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An 80-year-old male presented with persistent right shoulder pain, achy in nature for the last couple of weeks. No significant improvement post local cortisone injection.

PMH: CAD s/p 4V CABG (grafts occluded except RCA graft). Coronary/graft angiogram in 5/2022 performed for similar symptoms showed RCA vein graft ostial 95% stenosis s/p PCI with resolution of his shoulder pain. Also, had balloon angioplasty only to proximal LAD in-stent restenosis as already has 2 stents at that location. He was doing well till 4-6 weeks ago when his right shoulder pain recurred. He also has CKD stage IV, PVD, carotid artery disease s/p intervention and ischemic CVA with no obvious residual weakness.

His initial EKG from 12/2022 and second EKG done this week. Also, limited echo images posted. His echo in 4/2022 showed LVEF 55% with no regional wall motion abnormality.

It is a bread and butter case. What is the echocardiogram findings?

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Would like to share this case from last week. It is an acute MI but with a couple of twists in presentation that I thought worth sharing.

A 61 year-old-male with family h/o CAD. Presented to ED with 30 min of left sided chest pain radiates to the left shoulder. EKG on arrival shown.

Initial hs-cTnT: 7 and 1-hr later was 11 (normal NTG lowered CP from 10/10 to 4/10, morphine helped as well.

Repeat hs-cTnT at 3-hr is: 41. EKG 2 hours later shown:

The patient was taken to the Cath lab and found to have a coronary lesion.  Where is that lesion?

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You are planning to do PCI on proximal LAD lesion via Rt. Radial approach. 

You have difficulty advancing a guide catheter (6 Fr EBU 3.5). You get the video below. 

What is the next step?

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