60-something with 2 days of intermittent epigastric pain. Why does the cardiologist disagree?
One of our residents who just graduated 3 months ago texted me this ECG:" Hey Steve, would be grateful for any thoughts on this EKG.  60-something with 2 days of waxing and waning epigastric pain and diaphoresis.  Also diffuse abdominal tenderness. "Presenting ECG:What was my answer?What is the management? My Answer: " Inferior and lateral OMI "Detailed Interpretation:Sinus rhythm.  Left axis deviation, but not quite LAFB (no r-wave in inferior leads; no q-wave in aVL).  There is less than 1 mm STE in inferior leads, with reciprocal ST depression. There are hyperacute T-wav...
Source: Dr. Smith's ECG Blog - October 20, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

What could this rhythm be? And what is going on after it breaks?
Written by Pendell Meyers, edits by Steve SmithA man in his 30s with no prior medical history presented with palpitations. His vitals and exam were within normal limits with the exception of his heart rate.Here is his initial ECG:What do you think? What is the differential?This shows a regular narrow complex tachycardia, thus the differential is sinus tach, SVT (including AVNRT most commonly, AVRT [which is SVT in the setting of WPW with an accessory pathway] next most common, then atrial tachycardia, etc.) or atrial flutter.It it were atrial flutter, and because it is regular at a rate of 210, the flutter would have ...
Source: Dr. Smith's ECG Blog - October 16, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Do you understand these T-wave inversions?
Case submitted and written by Alex Bracey, with edits by Pendell MeyersA man in his 50s without prior medical history was sent to the emergency department from an urgent care facility for concern of an " abnormal ECG " after he had complained of chest pain earlier in the day. He was symptom free at the time of arrival.Here is the triage ECG at the Emergency Department (we did not immediately have access to the urgent care ECG just yet):ED ECG#1What do you think? What do you think his urgent care ECG (done during pain) will show?This ECG shows sinus bradycardia with terminal ST depressions in II, III, aVF, V3-V6, ...
Source: Dr. Smith's ECG Blog - October 10, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

