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👈🏻✅ 🫀 STEMI ECG Evolution: A Timeline #Cardiology #ECG #STEMI #MI #HeartAttack #CardioEd #MedEd #EKG

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AbdAllah Othman

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22,409 Aufrufe • vor 8 Monaten •via X (Twitter)

#Cardiology#ECG#STEMI#MI#HeartAttack#CardioEd#MedEd#EKG
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Humble day for a cardiologist… A patient of 44 years came with an axillary chest pain and scapular pain. (I have indicated the pain sites in the accompanying picture). He has had diabetes for the past three years and also has a family history of heart disease. He is not a smoker and doesn’t have any other coronary risk factors. His ECG, ECHO and TMT were normal. Because the pain was atypical and non-exertional and his non-invasive testing was normal, I prescribed medication and sent him home. He came back again with more severe pain at the same site after a month, and again, the ECG and Troponin were normal. I reassured him once more. He came back the next day (last Saturday) with the same complaints, but this time I suggested doing an angiogram to investigate the persistent pain. What I found was a 90% lesion in the PLV artery. I stented the vessel, and he experienced total relief from his chest pain. Physicians and cardiologists should be willing to modify their diagnosis when the initial line of management does not provide clinical benefit to the patient. Ego has no role in medicine. #chestpain #heartattack #medtwitter

