The T-wave findings in these patients are typically shallow inversions in the inferior leads. Patients with pulmonary embolism (PE) may also display T-wave abnormalities, including T-wave inversions (Figure 2A). Lastly, patients with past MI can demonstrate persistent T-wave inversions as a manifestation of the MI. In patients with this history and these ECG findings, Wellen syndrome is diagnosed, which is frequently associated with proximal left anterior descending coronary artery critical stenosis the natural history of Wellen syndrome is anterior wall ST-segment elevation myocardial infarction. Pulmonary embolism angina (ie, unstable angina) can present with significantly abnormal T-wave inversions-either symmetric, deeply inverted T waves or biphasic T waves in the precordial leads (V1, V2, and V3 in particular). An important subgroup of patients with pre-infarctionįigure 2A. In general, inverted T waves related to acute coronary syndrome are symmetric in shape this symmetry means that the downsloping limb is a mirror image of the upsloping limb. T-wave inversions associated with coronary artery disease may result from myocardial ischemia (ie, unstable angina), non–ST-segment elevation acute myocardial infarction (NSTEMI-MI), or previous MI (Figure 1A-D). Wellens syndrome (biphasic T wave) Coronary artery disease (acute coronary syndrome, chronic ischemic syndromes) Secondary T-wave changes result from aberrant ventricular activation in the context of normal action potential characteristics examples include bundle-branch blocks, ventricular pre-excitation states (eg, Wolff-Parkinson-White syndrome), ventricular paced rhythms, and ventricular ectopic beats.įigure 1D. Alterations in the duration or morphology of the action potential, without concurrent changes in the orderly sequence of activation, are termed “primary changes.” Primary T-wave inversions are associated with benign syndromes, such as the persistent juvenile T-wave pattern and the digitalis effect, as well as morbid conditions, including acute coronary ischemic events and CNS catastrophe. The causes of T-wave inversions have commonly been grouped into 2 categories: primary T-wave changes and secondary T-wave changes. Wellens syndrome (deeply inverted T wave) Electrophysiologic considerations: primary and secondary T-wave inversion Figure 1C. For example, the patient with an isolated T-wave inversion in lead III in the setting of a musculoskeletal chest pain syndrome would be considered a normal variant ECG finding. This interpretation strategy allows the clinician to discern among normal, potentially abnormal, and abnormal. The interpretation of the ECG in the context of the individual patient presentation is mandatory. Acute coronary syndromewave in either lead III or aVF can be a normal variant. In general, an inverted T wave in a single lead in one anatomic segment (ie, inferior, lateral, or anterior) is unlikely to represent acute pathology for instance, a single inverted Tįigure 1B. The T wave is normally upright in leads I, II, and V2 to V6 inverted in lead aVR and variable in leads III, aVL, aVF, and V1. This relative asymmetry may vary because many females and elderly individuals, without identifiable cardiac disease, may have symmetric T waves. The normal T wave has been described to have a gradual upstroke with a more rapid downstroke in the terminal portion. A variety of clinical syndromes can cause T-wave inversions, ranging from life-threatening events, such as acute coronary ischemia, pulmonary embolism, and CNS injury, to entirely benign conditions, such as normal variant T- wave inversions and the persistent juvenile T-wave inversion. Acute coronary syndromecardiac or respiratory syndromes. The natural history of the inverted T wave is variable, ranging from a normal life without pathologic issues to sudden death related toįigure 1A.
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Some days have come close to matching, but none have conquered the consumption. Games against Auburn, LSU, Tennessee and, more recently, Ole Miss always result in increased sales.Īs good as business has been lately, Alabama's legendary "Game of the Century" against LSU in 2011 was a record for Yellow Hammers. The interest is not limited to when Alabama is playing next door, although the proximity of games doesn't hurt business whatsoever. Even the thought of putting a number on it makes him laugh. For whatever reason, the original always tastes best."Īlthough he can't put an exact number on it, Sirkin says Gallettes goes through thousands of gallons of the drink every home game. They're always a couple of ingredients off. "There are some recipes floating around out there online, but none of them get them right. "We are the only bar that sells it, but people try and make it for their tailgates. Many have tried to recreate the magic in this plastic cup, although no one-beyond the occasional former employee privileged to the secret, of course-has succeeded. That's what makes the Yellow Hammer challenging to dissect. It has its own distinct taste, and there are ingredients that are nearly impossible to identify. I would say it's in the Mai Tai family, although it's by no means similar. And another, because I take my job very seriously. But I need to know more, so I take another. That much is clear on the very first sip. The true intrigue of the Yellow Hammer, however, exists in its concoction. "These cups are fine china in Tuscaloosa," Matt Principe, who has worked at Gallettes for two years, said. The cups change regularly, and they are very much part of the mystique. As Sirkin discusses the possibility, he knocks the wooden table for good luck. A new national championship design for this year, if it comes to that, could be in the works. When Alabama last won a national championship, the bar created a special design to celebrate the achievement. If Auburn plays in Tuscaloosa, Gallettes will produce a special Iron Bowl cup. The drink comes served in a special 16-ounce collector's cup-a plastic goblet that changes for special occasions.Įach year it changes, although it does not stop there. And yet, sitting down at a table, I have not seen a single soul order anything else.Ĭollege students, more college students, an elderly couple-each person that has stepped in on this Friday afternoon has paid $8 for this liquid delight. There is not a single sign or advertisement for the Yellow Hammer hanging up in the bar. This state bird also happens to have a distinct presence in "Rammer Jammer," a popular piece of Crimson Tide game-day gospel. The drink is named after Alabama's state bird: the northern flicker of the woodpecker family, also known as the yellowhammer. The Yellow Hammer is their business, and they treat the preparation as such. After that, they never really stop mixing. Not with seven employees preparing enough Yellow Hammers to fill a swimming pool in the backroom shortly after the sun rises. The thing is, that has happened to one of the many chicken stops. "That's like asking KFC if they've ever run out of chicken," he said. I waste little time asking the obvious: Have you ever run out? Somewhere between amused and offended, Sirkin fired back a response. Among other things, Sirkin is ensuring there are enough Yellow Hammers through the last night. On this particular day, the Friday before Alabama's final home game of the year, he is pinballing back and forth, knocking out a variety of tasks. We talk about our long hours during the season, and suddenly I am the one who needs to clock in more. On days when Alabama plays at home, he will often work 20-hour days. Despite the title, Sirkin rarely stops moving. In 2003, he was offered ownership in the bar, and he didn't hesitate. Damn near 40 years is a long time, although Sirkin signed on as an employee while in college back in 1997. |
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