A 40-Something male with a " Seizure, " Hypotension, and Bradycardia
This is by one of ouroutstanding 3rd year residents, Aaron Robinson, with some edits and comments by SmithEMS responded to a reported seizure in a 42 year old male. Per bystanders, he went down after some intense sporting activity, and had “shaking” type movement. He reports no personal or familial history of seizures.One of our EMS Fellows along with a Senior EM Resident were on duty that evening, and arrived on the scene with the Fire Department. When the physicians approached him, he was ashen, diaphoretic, and appeared in shock. Fire was able to obtain a BP of 60/palp and a pulse in the 40s. The physicians ...
Source: Dr. Smith's ECG Blog - October 7, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Shark Fin morphology recognized only by EM physician
Case submitted by Alex Bracey, Written by Alex Bracey and Pendell MeyersA man in his 70s complained of acute chest pain followed by witnessed cardiac arrest. He received immediate bystander CPR prior to EMS arrival. EMS found him in VF and administered 4 shocks, multiple doses of epinephrine, and amiodarone with intermittent ROSC, however he was in arrest on arrival to the ED with ongoing CPR via LUCAS device. Overall down time was 35 minutes from the time of arrest to arrival at the ED.First rhythm check in the ED showed PEA with a wide complex at a rate of approximately 30 bpm. Calcium and epinephine were given at CPR wa...
Source: Dr. Smith's ECG Blog - October 4, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Look at this ST Depression
DiscussionAtrial repolarization waves are recognized by a downsloping PR segment and are a common cause of false positive stress tests.  They are augmented by tachycardia.See this paper:Sapin PM et al. Identification of false positive exercise tests with use of electrocardiographic criteria: a possible role for atrial repolarization waves. JACC 18(1):127-35; July 1991.  (link is full text)Link to abstract: http://www.onlinejacc.org/content/18/1/127.abstractHere is a schematic from my book,The ECG in Acute MI (this is a link to a free pdf)Learning Points:1. Recognize the atrial repolarization wave. ...
Source: Dr. Smith's ECG Blog - October 2, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 70s with chest pain during a bike ride
Case written and submitted by Ryan Barnicle MD, with edits by Pendell MeyersWhile vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding. It was a constant ache on the left side of his chest that forced him to stop cycling and call for an ambulance. It was radiating to his bilateral upper arms. It was associated with nausea but he denied dyspnea, dizziness, and headache.He explained that he had the same chest pain the day prior as well, on and off....
Source: Dr. Smith's ECG Blog - September 30, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain with NonDiagnostic ECG but Diagnostic CT Scan
An elderly woman presented with chest pain that radiated to the back for several hours.Here is here initial ECG:There is only a nonspecific flat T-wave in aVL.  It is essentially normal.The first troponin returned at 0.099 ng/mL (elevated, consistent with Non-Occlusion MI)Providers were concerned with aortic dissection, so they order a chest aorta CT.This showed no dissection but did show the following:Notice the area of the lateral wall (lower right) that has no contrast enhancement (It is dark, where areas of enhancement are light-colored). This transmural ischemia, but not necessarily completed infarction...
Source: Dr. Smith's ECG Blog - September 27, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 50-something woman with chest pain, BP 230/120, and LBBB with 7 mm ST Elevation
A 50-something woman with history of CHF of unknown etiology, and of HTN, presented for evaluation of chest pressure.Her BP was 223/125, Sp02 98% on RA. HR 106, RR 18. Here was her ED ECG:There is sinus rhythm with Left Bundle Branch Block (LBBB)There is a large amount of ST Elevation in V2 and V3 (more than 5 mm)Thus, this meets the unweighted Sgarbossa Criteria of 5 mm of discordant ST ElevationBut it does NOT meet the Smith Modified Sgarbossa Criteria, which depend on the ST/S ratio.This ratio is critical because LBBB with very large depolarization voltage (QRS) also has very large repolarization voltage (ST/T).Her...
Source: Dr. Smith's ECG Blog - September 25, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 40-something healthy male with transient chest squeezing
A 40-something man with Hx of treated HTN had chest " squeezing, " with SOB and diaphoresis, 10 hours prior to presentation. It lasted 5 minutes then resolved.  There was an exertional component.  Then, 1 hour before arrival, it recurred, again lasting 5 minutes.  His 3rd and last episode was worse, had radiation to both arms, and was 10/10.  911 was called and this prehospital ECG was recorded at time zero:Limb leads:Note the artifact that is simultaneously recorded in all limb leads.  This was mistaken by the treating physicians for ST depression initially.Precordial leads:Wha...
Source: Dr. Smith's ECG Blog - September 22, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Teach your learners: when the QRS is wide, the J-point will hide, so trace it down and copy it over!
Case submitted by Alexis Cates, written by Pendell MeyersA middle aged man with history of HTN, DM, and VSD repair at age 6, presented to the ED with chest pain and diaphoresis while exercising.Here is his initial ECG:What do you think?Hopefully this is too easy for most readers, but it it shows a massive, obvious inferoposterior OMI, in the setting of sinus tachycardia with RBBB and LPFB. It may be too easy for you, but there is a very valuable teaching point for you as you spread ECG knowledge to your group, your residents, your learners.Over the past 3 years I have shown this ECG and many similar ones to many residents ...
Source: Dr. Smith's ECG Blog - September 20, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Unusual: Troponin Trajectory to Help Determine Ongoing/Recurrent Infarction vs. Completed Infarction.
A 40-something male with no PMH of any kind presented  to urgent care on a weekend (cath team is at home) with cough starting 2 weeks prior and SOB one week prior.He underwent a chest x-ray:As this was consistent with " pulmonary edema vs. viral infection, " and he was transferred to the EDThe faculty physician did an immediate cardiac and lung ultrasound:Many B lines (probable pulmonary edema)Parasternal short axis cardiac ultrasound:The anterior wall is closest to the transducer and shows an obvious wall motion abnormalityFurther history:The patient denied chest pain but stated that he had had ab...
Source: Dr. Smith's ECG Blog - September 17, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain, pelvic and abdominal pain, hypotension, and severe ischemia on the ECG
An elderly male was lethargic at the nursing home and complained of some pelvic pain, but then also chest pain and abdominal pain.  He was hypotensive.  His medications include beta blockers.BP on arrival was 66/31, pulse 80, saturations 90% room air.  The patient was lethargic and shocky.An ECG was recorded:There is severe diffuse ST depression of subendocardial ischemia, with the obligatory reciprocal ST Elevation in aVR.One might also think there are hyperacute T-waves in inferior leads, with reciprocal STD and T inversion in aVL.  A bedside echo showed good LV function, no pericardial effusion,...
Source: Dr. Smith's ECG Blog - September 12, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Do you recognize this ECG yet?
Case contributed by Dr. David GordonSee if you can recognize this ECG without the clinical context:Sinus tachycardiaWide QRSTerminal R-wave in aVR, V1, and V2 with STE and coved downsloping ST segmentsSlightly peaked T-waves, most evident in V5-6Together, these features make this ECG consistent only with hyperkalemia or another toxic/metabolic abnormality such as Na channel blockade. Sometimes a patient with profound metabolic acidosis may have this pattern as well, generally in the context of profound metabolic intoxication, usually critically ill, with down time, peri-arrest, post-ROSC, etc. V1-V2 morphology would be con...
Source: Dr. Smith's ECG Blog - September 8, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