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El Hamriti Mustapha

15,470 Aufrufe • vor 1 Jahr

🫀♒️𝗥𝗶𝘁𝗺𝗼𝘀 𝗱𝗲𝗹 𝗘𝗖𝗚 𝗾𝘂𝗲 𝘁𝗼𝗱𝗼 𝗰𝗹𝗶́𝗻𝗶𝗰𝗼 𝗱𝗲𝗯𝗲 𝗿𝗲𝗰𝗼𝗻𝗼𝗰𝗲𝗿 𝗱𝗲 𝘂𝗻 𝘃𝗶𝘀𝘁𝗮𝘇𝗼👀 ⬇️⬇️⬇️⬇️ 📌El 𝙀𝘾𝙂 sigue siendo una de las herramientas diagnósticas más poderosas y subestimadas. ¿Sabes diferenciar estos 4 ritmos en segundos? 👇 ✅ 𝙍𝙞𝙩𝙢𝙤 𝙨𝙞𝙣𝙪𝙨𝙖𝙡 𝙣𝙤𝙧𝙢𝙖𝙡 → 𝙊𝙣𝙙𝙖 𝙋 antes de cada QRS → FC 60–100 lpm → Intervalo PR constante (120–200 ms) 𝘓𝘢 𝘭𝘪́𝘯𝘦𝘢 𝘣𝘢𝘴𝘦 𝘥𝘦 𝘤𝘰𝘮𝘱𝘢𝘳𝘢𝘤𝘪𝘰́𝘯 𝘱𝘢𝘳𝘢 𝘵𝘰𝘥𝘰 𝘭𝘰 𝘥𝘦𝘮𝘢́𝘴． ⚡ 𝙁𝙞𝙗𝙧𝙞𝙡𝙖𝙘𝙞𝙤́𝙣 𝘼𝙪𝙧𝙞𝙘𝙪𝙡𝙖𝙧 → 𝘼𝙪𝙨𝙚𝙣𝙘𝙞𝙖 de ondas P definidas → Línea de base irregularmente irregular → QRS estrecho (salvo aberrancia) 𝘓𝘢 𝘢𝘳𝘳𝘪𝘵𝘮𝘪𝘢 𝘴𝘰𝘴𝘵𝘦𝘯𝘪𝘥𝘢 𝘮𝘢́𝘴 𝘧𝘳𝘦𝘤𝘶𝘦𝘯𝘵𝘦. Siempre descartar en palpitaciones + pulso irregular. 📈 𝙁𝙡𝙪𝙩𝙩𝙚𝙧 𝘼𝙪𝙧𝙞𝙘𝙪𝙡𝙖𝙧 → Patrón en “𝙙𝙞𝙚𝙣𝙩𝙚𝙨 𝙙𝙚 𝙨𝙞𝙚𝙧𝙧𝙖” (ondas F a 300 lpm) → Conducción 2:1, 3:1 o 4:1 → Bloqueo AV regular Clave: 𝘣𝘶𝘴𝘤𝘢 𝘭𝘢𝘴 𝘰𝘯𝘥𝘢𝘴 𝘍 𝘦𝘯 𝘋𝘐𝘐, 𝘋𝘐𝘐𝘐, 𝘢𝘝𝘍. ⚠️ 𝙏𝙖𝙦𝙪𝙞𝙘𝙖𝙧𝙙𝙞𝙖 𝙎𝙪𝙥𝙧𝙖𝙫𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 (𝙏𝙎𝙑) → FC > 150 lpm → QRS estrecho y regular → Inicio y fin bruscos 𝘔𝘢𝘯𝘪𝘰𝘣𝘳𝘢𝘴 𝘷𝘢𝘨𝘢𝘭𝘦𝘴 como primer paso. Si persiste → 𝙖𝙙𝙚𝙣𝙤𝙨𝙞𝙣𝙖. 💥 𝙏𝙖𝙦𝙪𝙞𝙘𝙖𝙧𝙙𝙞𝙖 𝙑𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 (𝙏𝙑) → QRS ancho (> 120 ms) y regular → FC 100–250 lpm → Disociación AV (signo clave) Regla: 𝙌𝙍𝙎 𝙖𝙣𝙘𝙝𝙤 + 𝙧𝙖́𝙥𝙞𝙙𝙤 = TV hasta demostrar lo contrario. No la trates como TSV. 