A 60-something Woman with Chest Pain and a Wide QRS

CONCLUSION to the Case: The interventionalist finally took the patient to the cath lab. There was 100% occlusion of the RCA, which was stented.================NOTE: My sincere THANKS to Emmanuel Reisman (New York) for sharing the tracings and this case with us!================SmithQuickComments:Ken,Great case and great discussion!The modified Sgarbossa criteria are only 84% sensitive (if you use 20%) in our studies (Meyers Validation study), and if used on a consecutive group of chest pain patients with LBBB, it would probably be lower.  So indeed we need to look beyond these criteria in order to NOT miss OMI in LBBB.That said, this initial ECGdoes meet the modified Sgarbossa criteria.Here,aVF has discordant STE of 25%.  The ST segment is 1 mm and the S-wave is 4 mm.  Thus, there is one lead with at least 1 mm of STE and a ratio of 25%, and so the criteria are met.Even if you measure the ST segment as 0.75 mm, 0.75 divided by 4 = 0.19 (19%) which is also quite specific for OMI.  However, all our measurements in our studies were to the nearest 0.5 mm. So cases like this would have been classified as " 1 mm concordant STE.In our studies, the mean maximal ST/S ratio for LBBB is 0.11.  The mean overall is ratio 0.85, so a value of 0.1875 is very high indeed.Also,lead II has aconcordant ST segment.  To be positive by the modified Sgarbossa criteria, 1 mm of concordant STE is required in at least 1 lead. This does not meet that crit...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

Related Links:

Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This 50-something male with previous history of MI presented for intermittent CP and SOB for 2 days. CP lasted for hours at a time, was described as pleuritic, without radiation, but relieved by nitro. He was given nitro and full dose aspirin by EMS.  Prehospital ECG was similar to first ED ECG.Here is the ED ECG for ED visit #1:It is very abnormal, with potentially ischemic downsloping ST depressionThere were 3 ECGs during an ED visit for chest pain one month earlier.  Let's call that ED visit zero.Here is the last EKG from ED visit zero:There is minimal ST depression without the downsloping.Here ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Conclusion: I suspect one or more of the anterior leads was placed too high on the chest (especially given the deep negative P wave in lead V1) — butregardless, the poor R wave progression we see in ECG #1 is consistent with prior anterior infarction (and this patient ’s past medical history is remarkable for a prior “silent” heart attack).ReST-T Wave Changes — There are some nonspecific ST-T wave changes in some limb leads (ie,leads I, II, aVL) — but these do not look acute. Of much more concern (as per Drs. Oberst, Mogul and Meyers) — there is 0.5-1.0mm of J-point ST elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.Previously, Knotts et al. had published different, but also convincing, data:Knotts et al. found that such ECG findings (STE in aVR) only represented left main ACS in 14% of such ECGs: Only 23% of patients with the aVR STE pattern had any LM disease (fewer if defined as  ≥ 50% stenosis). Onl...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Post by Smith and MeyersSam Ghali (https://twitter.com/EM_RESUS) just asked me (Smith):" Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR? "Smith and Meyers answer:First, LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.But if they do present:The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion, though it might be due to subtotal LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell MeyersA male in his 60s with no known past medical history presented at midnight with chest pain over the past 3 hours. The pain started just after eating, and at first he thought it was " reflux, " however he decided to call 911 after a few hours when it did not improve.Here is his presenting ECG:What do you think?Here are the relevant findings:Slight STE in V12.5 mm STE in V2Slight STD in V4-V6Definite STD in II, III, and aVFHyperacute T-waves in V2, and likely also in aVLThese findings are highly specific for LAD occlusion. We have many cases of this pattern on this blog, involving STE and h...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A patient with DM presented with acute chest pain.Here was his ED ECG:There isLVH in limb leads, with a 17 mm R-wave in aVL, and deep S-wave in inferior leads.With this much voltage, one expects some repolarization abnormalities.Indeed, there is a bit of ST depression in aVL (discordant to the tall R-wave) that does not appear to be out of proportion.There is inferior ST Elevation, but the S-waves are also of high voltage.Is this an inferior STEMI?  Or is the LVH with expected repolarization abnormalities? There is also some ST depression in V2.  Possible posterior involvement?CommentTo me, the inferior ST E...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This ECG was presented in a conference.The patient had presented many times for SOB.  On this occasion he was intubated for respiratory failure due to presumed asthma.I was asked to interpret his ECG in the conference.  I had never seen it before.ECG-1:What do you think I said?Here is the computer interpretation:This is what I said: " This is diagnostic of an acute inferior MI.  There is upsloping ST elevation in III, with reciprocal ST depression in aVL.  You do NOT see this in normal variant STE, nor in pericarditis.  The only time you see this without ischemia is when there is an abnor...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath.This ECG was recorded on arrival:What do you think?This is technically a STEMI, with 1.5 mm STE in V1 and 1.5-2.0 mm in V2. The current criteria only require 1mm in V1 and 1.5mm in V2 for a female. However, I think many practitioners might not see this as a clear STEMI, and would instead call this " borderline. " The normal QRS complex with STE and large volume underneath the T-waves in V1-V3 confirm Occlusion MI (OMI). There is not technically STD in V6 and I, how...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This study is unable to comment on whether patients with STEMI(-) Occlusion MI have benefit from emergent cath, because that is not the population studied and this subgroup is not commented on.This study is just the most recent in a long long line of similar literature. Context is everything for understanding this study. See below for an excerpt from theOMI Manifesto which summarizes the existing literature and provides details on each study:-------------------------------------------------------------------------------------------------------------- Counter-argument:“Haven’t there been RCTs showing no benefit ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
More News: Blogging | Cardiology | Depression | Electrocardiogram | Emergency Medicine | Heart | Heart Attack | Pain | Pain Management | Study