What is the differential of this very unusual ECG?
Take a look at this ECG first without clinical context:What do you think?There is sinus bradycardia with very unusual shortened QT interval (approximately 400 ms), for a QTc (Bazett) 358 ms. The T-waves have high amplitude and narrow bases, reminiscent of hyperkalemia, maybe also with hypercalcemia. The T-waves are not bulky or fat, and are therefore not hyperacute regardless of their amplitude.Short QTc is rare, but has been described as less than 360 ms for males and less than 370 ms for females. Furthermore, less than 330 ms (males) or less than 340 ms (females) can be termed " very short QTc " and, in the abs...
Source: Dr. Smith's ECG Blog - September 2, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

An ECG sent to me with concern for hyperacute T-waves
Written by Pendell MeyersA woman in her 70s with diabetes, hypertension, and hyperlipidemia suddenly developed nausea, diaphoresis, and brief syncope while eating at a restaurant. She did not report any chest pain or pressure.She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms:What do you think? No baseline was available for comparison.Sinus rhythmGrossly normal QRS complexLess than 1mm STE in II, III, and aVF, as well as V4-6, all with extremely upward concavityaVL has the smallest possible amount of STD in...
Source: Dr. Smith's ECG Blog - August 26, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Editorial by Meyers and Smith, full text: Prospective, real-world evidence showing the gap between ST elevation myocardial infarction (STEMI) and occlusion MI (OMI)
Read this full text article on the OMI paradigm, from International Journal of Cardiology:Prospective, real-world evidence showing the gap between ST elevation myocardial infarction (STEMI) and occlusion MI (OMI)https://authors.elsevier.com/a/1Zbyec5r~MxXk (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - August 23, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Elderly with Paced Rhythm, Possible Ischemic symptoms, and an Equivocal Smith Modified Sgarbossa ECG
An 80 year old presented with a couple days of SOB, weakness, and diaphoresis.  There was no chest pain.Here was her initial ECG:What do you think?-There is a paced rhythm. -There is some concordant ST Elevation (STE) in V5 and V6. -There is ST depression in V2. -There is minimal concordant ST depression in V3 (remember there should be, if anything, appropriately discordant STElevation).The treating physician did not think that there was sufficient concordant STE in V5 and V6.  He saw the ST depression in V2, but did not see it as concordant or excessively discordant because the R-wave and S-wave w...
Source: Dr. Smith's ECG Blog - August 20, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Acute Chest pain in a 50-something, and a " Normal " ECG
Chris Mondie of the Newark Beth Israel Emergency Medicine Residency sent this caseA 50-something man presented with acute chest pain.Here is his ECG:As you can see, the computer called it completely normalWhat do you think?The computer did not even mention the ST elevation.  It could at least say: " ST Elevation, consistent with normal variant, " or " consistent with ischemia or normal variant, " or " consistent with early repolarization. "  But it simply says " normal. " An interpretation of " normal " could, of course, deceive many providers....
Source: Dr. Smith's ECG Blog - August 17, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

