A patient in their 70s with chronic obstructive pulmonary disease and hypertension presented with a 2-day history of cough, expectoration, and shortness of breath. On admission, their heart rate was 91/min, and their blood pressure was 126/65 mm Hg. An arterial blood gas analysis on supplemental low-flow oxygen (2 L/min) revealed a partial pressure of arterial oxygen level of 51 mm Hg, which suggested a diagnosis of moderate acute respiratory distress syndrome (ARDS), according to the profound degree of hypoxemia (the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen was 175.9 mm Hg). The patient was immediately placed in a prone position and received mechanical ventilation. On the second day of hospitalization, blood test results revealed a troponin I level of 0.68 ng/mL (reference range, <0.16 ng/mL) and a creatine kinase isoenzyme level of 18.70 U/L (reference range, <16 U/L). (To convert troponin I to μg/L, multiply by 1.0; creatine kinase to μkat/L, multiply by 0.0167.) To exclude acute myocardial infarction, an electrocardiogram (ECG) was obtained in the prone position with mirror lead placement (Figure, A). In brief, V1 and V2 leads were placed on the 2 sides of the seventh thoracic vertebra. The V3 lead was located at the midpoint between V2 and V4. The location of V6 was in the fifth intercostal space, at the left midaxillary line. The V4 and V5 leads were positioned at the same level as V6, with V4 in the left midscapular line and V5 in the left posterior axillary line.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Kang-Yin Chen, MD, PhD, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, the Second Hospital of Tianjin Medical University, No. 23, Pingjiang Rd, Hexi District, Tianjin 300211, China (email@example.com).
Published Online: June 12, 2023. doi:10.1001/jamainternmed.2023.1554
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was funded by Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-029A) and the clinical medical research project of the Second Hospital of Tianjin Medical University (2020LC12).
Role of the Funder/Sponsor: The funders had no role in the collection, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank Gary Tse, PhD, Second Hospital of Tianjin Medical University and Kent and Medway Medical School; Nan Zhang, MD, Second Hospital of Tianjin Medical University; and Chuan-Hai Zhang, MD, The First Affiliated Hospital of Jinzhou Medical University, for their helpful comments. They did not receive any compensation.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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