🌀 𝙏𝙤𝙧𝙨𝙖𝙙𝙚 𝙙𝙚 𝙋𝙤𝙞𝙣𝙩𝙚𝙨 → TV polimórfica que “gira” alrededor de la línea base → Asociada a QT largo (congénito o adquirido) → Puede degenerar en FV 𝘚𝘪𝘦𝘮𝘱𝘳𝘦 𝘳𝘦𝘷𝘪𝘴𝘢 𝘧𝘢́𝘳𝘮𝘢𝘤𝘰𝘴: antiarrítmicos, antipsicóticos, antibióticos. Tx: Sulfato de Magnesio IV. ⛔ 𝙁𝙞𝙗𝙧𝙞𝙡𝙖𝙘𝙞𝙤́𝙣 𝙑𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 (𝙁𝙑) → Actividad eléctrica 𝙘𝙖𝙤́𝙩𝙞𝙘𝙖, 𝙨𝙞𝙣 𝙌𝙍𝙎 definido → Sin gasto cardíaco = paro cardiorrespiratorio → 𝘿𝙚𝙨𝙛𝙞𝙗𝙧𝙞𝙡𝙖𝙘𝙞𝙤́𝙣 𝙞𝙣𝙢𝙚𝙙𝙞𝙖𝙩𝙖 Cada minuto sin descarga = 10% menos de sobrevida. No hay tiempo que perder. 🔒 𝘽𝙡𝙤𝙦𝙪𝙚𝙤𝙨 𝘼𝙑 1️⃣𝟭° 𝙜𝙧𝙖𝙙𝙤 → PR > 200 ms, constante. Benigno. 2️⃣𝟮° 𝙜𝙧𝙖𝙙𝙤 𝙈𝙤𝙗𝙞𝙩𝙯 𝙄 (𝙒𝙚𝙣𝙘𝙠𝙚𝙗𝙖𝙘𝙝) → PR se alarga hasta que falla un QRS. Vagal. 2️⃣𝟮° 𝙜𝙧𝙖𝙙𝙤 𝙈𝙤𝙗𝙞𝙩𝙯 𝙄𝙄 → PR fijo, QRS cae sin aviso. ⚠️ Riesgo de progresión. 3️⃣𝟯° 𝙜𝙧𝙖𝙙𝙤 (𝙘𝙤𝙢𝙥𝙡𝙚𝙩𝙤) → P y QRS sin relación. 𝘔𝘢𝘳𝘤𝘢𝘱𝘢𝘴𝘰𝘴 𝘶𝘳𝘨𝘦𝘯𝘵𝘦． 💀 𝘼𝙨𝙞𝙨𝙩𝙤𝙡𝙞𝙖 → 𝙇𝙞́𝙣𝙚𝙖 𝙞𝙨𝙤𝙚𝙡𝙚́𝙘𝙩𝙧𝙞𝙘𝙖. Sin actividad eléctrica ni mecánica. → Confirmar en 2 derivaciones → RCP + adrenalina. 𝘕𝘰 𝘦𝘴 𝘥𝘦𝘴𝘧𝘪𝘣𝘳𝘪𝘭𝘢𝘣𝘭𝘦. El pronóstico más sombrío del paro. La prevención y el reconocimiento precoz lo son todo. 📌 𝙍𝙚𝙜𝙡𝙖 𝙧𝙖́𝙥𝙞𝙙𝙖: •𝙄𝙧𝙧𝙚𝙜𝙪𝙡𝙖𝙧 + 𝙨𝙞𝙣 𝙋 → 𝙁𝘼 •𝘿𝙞𝙚𝙣𝙩𝙚𝙨 𝙙𝙚 𝙨𝙞𝙚𝙧𝙧𝙖 → 𝙁𝙡𝙪𝙩𝙩𝙚𝙧 •𝙍𝙖́𝙥𝙞𝙙𝙤 + 𝙧𝙚𝙜𝙪𝙡𝙖𝙧 + 𝙌𝙍𝙎 𝙚𝙨𝙩𝙧𝙚𝙘𝙝𝙤 → 𝙏𝙎𝙑 •𝙌𝙍𝙎 𝙖𝙣𝙘𝙝𝙤 + 𝙧𝙖́𝙥𝙞𝙙𝙤 → 𝙏𝙑 •𝙌𝙏 𝙡𝙖𝙧𝙜𝙤 + 𝙜𝙞𝙧𝙤 → 𝙏𝙤𝙧𝙨𝙖𝙙𝙚 → Mg²⁺ •𝘾𝙖𝙤𝙨 𝙨𝙞𝙣 𝙌𝙍𝙎 → 𝙁𝙑 → ¡Defibrilar YA! •𝙎𝙞𝙣 𝙣𝙖𝙙𝙖 → 𝘼𝙨𝙞𝙨𝙩𝙤𝙡𝙞𝙖 → 𝙍𝘾𝙋 + adrenalina •𝙋𝙍 𝙦𝙪𝙚 𝙛𝙖𝙡𝙡𝙖 → 𝘽𝙡𝙤𝙦𝙪𝙚𝙤 𝘼𝙑 → evalúa grado 🧠𝙂𝙪𝙖𝙧𝙙𝙖 𝙚𝙨𝙩𝙚 𝙝𝙞𝙡𝙤 𝙥𝙖𝙧𝙖 𝙩𝙪 𝙜𝙪𝙖𝙧𝙙𝙞𝙖 🏥 ‼️Si te sirve: ❤️ Me gusta | 🔁 Repost | ➕ Follow para más #MedED en #ClubCrit 😄🧠🫶 👇🏼👇🏼👇🏼👇🏼 📚📖#ClubCrit #EKG #ECG #Arritmias #CardioX #Cardiología #icu #intensivecare #diagnosis #management #POCUS #VExUS #MedicinaBasadaEnEvidencia #Terapia #MedEd #Medicina #FOAMed #FOAMcc #CuidadoCrítico #MedX #EducaciónMédica #MedIntensiva #MedXCommunity #MedicinaCrítica #MedED #CritCare #ICUManagement #MustRead #LecturaRecomendada