5 Cardiologists said this is not a STEMI. But was it an OMI?
Written by Pendell MeyersA male in his early 50s presented with waxing and waning chest pain starting at rest. He had multiple cardiovascular risk factors and the EM physician strongly suspected ACS.Here is his initial ECG:What do you think?Sinus rhythm-STE in V1-V5, possibly a tiny amount in V6, and small amount in I and aVL, and II-Reciprocal STD (although perhaps isoelectric at J point, immediate STD after the J point) with very ischemic appearance in lead III (down-up T-wave is strongtly suggestive)-Large T-waves in V2-V4, which may be either a normal variant or hyperacute-Very tiny Q wave in lead V2, as well as V6, I,...
Source: Dr. Smith's ECG Blog - August 15, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

The ECG was correct. The angiogram was not.
In this study, approximately 10% of Transient STEMI had no culprit found:Early or late intervention in patients with transient ST ‐segment elevation acute coronary syndrome: Subgroup analysis of the ELISA‐3 trialOne must use all available data, including the ECG, to determine what happened.Final Diagnosis?If the troponin remained under the 99% reference, then it would be unstable angina.  If it rose above that level before falling, it would be acute myocardial injury due to ischemia, which is, by definition, acute MI.  If that is a result of plaque rupture, then it is a type I MI.  The clinical presentat...
Source: Dr. Smith's ECG Blog - August 13, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

How does acute left main occlusion present on the ECG?
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 - August 9, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A young woman with altered mental status and hypotension
Written by Pendell MeyersI texted this Prehospital ECG with no clinical information to Dr. Smith.What do you think?Dr. Smith texted back " Pulmonary Embolism " within seconds.Here is the clinical information:A woman in her 30s with no known past medical history presented by ambulance for altered mental status and syncope. She was delirious, ill-appearing, hypotensive, tachycardic, afebrile, satting 99% on 2L/min masal cannula.Sinus tachycardiaAcute RV strain pattern evidenced by the morphology of the QRS and T-wave in V1-V3, including small-moderate R-wave followed by deep S-wave, then concave ST segment into who...
Source: Dr. Smith's ECG Blog - August 7, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

What are all these little spikes?
An elderly woman fell and had an ECG recorded:What are all these spikes?They can't be anything but artifact, but from what??These are typical spikes for nerve stimulators.  In this case, the woman did not remember that she has abladder stimulator for neurogenic bladder, but deep chart review found that this is the case.ECG artifact of bladder stimulators has been reported in the Journal of Electrocardiology:https://search.proquest.com/openview/aafa4a4cf87e7229eddc54d300209a9f/1?pq-origsite=gscholar&cbl=6950 (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - August 4, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

OMI Confirmed by POCUS Echo in a 50 year man
Case submitted and written by Alex BraceyA man in his 50s with no significant past medical history presented from a local beach with epigastric " burning " pain that had been intermittent for 4 days until this morning when it became constant at rest. He had associated nausea and diaphoresis, but overall looked well and had arrived by private vehicle to front triage. An ECG was performed there and brought to me for review:What do you think?STE in V2-4 that might just barely meet STEMI criteriaSTE in aVL, and to a lesser extent lead IObvious reciprocal STD in II, III, aVFRegardless of whether this ECG truly meets S...
Source: Dr. Smith's ECG Blog - August 2, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

A 60-something who has non-specific generalized malaise and is ill appearing.
An anonymous paramedic sent this.A 60-something with past history only of colon cancer called 911 for non-specific generalized malaise.The medics state that he was ill appearing.They recorded an ECG:What do you think?This is extremely wide, and even if it is VT, it is so wide that there must be hyperkalemia or a severe Na channel blocking overdose.  The patient was not on a sodium channel blocker.The paramedic knew instantly what it was (he credits his regular reading of this blog!)The patient was only a couple blocks from the hospital, so there was no time for treatment before arrival.K was 8.9 mEq/L.Etiology was a c...
Source: Dr. Smith's ECG Blog - July 30, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

