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By Eugene C. Toy, John T. Patlan Jr.

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ST-segment elevation is typical of acute transmural ischemia, that is, a greater degree of myocardial involvement than in NSTEMI. From the ECG we can localize the ischemia related to a vascular territory supplied by one of the three major coronary arteries. 1 mV in two or more contiguous leads (ie, in the same vascular territory) and/or a new left bundle branch block (LBBB) (which obscures usual ST-segment analysis). As a general rule, leads II, III, and aVF correspond to the inferior surface of the heart supplied by the right coronary artery (RCA), leads V2 to V4 correspond to the anterior surface supplied by the left anterior descending coronary artery (LAD), and leads I, aVL, V5, and V6 correspond to the lateral surface, supplied by the left circumflex coronary artery (LCX).

Heart failure can be caused by impaired systolic function (ejection fraction <40%) or impaired diastolic function (with preserved systolic function). ᭤ Chronic heart failure is a progressive disease with a high mortality. A patient’s functional class, that is, his or her exercise tolerance, is the best predictor of mortality and often guides therapy. ᭤ The primary goals of therapy are to relieve congestive symptoms with salt restriction, diuretics, and vasodilators. Angiotensin-converting enzyme inhibitors, beta-blockers, and aldosterone antagonists can decrease mortality.

Confirmation may be achieved by serology (rapid plasma reagent [RPR] 16 CASE FILES: INTERNAL MEDICINE or Venereal Disease Research Laboratory [VDRL] test); however, there is a significant possibility that patients with primary syphilis may not have developed antibody response yet, and have negative serology. Thus, confirmation of the diagnosis is attained with dark-field microscopy. Knowing the limitations of diagnostic tests and the manifestations of disease aids in this area. Summary 1. There is no replacement for a careful history and physical examination.

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