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🫀♒️𝗥𝗶𝘁𝗺𝗼𝘀 𝗱𝗲𝗹 𝗘𝗖𝗚 𝗾𝘂𝗲 𝘁𝗼𝗱𝗼 𝗰𝗹𝗶́𝗻𝗶𝗰𝗼 𝗱𝗲𝗯𝗲 𝗿𝗲𝗰𝗼𝗻𝗼𝗰𝗲𝗿 𝗱𝗲 𝘂𝗻 𝘃𝗶𝘀𝘁𝗮𝘇𝗼👀 ⬇️⬇️⬇️⬇️ 📌El 𝙀𝘾𝙂 sigue siendo una de las herramientas diagnósticas más poderosas y subestimadas. ¿Sabes diferenciar estos 4 ritmos en segundos? 👇 ✅ 𝙍𝙞𝙩𝙢𝙤 𝙨𝙞𝙣𝙪𝙨𝙖𝙡 𝙣𝙤𝙧𝙢𝙖𝙡 → 𝙊𝙣𝙙𝙖 𝙋 antes de cada QRS → FC 60–100 lpm → Intervalo PR constante (120–200 ms) 𝘓𝘢 𝘭𝘪́𝘯𝘦𝘢 𝘣𝘢𝘴𝘦 𝘥𝘦 𝘤𝘰𝘮𝘱𝘢𝘳𝘢𝘤𝘪𝘰́𝘯 𝘱𝘢𝘳𝘢 𝘵𝘰𝘥𝘰 𝘭𝘰 𝘥𝘦𝘮𝘢́𝘴． ⚡ 𝙁𝙞𝙗𝙧𝙞𝙡𝙖𝙘𝙞𝙤́𝙣 𝘼𝙪𝙧𝙞𝙘𝙪𝙡𝙖𝙧 → 𝘼𝙪𝙨𝙚𝙣𝙘𝙞𝙖 de ondas P definidas → Línea de base irregularmente irregular → QRS estrecho (salvo aberrancia) 𝘓𝘢 𝘢𝘳𝘳𝘪𝘵𝘮𝘪𝘢 𝘴𝘰𝘴𝘵𝘦𝘯𝘪𝘥𝘢 𝘮𝘢́𝘴 𝘧𝘳𝘦𝘤𝘶𝘦𝘯𝘵𝘦. Siempre descartar en palpitaciones + pulso irregular. 📈 𝙁𝙡𝙪𝙩𝙩𝙚𝙧 𝘼𝙪𝙧𝙞𝙘𝙪𝙡𝙖𝙧 → Patrón en “𝙙𝙞𝙚𝙣𝙩𝙚𝙨 𝙙𝙚 𝙨𝙞𝙚𝙧𝙧𝙖” (ondas F a 300 lpm) → Conducción 2:1, 3:1 o 4:1 → Bloqueo AV regular Clave: 𝘣𝘶𝘴𝘤𝘢 𝘭𝘢𝘴 𝘰𝘯𝘥𝘢𝘴 𝘍 𝘦𝘯 𝘋𝘐𝘐, 𝘋𝘐𝘐𝘐, 𝘢𝘝𝘍. ⚠️ 𝙏𝙖𝙦𝙪𝙞𝙘𝙖𝙧𝙙𝙞𝙖 𝙎𝙪𝙥𝙧𝙖𝙫𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 (𝙏𝙎𝙑) → FC > 150 lpm → QRS estrecho y regular → Inicio y fin bruscos 𝘔𝘢𝘯𝘪𝘰𝘣𝘳𝘢𝘴 𝘷𝘢𝘨𝘢𝘭𝘦𝘴 como primer paso. Si persiste → 𝙖𝙙𝙚𝙣𝙤𝙨𝙞𝙣𝙖. 💥 𝙏𝙖𝙦𝙪𝙞𝙘𝙖𝙧𝙙𝙞𝙖 𝙑𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 (𝙏𝙑) → QRS ancho (> 120 ms) y regular → FC 100–250 lpm → Disociación AV (signo clave) Regla: 𝙌𝙍𝙎 𝙖𝙣𝙘𝙝𝙤 + 𝙧𝙖́𝙥𝙞𝙙𝙤 = TV hasta demostrar lo contrario. No la trates como TSV. 