What is the Diagnosis in this 70-something with Chest Pain?
This is a very commonly missed ECG of a terrible condition.  In this case, it was almost dismissed.  I present many other similar ECGs at the bottom that were indeed missed or dismissed.CaseI was texted this ECG from a physician assistant who works by himself in several small Emergency Departments.He is a particularly smart and well trained emergency medicine PA (because he trained at Hennepin).He added the words:" What do you think?  70-something male with DM, HTN, no previous MI, with Chest pain "What doyouthink?Here was my response:" Definite Huge Occlusion MI (OMI). STEMI! This is a bad on...
Source: Dr. Smith's ECG Blog - July 28, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

" Long QT " after droperidol
A patient presented to the ED with intractable hiccups.  He also had " ongoing GERD symptoms with heartburn......but no chest pain "  (Whatever that means).  He was treated with droperidol and benadryl and this decreased his symptoms and he was discharged.  No ECG was recorded (!).Later, the patient returned with altered mental status and reports of falls.He had an ECG recorded:The QT was 504 msThe computerized QTc (Hodges correction) was listed as 530 ms.Bazett correction would be 563 msThe providers were worried that the droperidol had resulted in a long QT.What do you think?See below for ex...
Source: Dr. Smith's ECG Blog - July 26, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Bizarre T-wave inversions, with Negative U-waves and Very long QT. And a myocardial viability study.
This 60-something year old male was admitted and his hospital course complicated by GI bleed, hemodynamic instability, and a nadir hemoglobin less than 5 g/dL.  An ECG was relatively normal.The next AM, his potassium was measured at 2.9 mEq/L, so another ECG was recorded.He was asymptomatic.The previous ECG from one week prior had been relatively normal.There are bizarre inverted T-waves and also inverted U-waves (see the 2nd inverted bump?)The QT is incredibly longThere is some subtle STE in inferior leads but also STE in I, aVL.There is STE before the bizarre TU inversion in leads V3-V6.There are some artifacts that...
Source: Dr. Smith's ECG Blog - July 24, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

What does this ECG with significant ST Elevation represent?
These 2 serial ECGs were texted to me recently.  They were recorded 12 minutes apart:" Hey Steve, 30-something with one week of chest pain, mostly right-sided, better with sitting up. " :What do you think?QTc's were 330 ms and 373 msThis is what I texted back:These look like they are a very pronounced case ofBenign T-wave Inversion.  I do not think this is acute occlusion myocardial infarction (OMI).  Get an emergent contrast echocardiogram.p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Helvetica}These are reasons why it does not look like OMI: 1. flat ST segment in V42. huge R-wave ...
Source: Dr. Smith's ECG Blog - July 21, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 40s with chest pain and syncope after cocaine use
Written by Pendell Meyers, with edits by Steve SmithA man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). He also described a syncopal episode just prior to onset of symptoms. He had used cocaine approximately 20 minutes prior to onset of symptoms.He still had active pain on arrival to the ED.Here is his triage ECG:What do you think?His baseline ECG was on file:--Sinus rhythm--Subtle STE in V1-V5, II, III, and aVF--Q-waves in V1-V5, as well as II, III, and aVF which must...
Source: Dr. Smith's ECG Blog - July 19, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

