And if you go down, this is just the other view video too, again, showing the anterior wall. Can we go up to the accordion room? Yeah. Let's see if the ECG gives anything away. It does very much. Go up, way up to the stem. It does. It's a tombstone pattern. You want to maybe say that cardiac enzymes and ECG confirm an acute ischemic event or ACS or something like that and maybe not show it? Maybe show it in the answer? Yeah. I can show it in the answer. It's just such a beautiful EKG that I felt like I needed to show it, but I can move it to the answer. You could answer that question without looking at the ultrasound. Yeah. Yeah. That's true. I'll move it to the answer. Just a couple of flow. Yeah. It's a great EKG. Yeah. It's a couple of flow things, no pun intended here. So you start and say choice B is the correct choice. I would just kind of put up towards the top why the first one's correct and then just put in parentheses choice B is correct. And then see figure two. You can just put that in parentheses wherever we're referring to it rather than a separate sentence. And then try to stay in the third party. So you say we see. Where was that? Oh, it was in the commentary it says in these patients. We saw. Oh, it's in the thrombotic events, I think. Yeah. A little bit. Yeah. Yeah. We witnessed many thrombotic events. I would just say, you know, in association with COVID disease, increased prevalence of thrombotic events in both the arterial venous system have been identified or something like that. Okay. These are little. Yep. Subtle flow things. Following these little things. And this diagram, Martha, is from a chess paper that's in the references that that was one of the authors on. So the diagram should be okay. Sorry. Sorry. Were you saying? No, I'm just saying, you know, I know I think it was just Jesse who'd always suggested that we use a man or woman as opposed to male. But I understand why you use male because you were you were segueing it with physician. But I can change that to just male, male, male instead of male physician. Actually, you know, Mangala, when you mentioned physician, we'll all pay attention. Okay, fine. So I'll leave it there. You open the door on a, you know, a tough area, even though you use the case is like just beautiful and, you know, it's so clear in one extreme. But you know, you state many of the stress-induced situations. In other words, there are nonspecific cardiographic changes and a troponin leak, you know, as soon as you take 40-year-olds and make them critically ill in any way. Things happen. You might just, you know, indicate that, you know, when you have the blessing of a regional abnormality on echo, you have a regional positive troponin. Right. Yeah. But that many circumstances would I probably would just say, you know, may benefit from cardiologic consultation or something like that, you know, because there's no we've seen incredibly high troponin leaks. We've seen pretty impressive EKG changes that at the end of the day are just a stress-related phenomenon. Yeah. Yeah. Yeah. This one's different. He had like acute chest pain and, you know. Oh, I know. I know. This one's great. But, you know, often it's an intubated, sedated, can't relate symptoms patient and the troponins go up and we're all kind of scratching our head about in the midst of all of this stuff, do they warrant, you know, further study? So you want me to scratch out the part that says that many of these are stress-induced situations that resolve? You know, I could say when, you know, when there aren't clear symptoms or regional abnormalities on your echo and EKG that you would, you may find yourself trying to determine whether invasive evaluation is necessary. Okay. Okay. Yeah. Mangala, I think the case is great. The pictures are really cool. The one little area I guess I would ask you to consider if you want to walk into or not is the bottom of the commentary when you get into COVID and the risk of thrombosis because that's like changing the new ACTIV-4 data came out and, you know, with non-anticoagulating the super sick and, you know, it's like it's such a moving target and D-dimers are helpful, D-dimers are not helpful and you can only imagine that it's going to be changing a hundred times moving forward. So I think the COVID-19 played a large part maybe because he was stressed, maybe because there was a clot in the LAD, I don't know, but I think I can take out that paragraph but it definitely was the reason why he had this event. I agree totally. I guess what I was saying is I would consider the COVID-19 related disease, yada, yada, cardiac events, including sudden cardiac death and then I would leave it at that. Okay. Okay. I can do that. This is a great ultrasound case. That's the point. This whether we should follow D-dimers, how we should anticoagulate. Right. Okay. That's fine. That's fair. So my point is to say that cardiovascular events have been associated with different respiratory sorts of infections or many other infections. So this is being reported already with influenza, with pneumococcus, with several other staphylococcus aureus, bacteremia. So cardiovascular events occur mainly in people that have cardiovascular preexisting conditions. So this could be like the perfect storm like you're describing. So you can also refer to that literature that is already existing beyond COVID-19. So just leave it as respiratory events can trigger this such as influenza, COVID-19, et cetera. Oh, infections. Infections in general. Severe infections. Infections. That really help. Yeah. So this has been associated with cardiovascular events and particularly people that have pre-existing cardiovascular conditions. Okay. I can do that. I can broaden it to add other things besides COVID. That's fine. Yeah. I would second that. I mean, there's lots of data on this occurring with influenza. Just we haven't been overwhelmed with it and paying as much attention, but it's really well-described. Okay. Nice case, Angela.

ECG

tombstone pattern

acute ischemic event

COVID-19

cardiovascular events