🌀 𝙏𝙤𝙧𝙨𝙖𝙙𝙚 𝙙𝙚 𝙋𝙤𝙞𝙣𝙩𝙚𝙨 → TV polimórfica que “gira” alrededor de la línea base → Asociada a QT largo (congénito o adquirido) → Puede degenerar en FV 𝘚𝘪𝘦𝘮𝘱𝘳𝘦 𝘳𝘦𝘷𝘪𝘴𝘢 𝘧𝘢́𝘳𝘮𝘢𝘤𝘰𝘴: antiarrítmicos, antipsicóticos, antibióticos. Tx: Sulfato de Magnesio IV. ⛔ 𝙁𝙞𝙗𝙧𝙞𝙡𝙖𝙘𝙞𝙤́𝙣 𝙑𝙚𝙣𝙩𝙧𝙞𝙘𝙪𝙡𝙖𝙧 (𝙁𝙑) → Actividad eléctrica 𝙘𝙖𝙤́𝙩𝙞𝙘𝙖, 𝙨𝙞𝙣 𝙌𝙍𝙎 definido → Sin gasto cardíaco = paro cardiorrespiratorio → 𝘿𝙚𝙨𝙛𝙞𝙗𝙧𝙞𝙡𝙖𝙘𝙞𝙤́𝙣 𝙞𝙣𝙢𝙚𝙙𝙞𝙖𝙩𝙖 Cada minuto sin descarga = 10% menos de sobrevida. No hay tiempo que perder. 🔒 𝘽𝙡𝙤𝙦𝙪𝙚𝙤𝙨 𝘼𝙑 1️⃣𝟭° 𝙜𝙧𝙖𝙙𝙤 → PR > 200 ms, constante. Benigno. 2️⃣𝟮° 𝙜𝙧𝙖𝙙𝙤 𝙈𝙤𝙗𝙞𝙩𝙯 𝙄 (𝙒𝙚𝙣𝙘𝙠𝙚𝙗𝙖𝙘𝙝) → PR se alarga hasta que falla un QRS. Vagal. 2️⃣𝟮° 𝙜𝙧𝙖𝙙𝙤 𝙈𝙤𝙗𝙞𝙩𝙯 𝙄𝙄 → PR fijo, QRS cae sin aviso. ⚠️ Riesgo de progresión. 3️⃣𝟯° 𝙜𝙧𝙖𝙙𝙤 (𝙘𝙤𝙢𝙥𝙡𝙚𝙩𝙤) → P y QRS sin relación. 𝘔𝘢𝘳𝘤𝘢𝘱𝘢𝘴𝘰𝘴 𝘶𝘳𝘨𝘦𝘯𝘵𝘦． 💀 𝘼𝙨𝙞𝙨𝙩𝙤𝙡𝙞𝙖 → 𝙇𝙞́𝙣𝙚𝙖 𝙞𝙨𝙤𝙚𝙡𝙚́𝙘𝙩𝙧𝙞𝙘𝙖. Sin actividad eléctrica ni mecánica. → Confirmar en 2 derivaciones → RCP + adrenalina. 𝘕𝘰 𝘦𝘴 𝘥𝘦𝘴𝘧𝘪𝘣𝘳𝘪𝘭𝘢𝘣𝘭𝘦. El pronóstico más sombrío del paro. La prevención y el reconocimiento precoz lo son todo. 📌 𝙍𝙚𝙜𝙡𝙖 𝙧𝙖́𝙥𝙞𝙙𝙖: •𝙄𝙧𝙧𝙚𝙜𝙪𝙡𝙖𝙧 + 𝙨𝙞𝙣 𝙋 → 𝙁𝘼 •𝘿𝙞𝙚𝙣𝙩𝙚𝙨 𝙙𝙚 𝙨𝙞𝙚𝙧𝙧𝙖 → 𝙁𝙡𝙪𝙩𝙩𝙚𝙧 •𝙍𝙖́𝙥𝙞𝙙𝙤 + 𝙧𝙚𝙜𝙪𝙡𝙖𝙧 + 𝙌𝙍𝙎 𝙚𝙨𝙩𝙧𝙚𝙘𝙝𝙤 → 𝙏𝙎𝙑 •𝙌𝙍𝙎 𝙖𝙣𝙘𝙝𝙤 + 𝙧𝙖́𝙥𝙞𝙙𝙤 → 𝙏𝙑 •𝙌𝙏 𝙡𝙖𝙧𝙜𝙤 + 𝙜𝙞𝙧𝙤 → 𝙏𝙤𝙧𝙨𝙖𝙙𝙚 → Mg²⁺ •𝘾𝙖𝙤𝙨 𝙨𝙞𝙣 𝙌𝙍𝙎 → 𝙁𝙑 → ¡Defibrilar YA! •𝙎𝙞𝙣 𝙣𝙖𝙙𝙖 → 𝘼𝙨𝙞𝙨𝙩𝙤𝙡𝙞𝙖 → 𝙍𝘾𝙋 + adrenalina •𝙋𝙍 𝙦𝙪𝙚 𝙛𝙖𝙡𝙡𝙖 → 𝘽𝙡𝙤𝙦𝙪𝙚𝙤 𝘼𝙑 → evalúa grado 🧠𝙂𝙪𝙖𝙧𝙙𝙖 𝙚𝙨𝙩𝙚 𝙝𝙞𝙡𝙤 𝙥𝙖𝙧𝙖 𝙩𝙪 𝙜𝙪𝙖𝙧𝙙𝙞𝙖 🏥 ‼️Si te sirve: ❤️ Me gusta | 🔁 Repost | ➕ Follow para más #MedED en #ClubCrit 😄🧠🫶 👇🏼👇🏼👇🏼👇🏼 📚📖#ClubCrit #EKG #ECG #Arritmias #CardioX #Cardiología #icu #intensivecare #diagnosis #management #POCUS #VExUS #MedicinaBasadaEnEvidencia #Terapia #MedEd #Medicina #FOAMed #FOAMcc #CuidadoCrítico #MedX #EducaciónMédica #MedIntensiva #MedXCommunity #MedicinaCrítica #MedED #CritCare #ICUManagement #MustRead #LecturaRecomendada