A Text Message in the Middle of the night. Do you give thrombolytics?
I awoke in the morning and discovered a text with this ECG that was sent 6 hours prior by a former resident:" 60 year old with classic chest pain.  The cath lab is occupied for the next 90 minutes.  Cards says " not a STEMI " .  Thinking of giving lytics. "What do you think?What do you do?I texted back: " Sorry for delay!  Was sleeping.  This is OMI!!  Did you give lytics?  Proximal LAD.  Great catch! "There is 0.5 mm of ST Elevation in V3-V6.  The T-wave in V4 is far too large for the QRS.  The LAD occlusion formula would be very high due to t...
Source: Dr. Smith's ECG Blog - July 17, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A female in her 60s with sudden chest pressure
Written by Pendell MeyersA female in her mid 60s with history of SVT and HTN presented with sudden onset 3/10 chest tightness while lying in bed in the early morning. She had nausea and diaphoresis with this event, as well as tightness between her scapula, and a loose bowel movement.Here is her initial ECG at presentation to the ED at time zero (no prior available):What do you think?Sinus rhythm with significant downsloping STD in V1-V3, maximal in V1-V2. There is also subtle STE in V6 with large-area T-wave with straight/convex ST segment morphology. The T-waves in the inferior leads could be large if a prior ECG wer...
Source: Dr. Smith's ECG Blog - July 15, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

A 40 year old man with chest pain since last night
Written and submitted by Ashley Mogul, with edits by Pendell Meyers and Steve SmithA man in his 40s with recent smoking cessation but otherwise no known past medical history presented due to chest pain since the previous evening. The pain has been constant and associated with vomiting and diaphoresis. He decided to present the following day when the pain had not stopped.Here is the presenting ECG (no prior available):What do you think?Relevant findings include slight STE in V1 with an upright T-wave, slightly large T-waves in V2-3 (possibly hyperacute if compared to baseline), and slight reciprocal depression in II, III, a...
Source: Dr. Smith's ECG Blog - July 11, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

The OMI Manifesto Lecture (1 Hour Video Lecture)
Written and recorded by Pendell MeyersHere is a 1-hour video lecture accompanying our OMI Manifesto (released last year onDr. Smith's ECG Blog andEMCrit)Click here for full PDF of the OMI Manifesto (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - July 9, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Would you have given thrombolytics to this NSTEMI patient?
Case submitted by Dr. James AlvaA middle aged male called EMS for chest pain. EMS arrived and confirmed that the patient was complaining of chest pain and shortness of breath.They recorded this prehospital ECG:What do you think?Normal QRS complex rhythm with hyperacute T-waves in V2-V6, I and aVL. Slight STE in V2 only, with significant STD and thus de-Winter pattern in V4-V6. Leads II and III show reciprocal depression of the ST segment (II) and T-wave (III). This is diagnostic of acute myocardial infarction of the anterolateral walls, with the most likely etiology being Occlusion of the LAD. In other words, this ECG show...
Source: Dr. Smith's ECG Blog - July 7, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Acute MI, pain onset 24-48 hours ago. Should the patient go for emergent angiogram/PCI?
DiscussionWhich subacute STEMI should go to the cath lab?Simplified:IF there is subacute STEMI by ECG or other criteria AND:1. Symptoms onset is within 48 hours AND2. There are persistent symptoms OR persistent ST ElevationThen the patient should go for emergent angiogram/PCI.I think it makes sense to extend this beyond 48 hours because ischemia can be so intermittent.Schomig et al. randomized patients with:STEMI12-48 hours of symptomsNo persistent symptomsPersistent ST ElevationNo hemodynamic or electrical instability, no pulmonary edemaThe patients who received emergent PCI had significantly smaller median left ventricul...
Source: Dr. Smith's ECG Blog - July 5, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Two patients with RBBB
Case 1.A 60-something woman presented with dyspnea.  She had a history of chronic respiratory disease and hypoxia, but hypoxia was no worse than normal.ECG:There is abnormal ST Elevation in I and aVL.Although as a general rule, there should be no ST elevation in RBBB in the absence of ischemia, there sometimes is ST elevation that looks like this.Therefore, I went to find an old ECG and it looked the same.The patient ruled out for acute MI with all negative troponins.She had a completely normal formal echo.All previous ECGs were identical.This was her baseline ST elevation, and I have seen this many times.Case 2: sent...
Source: Dr. Smith's ECG Blog - July 1, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?
60-something with h/o MI and stents presented with chest pain radiating to the back and nausea/vomiting.Time zeroWhat do you think?There is inferior ST elevation.  Is it normal variant?  Is it ischemic (OMI)?  [Pericarditis? (NOT!)]There is one finding that argues against inferior OMI (There is absence of reciprocal ST depression in aVL; STD aVL is extremely sensitive for inferior OMI;  Reference: Bischof and Smith). However, there is alsostraightening of the inferior ST segments, and astraight ST segment in aVF; this is extremely rare in normal variant STE)._______There is alsoterminal QRS di...
Source: Dr. Smith's ECG Blog - June 28, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Serial Evolving ECGs all diagnostic of LAD OMI, but never meet STEMI criteria
A 60-something called 911 for chest pain.Medics recorded an ECG at time zero:What to you think?There is no ST elevation, but V2 has a definite hyperacute T-wave.  Inferior leads have a tiny bit of ST depression (this is very significant).  aVL has a tiny amount ofcoved ST elevation in the presence of a tiny QRS.  These are all very very suspicious for proximal LAD OMI.They recorded another at 20 minutes: Evolving anterior OMI, but with barely any ST Elevation. Look at the huge size of the T-wave in V4 relative to the R-wave.Increasing STE in aVLIncreasing inferior reciprocal ST depressionIf you dou...
Source: Dr. Smith's ECG Blog - June 26, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

