sloan School of Management.

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I like the results of the study but fail to understand how the value of the data is not undermined by the "Halo Effect". By asking managers if this or that practice exists, the manager has a lot of leeway in judging its existence (and even more its quality). Is it not so that the overall performance of a business lets a manager make overly optimistic statements, the more successful a company is? I am curious to hear from the authors about this.

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