Dr.Marlon Villanueva™ 🩺 𝕏

96,502 Aufrufe • vor 5 Monaten

How the 🆅🅴🅽🆃🆁🅸🅲🅻🅴 contracts.. . . . 💗Another great thing I picked up from Cardiothoracic surgery was understanding how the ventricles contract. The ventricle Is such a complex structure that we are learning more and more about. One thing that has helped us understand this complex structure is strain imaging and 3D echocardiography. We have learned that the ventricle contracts in 4 ways: contraction (radial) motion but it also has a twisting (torsional and circumferential) and shortening (longitudinal) motion. . . . 👐🏽The surgeon I always work with often described the hearts motion as “wringing of a towel.” This can be seen in the video above. The understanding of the multiple different motions of the heart has allowed us to better understand intrinsic myocardial disease and pick up disease earlier in its process allowing us to add disease modifying agents to slow and sometimes reverse the negative remodeling of the heart. . . . 💓So next time you think of your heart pumping don’t think of it in one motion (squeeze) but rather a Towel being wrung of water. The heart is such an amazing organ and we are just now really beginning to understand it’s truly complex physiology! . . . Have a great day! . . . . #Medicalschool #medschool #cardiologia #doctors #cardiotwitter #meded #EKG #Medstudent #cardiology #internalmedicine #patient #hospital #radiology #physiology #paschool #foamed #echo #physicalexam #anatomy #scrubs #surgery #pastudent #nursingstudent #nursing #PA #DO #Echocardiogram #MD #USMLE
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How the 🆅🅴🅽🆃🆁🅸🅲🅻🅴 contracts.. . . . 💗Another great thing I picked up from Cardiothoracic surgery was understanding how the ventricles contract. The ventricle Is such a complex structure that we are learning more and more about. One thing that has helped us understand this complex structure is strain imaging and 3D echocardiography. We have learned that the ventricle contracts in 4 ways: contraction (radial) motion but it also has a twisting (torsional and circumferential) and shortening (longitudinal) motion. . . . 👐🏽The surgeon I always work with often described the hearts motion as “wringing of a towel.” This can be seen in the video above. The understanding of the multiple different motions of the heart has allowed us to better understand intrinsic myocardial disease and pick up disease earlier in its process allowing us to add disease modifying agents to slow and sometimes reverse the negative remodeling of the heart. . . . 💓So next time you think of your heart pumping don’t think of it in one motion (squeeze) but rather a Towel being wrung of water. The heart is such an amazing organ and we are just now really beginning to understand it’s truly complex physiology! . . . Have a great day! . . . . #Medicalschool #medschool #cardiologia #doctors #cardiotwitter #meded #EKG #Medstudent #cardiology #internalmedicine #patient #hospital #radiology #physiology #paschool #foamed #echo #physicalexam #anatomy #scrubs #surgery #pastudent #nursingstudent #nursing #PA #DO #Echocardiogram #MD #USMLE

Jay Mohan, D.O., FACC, FSCAI, FASE, RPVI

37,193 Aufrufe • vor 2 Jahren