2 ECGs texted to me. Minimal STE in inferior leads. How important is it?
These 2 ECGs were texted to me with the words " I think acute MI, but cardiology does not. "I believed these to be 2 serial ECGs:ECG 1: (later found to be time zero):Computer read: " minimal ST depression 0.025 mm "There is a small amount of STE in II, III, aVFFrom less than 0.5 mm - 0.5 mm.There is les than 0.5 mm of reciprocal ST depression in aVL, and an inverted T-waveAnd the other: (later found to be time 24 minutes):Now there is more STE and more STDOne very telling finding are the ST segments in V2-V6:ST depression has developed in V2-V6, downsloping in V4-V6.Though minimal, this is very specific...
Source: Dr. Smith's ECG Blog - June 23, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

ST segment concavity is just one small piece of the puzzle that is pattern recognition
Written by Pendell MeyersHere are two striking examples from a single shift highlighting the fallibility of the standard " smiley face " or upwardly concave ST segment morphology " rule " .Case 1.Obvious STEMI and OMI with massive STE in the inferior and lateral leads, even extending back into V3. All STE has concave upward (smiley face) morphology. V2 shows STD indicating posterior involvement. V1 may be in a tug-of-war between STD from posterior involvement and STE from possible RV involvement. Reciprocal STD in I and aVL. Sinus bradycardia with first degree heart block present, cl...
Source: Dr. Smith's ECG Blog - June 22, 2019 Category: Cardiology Authors: Pendell Source Type: blogs

Do you recognize these ECGs? STEMI? LVH? What?
What do you think of these ECGs?I came across the first one reading it blind for a study.  I was certain I knew the diagnosis, and went to the chart to confirm.The first 3 were recorded on one day.ECG 1:ECG 2:ECG 3:ECG 4, recorded 12 days later:These ECGs are classic for abenign variant in Black males.  I was certain it would be a relatively young black male without cardiac pathology.Result from chart:It was a black male in his 40s.The first ECG, and then the next two (1-3), were recorded for chest and abdominal pain.  The patient was ultimately diagnosed with biliary colic.The patient ruled out for MI by se...
Source: Dr. Smith's ECG Blog - June 20, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

ROSC: does the ECG rule out OMI? And why does a heart just stop beating? And what rhythm is this?
This study had afatal flaw: they did not keep track of all the Non-STEMI patients who were NOT enrolled, but instead were sent for immediate angiogram.  It was done in Europe, where the guidelines suggest taking all shockable arrests emergently to the cath lab.  So it is highly likely that physicians were very reluctant to enroll patients; they did not want them to be randomized to no angiogram.  This strong suspicion is supported by their data:only 22 of 437 (5.0%) patients in this study had OMI.What percent of shockable arrests without STE have an OMI?  This large registry in Circulatio...
Source: Dr. Smith's ECG Blog - June 18, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

ROSC: does the ECG to rule out OMI? And why does a heart just stop beating? And what rhythm is this?
This study had afatal flaw: they did not keep track of all the Non-STEMI patients who were NOT enrolled, but instead were sent for immediate angiogram.  It was done in Europe, where the guidelines suggest taking all shockable arrests emergently to the cath lab.  So it is highly likely that physicians were very reluctant to enroll patients; they did not want them to be randomized to no angiogram.  This strong suspicion is supported by their data:only 22 of 437 (5.0%) patients in this study had OMI. What percent of shockable arrests without STE have an OMI?  This large registry in Circ...
Source: Dr. Smith's ECG Blog - June 18, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

More precise interpretation of the results of the 4-variable formula.
If you haven't heard of the 4-variable formula for differentiating Normal Variant ST Elevation in V2-V4 from Ischemic ST Elevation due to LAD occlusion, then go here:12 Example Cases of Use of 3- and 4-variable formulas to differentiate normal STE from subtle LAD occlusionI have often said that the closer the formula value is to the cutpoint of 18.2, the more accurate. But how wide is the variation?Here I plot the graphs:SpecificitySpecificity is 97% at a cutpoint of  20.7SensitivitySensitivity is 97% at a cutpoint of 17.0Accuracy (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - June 17, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Patient with Dyspnea. You are handed a triage ECG interpreted as " normal " by the computer.
I was handed this ECG of a patient with dyspnea:What do you think?Computer interpretation: Normal EKGPhysician Overread (Final interpretation): Normal EKGThe ST segment is very flat, with a sudden rise to the peak of the T-wave.  This makes the base of the T-wave look very narrow.  A narrow-based T-wave is nearly pathognomonic for hyperkalemia.  My diagnosis was hyperkalemia.The resident I showed it to saw nothing.  I explained all this to the resident, then went to see the patient.Turns out he is a dialysis patient.Later, the ECG computer interpretation was overread by another physician, and that physi...
Source: Dr. Smith's ECG Blog - June 15, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 20-something male with acute chest pain
I was texted this ECG with the words " sudden onset CP in a 20-something " :What do you think?This was my response:" This is abnormal in lateral leads. It probably is a normal variant but I would get a stat echo.It is out of the bounds of the usual with normal variant because the ST Elevation is so focal to the lateral wall. Most normal variant has as much inferior STE as lateral (and of course without ST depression in aVL).  This is myocarditis versus myocardial infarction. He should get an immediate echo.  Problem is, even myocarditis will have a wall motion abnormality. And then the on...
Source: Dr. Smith's ECG Blog - June 11, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A patient with chest pain that is resolving. Computer interprets ED ECG as completely Normal.
This study, discussed on Salim Rezaie's fine site REBEL EM, implies you can trust the computer interpretation of " normal. " (http://rebelem.com/triage-ecgs-reducing-interruptions-busy-ed/)We recently wrote an editorial debunking this study: Litell, John M., H. Pendell Meyers, and Stephen W. Smith. 2019. “Emergency Physicians Should Be Shown All Triage ECGs, Even Those with a Computer Interpretation of ‘Normal.’”Journal of Electrocardiology 54 (March): 79 –81. https://doi.org/10.1016/j.jelectrocard.2019.03.003.What to do?Recording serial ECGs would be useful. The ...
Source: Dr. Smith's ECG Blog - June 9, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 40-something woman with no medical history presented with 2 days of chest pain
A 40-something called 911 for 2 days of CP.  It was difficult to get a history because of language, but of course a prehospital ECG was recorded.  It is not available but looked just like the first ED ECG.(click on the image to enlarge)Here is the computer interpretation:p.p1 {margin: 0.1px 0.0px 0.1px 1.6px; font: 11.0px Arial}LEFT VENTRICULAR HYPERTROPHY AND ST-T CHANGEINFERIOR MYOCARDIAL INFARCTION, OF INDETERMINATE AGEPOSSIBLE ANTEROSEPTAL MYOCARDIAL INFARCTION , OF INDETERMINATE AGEWhat do you think?The medics noticed the inferior STE with reciprocal STD and were worried about inferior MI.  My partner s...
Source: Dr. Smith's ECG Blog - June 8, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs