Chest pain and Inferior T-wave Inversion. Does this patient need emergent cath lab activation?
This ECG was texted to me, initially with no information:What do you think?There are QS-waves in III and aVF.  There is a qR in lead II.  There is minimal STE, upsloping, with T-wave inversion in lead II.  Leads III and aVF only have deep, fairly symmetric T-wave inversion.My interpretation and reply (paraphrase):There is subacute inferior MI and there has probably been prolonged pain.  The initial troponin will be high.  With T-wave inversion, it is possible that the artery has opened, but with subacute MI, the T-wave may be invertedeven with persistent occlusion.  If there is persistent pain...
Source: Dr. Smith's ECG Blog - July 9, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

An Very Elderly Male with Epigastric pain, " ischemic ECG " and Interesting Imaging.
CONCLUSION: Prior to reviewing the literature for discussing this case — I had not fully appreciated the impact of the mechanism of cardiac compression as a causative factor in: i) altering QRS morphology; ii) precipitating supraventricular and/or ventricular arrhythmias (including VT, which can be sustained) — and, iii) producing ST-T wave changes (ST elevation and/or depression) that may mimic old or new infarction.CT imaging (as shown by Dr. Smith) clearly suggests there was compression of cardiac structures in thi...
Source: Dr. Smith's ECG Blog - July 7, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Massive Transfusion for Motorcycle Collision with Hemorrhage, Troponin Elevated.
This ECG was done in a middle aged woman who was in a motor vehicle collision in which her vehicle " T-boned " another, so there was trauma to the anterior chest.  She had multiple rib fractures as well as serious hemorrhage and underwent massive transfusion.Her initial troponin I, part of a critical care order set, returned at 0.55 ng/mL, and an ECG was recorded:There are no P-waves visible. RBBB and LAFB morphology. Rate 114.This could be a junctional rhythm with RBBB and LAFB.Or, much less likely, it could be a very accelerated escape rhythm from the posterior fascicle.Either could be a result of myocardi...
Source: Dr. Smith's ECG Blog - July 3, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

This patient has a severe electrolyte abnormality. Can you tell what it is? (Not hypokalemia)
This patient has a severe electrolyte abnormality.  Can you tell from the ECG what it is?IMPRESSION by computer and physician overread:Heart Rate 120SINUS TACHYCARDIA WITH FIRST DEGREE AV BLOCKPOSSIBLE LEFT ATRIAL ENLARGEMENT [-0.1mV P WAVE IN V1/V2]MODERATE ST DEPRESSION [0.05+ mV ST DEPRESSION]Prolonged QTABNORMAL ECGP-R Interval 220 msQRS Interval 84 msQT Interval 349 ms QTC Interval 419 msP Axis 125QRS Axis 13T Wave Axis 2I think the computer got the QT wrong.  It is at least 360 ms and possibly as high as 400 ms.Hodges Corrections using 360 ms: QTc = 465 msSmith Impression: The ECG shows ...
Source: Dr. Smith's ECG Blog - July 1, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Repost: 63 minutes of ventricular fibrillation, followed by shock. What is going on?
In this study, 5% of VF arrest was due to PE: V fib is initial rhythm in PE in 3 of 60 cases. On the other hand, if the presenting rhythm is PEA, then pulmonary embolism is likely.  When there is VF in PE, it is not the initial rhythm, but occurs after prolonged PEA renders the myocardium ischemic.--Another study by Courtney and Kline found that, of cases of arrest that had autopsy and found that a presenting rhythm of VF/VT had an odds ratio of 0.02 for massive pulmonary embolism as the etiology, vs 41.9 for PEA.    ===================================MY Comment by KEN ...
Source: Dr. Smith's ECG Blog - June 28, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Intermittent QRS Widening Without Any History
===================================MY Comment by KEN GRAUER, MD (6/25/2020):===================================I ’ve labeled the ECG in Figure-1 as, “The initial ECG in this Case” — as I found this tracing fascinating. Imagine you knew nothing about this patient.HOW would you interpret this tracing?Is there bundle branch block?Are there acute changes?Figure-1: The initial ECG in this case (See text).First Impression: The 12-lead ECG and long lead II rhythm strip shown in Figure-1 is difficult to interpret for several reasons:There...
Source: Dr. Smith's ECG Blog - June 25, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Diffuse T-wave inversions and a very long QT
This ECG was texted to me and I read it while mountain biking. My response was " takotsubo " .ECG 1There is are diffuse T-wave inversions and a bizarre QT interval, very longThis is very typical of takotsubo.Aside: I classify takotsubo ECGs into 2 broad categories:1) ST Elevation which often mimics STEMI2) T-wave inversion: does not mimic STEMI, but rather mimics NonSTEMI or reperfused STEMIThe next day I texted back to ask what the clinical presentation was, what the echo showed, and what the outcome was.It turned out that this patient had severe alcoholism, alcohol withdrawal, and seemed to have had a...
Source: Dr. Smith's ECG Blog - June 22, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Syncope and ST Elevation on the Prehospital ECG
DiscussionThus, no further ECGs were recorded and there was no angiogram or stress test or CT coronary angiogram.  Acute MI does not often present with syncope alone, without any other symptom, so the pretest probability of acute MI is low.However, the troponins are high and, in my opinion, the data above does not rule out the possibility of type 1 MI.  There were very elevated troponins without a significant known stress (which might cause a type 2 MI).  The troponins are NOT consistent with STEMI (OMI), which typically has a troponin I of at least 5 ng/mL.  Nevertheless, I don't think a thrombosis rel...
Source: Dr. Smith's ECG Blog - June 20, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 60-something has chest tightness, palpitations, and ST depression V1-V3
A 60-something has chest tightness, palpitations.  Charts showed a history of some mitral regurgitation and an enlarge left atrium, as well as hypertension treated with a thiazide diuretic.A prehospital ECG showed ST Depression in V1-V3 and the medics were concerned for posterior STEMI.On arrival, the patient was in minimal distress, stated that he " always has chest tightness " but that his " heart started jumping around " one hour prior.Pulse was 128 and irregular, BP was 141/75.Here is the 12-lead:Atrial Fibrillation with slightly rapid response.ST Depression maximal in V2 and V3.What do you thi...
Source: Dr. Smith's ECG Blog - June 17, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 60s with shockable arrest, then ROSC, and no STEMI - what will you do?
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 - June 15, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Drug Overdose with a Fascinating Arrhythmia
===================================MY Comment by KEN GRAUER, MD (5/28/2020):===================================Today ’s case features another look at a fascinating arrhythmia that Dr. Smith first posted on June 10, 2011. The patient presented to the ED following a drug overdose with oxcarbazepine. Although details of the case beyond this were not available — we ’ll assume this patient was hemodynamically stable at the time the ECG in Figure-1 was recorded.What is the cardiac rhythm in Figure-1?Is there AV block?HOW would you proceed inassessing this arrhyt...
Source: Dr. Smith's ECG Blog - June 13, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Serial ECGs highly suspicious for inferior OMI: Give thrombolytics prior to transfer for PCI?
One of my former residents texted this info to me with the EKGs:" I have here a 50 something-year-old female with multiple stents who presents with a concerning pain history. Pain relief with nitroglycerin, and I am starting a nitroglycerin drip. " I ’m worried about a hyperacute RCA infarct. " There is no old ECG available." I have to transfer for PCI, and am wondering if I should give thrombolytics first. "Here is the initial ECG:Inferior STE less than 1 mm, with reciprocal inverted T-wave and STD in aVL  I recorded this one 15 minutes later:Now with straightening of the...
Source: Dr. Smith's ECG Blog - June 12, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A very fast wide complex tachycardia
A patient presented by EMS with non-specific symptoms.  He had a very rapid rhythm that was not converted by 6 mg, then 12 mg of adenosine.On arrival, his BP was 94/75, pulse 127.Here is his 12-lead:Wide complex, Rate 265( " Pulse " was 127, so many of these beats are not resulting in a strong enough pulse to be palpated.)What do you think?Because of the extremely fast rate, the treating physicians thought that this was atrial fib with WPW.  However, this is clearly a misdiagnosis.When the rate is so fast, it is possible to mistake a regular rhythm for an irregular one.  So one should use calipers ...
Source: Dr. Smith's ECG Blog - June 9, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

50-something with STEMI and hypotension: What is the infarct artery?
A 50-something woman presented with chest pain, midsternal, 9/10.Her BP was 93/58, pulse 110.Here is her ECG:What is the infarct artery?There is STE in V1-V6, maximal in V2 and quite profound in V1.There is also STE in II, III, aVF, with reciprocal STD in I and aVL.The differential is:1) LAD occlusion proximal to the septal perforator with wraparound to inferior wall      (that much STE in V1 is quite specific for septal involvement with anterior STEMI)  vs. 2) Proximal RCA with RV involvement.  Is it important to know whether this is LAD or RCA?  S...
Source: Dr. Smith's ECG Blog - June 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his sixties with chest pain
Written by Pendell MeyersA man in his sixties with no prior history of CAD presented with fluctuating central chest pain that started the night before presentation, then went away, then woke him up from sleep the morning of presentation. The pain was 10/10 on arrival, with SOB. Although he also had some nasal drip and sore throat, he had no cough or fevers (this occurred during peak COVID).Here is his triage ECG:What do you think?Normal P-waves would have upright morphology in the inferior leads (especially lead II) and usually biphasic (up-down) morphology in V1. These p-waves are negative in almost all leads except for a...
Source: Dr. Smith's ECG Blog - June 3, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A Different Kind of Wide Rhythm -- Pleomorphic Ventricular Tachycardia
===================================MY Comment by KEN GRAUER, MD (6/1/2020):===================================YOU are asked to interpret the ECG shown in Figure-1. Unfortunately, no history is available to assist.WHAT are the diagnostic possibilities for the rhythm?What are the prognostic implications of this rhythm?Figure-1: The initial ECG in the ED. Please note that the long lead II rhythm strip is not simultaneously obtained with the 12-lead tracing above it. (See text).MY THOUGHTS on ECG #1: My initial impression on looking at the ECG...
Source: Dr. Smith's ECG Blog - June 1, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

A Young Woman with Regular Narrow Complex Tachy at both 160 and 240
This article studied their effect in pediatrics:https://www.ahajournals.org/doi/full/10.1161/CIRCEP.109.901629===================================MY Comment by KEN GRAUER, MD (5/30/2020):===================================Fascinating case presented by Dr. Smith (!) — about this young woman who presented with palpitations and sequential reentry SVT rhythms — initially at a ventricular rate of ~160/minute — and then following administration of 6mg IV adenosine, another reentry SVT at a much faster rate of ~240/minute. HOW could this happen?For ...
Source: Dr. Smith's ECG Blog - May 31, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A middle-aged male with chest pain
A 40-something male presented with chest pressure.Here is his triage ECG:What do you think?The triage physician suspected that this was a false positive due to benign normal variant ST Elevation (Often called " Early Repolarization, " though many are trying to get away from that terminology for this morphology)When I saw the ECG I immediately thought that this was not STEMI.I applied the Early Repol/LAD occlusion formula.See this post for explanation and references:12 Example Cases of Use of 3- and 4-variable formulas to differentiate normal STE from subtle LAD occlusionRemember it can only be applied when NONE o...
Source: Dr. Smith's ECG Blog - May 26, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

What do you think of this elderly man with " possible seizure " ?
Written by Pendell Meyers(with really great and thorough explanation of this finding by Ken Grauer).At my hospital, patients with any symptoms which could be vaguely interpreted as a possible stroke during the triage process are brought to the high acuity area and a provider is asked to do a " neuro check " , which involves a quick H and P and exam to determine if we should activate our stroke protocol.A man in his 70s was brought to me for a neuro check, and the triage providers commented that they were worried about a possible seizure as well. The patient was alert and oriented with normal vitals at triage. He ...
Source: Dr. Smith's ECG Blog - May 24, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A 50ish Man whose Wide Tachycardia was Treated
===================================MY Comment by KEN GRAUER, MD (5/22/2020):===================================The ECG in Figure-1 was obtained from a 50-ish year-old man, who was found by the EMS team to be in a wide tachycardia. The patient was treated on the scene with medication. ECG #1 shows the results of such treatment.Is this patient now in sinus tachycardia (RED arrow)?Figure-1: The 12-lead ECG and long lead II rhythm strip obtained after medication converted a wide tachycardia (See text).My THOUGHTS on ECG #1: It is tempting to accept the RED arrow in&nb...
Source: Dr. Smith's ECG Blog - May 22, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

1 hour of CPR, then ECMO circulation, then successful defibrillation....
An elderly woman had sudden ventricular fibrillation.She was unable to be defibrillated but was cannulated and placed on ECMO in our Emergency Department (ECLS - extracorporeal life support).  ECMO Flow was achieved after approximately 1 hour of high quality CPR.After good ECMO flow was established, she was successfully defibrillated.Here is her monitor rhythm:Notice the " Shark Fin " morphology in lead I monitor rhythm.Also notice that the arterial line mean arterial pressure is 63 mmHg, but there is no waveform (and SpO2 says " no pulse " ), as the flow is continuous on ECMO and the LV function a...
Source: Dr. Smith's ECG Blog - May 19, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Syncope and Chest Pressure, then an Unusual Bradycardia with Shock
This case is from one of our fantastic 3rd year residents, Aaron Robinson.A woman in her 60s with SyncopeA woman in her 60s presented to a facility with syncope. She had a history of CHF, pulmonary hypertension,CAD s/pCABG, and ESRD on hemodialysis. She had a dialysis run the day prior. Prehospital VS were: BP 115/70, HR 65, RR 12. The patient did not have a 12 lead completed pre-hospital.She arrived at the ED awake, alert, and complaining only ofmild chest discomfort. A 12 lead ECG was immediately completed:Aaron showed this to me and this is what I said:Suggestive of inferior posterior MI, but not dia...
Source: Dr. Smith's ECG Blog - May 16, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

What do you think the echocardiogram shows in this case?
A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG:Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVROf course this pattern is most often seen from etoliogies other than ACS.  The ECG only tells you there is ischemia, not the etiology of it.Nevertheless, the clinical situation made other etiologies unlikely.EMS gave 324 mg aspirin and 3 sublingual NTG, which the patient stated reduced the substernal chest pain from an 8/10 to 4/10.Here is the ED ECG on arrival:Less STE/STDProvider's Clinical Impression: ...
Source: Dr. Smith's ECG Blog - May 13, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 50s with fever and shortness of breath
Written by Pendell MeyersA man in his 50s with HTN, HLD, obesity, and restrictive lung disease presented with shortness of breath worsening over the past 3 days. He also had a cough and subjective fevers. He denied chest pain. His vitals were within normal limits.Here is his triage ECG (no baseline available):What do you think?Findings: - sinus rhythm at about 100 bpm - STE in I and aVL (meets STEMI criteria) - hint of STD in III and aVF - STD in V1 and V2 - hyperacute T-waves in I and aVL (with reciprocal negative hyperacute T in III)Interpretation:This is definitive evidence of acute transmural i...
Source: Dr. Smith's ECG Blog - May 11, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Adding to the many faces of Hypokalemia....
These 2 cases came in on one shift:Patient 1This patient was weak with a K of 2.4 mEq/LSee the U-waves that are most prominent in V2 (which is the usual lead) and in V3-V6. I magnify the precordial leads here:Now the U-waves are much easier to seePatient 2This patient was weak with a K of 2.0 mEq/LThis ECG appears to have an incredibly long QT in V2-V4, but that apparent T-wave really is stretched out by a 2nd hump which is the U-wave.Hyperkalemia is called the " syphilis of ECG findings " because it comes in so many forms, but hypokalemia ECGs are multiform also. However, they usually some variation of...
Source: Dr. Smith's ECG Blog - May 9, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Looking through a stack of ECGs for a troponin study.....
And I came across this one while reading EKGs for a high sensitivity troponin study:what do you think?Normally, if one sees STE in aVL with reciprocal STD in III, one would say " Acute OMI " .But I instantly knew it was not.I immediately recognized it as normal, and classified it for the study (blinded) as " normal with normal ST Elevation and " normal ST depression. "More on this ECG:All I know when I see the ECG for this study is that the patient has had at least 2 troponins drawn.I don't know whether it is for chest pain, weakness, whatever.I don't know for certain why my (our) mind immediately ...
Source: Dr. Smith's ECG Blog - May 7, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Is it VT or SVT with Aberrancy?
Here is a classic ECG, presented and analyzed by Ken Grauer:Figure-1: The initial ECG in this case, obtained by the EMS team (See text).===================================MY Comment by KEN GRAUER, MD (4/18/2020):===================================The 12-lead ECG in Figure-1 was obtained from a woman in her 80s who was seen by EMS for symptoms of new confusion and hypotension. She had a history of an MI in the past.WHAT is the rhythm in ECG #1?How certain are you of your diagnosis?Smith's comment on management:First, what do you want to do?The patient has confusion and hypot...
Source: Dr. Smith's ECG Blog - May 5, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

A young woman with vomiting
A 20-something presented with vomiting.An ECG was recorded:HR is 101The prior ECG was normal.The computerized QT measurement was 353 ms, and Hodges QTc was 411 msWhat is going on?There aredown-up T-waves, in which the QT interval (measure wrong by the computer) is too long.I measure it as460 ms in lead V3, with aHodges QTc of 532 ms.There is also some diffuse non-specific ST depression.Down-up T-waves should make you think one of two things:1) reciprocal to up-down T-waves  a) up-down waves in leads V7-V9 of reperfused posterior MI often manifest with down-up T-waves in V2 and V3  b) in lead III, reciprocal to aV...
Source: Dr. Smith's ECG Blog - May 3, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Cardiac Arrest. What does the ECG show? Also see the bizarre Bigeminy.
A 60-something woman presented after a witnessed cardiac arrest. CPR was started immediately.  EMS arrived and found her in a wide complex PEA rhythm. She was given 3 mg IV epinephrine and multiple rounds of ACLS over approximately 20 minutes.Her husband stated that she had not been feeling well in the past 2 weeks and c/o dizziness as well as diarrhea.She was never defibrillated.I was texted this ECG in real time, but it turns out to actually be the 2nd one recorded in the ED.What do you think?This is what I wrote:This looks like pseudoSTEMI to me.  What appears to be ST elevation seems to be a wide QRS.  I...
Source: Dr. Smith's ECG Blog - April 29, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Another Shark Fin. With a twist.
I was reading stacks of ECGs for a study, without any clinical information.I came across this one and immediately recognized it and knew the diagnosis (Pendell did too when I sent it to him):There is a Shark Fin!What is the diagnosis?But this is not the kind Shark Fin we usually see, which is due to STEMI! This ECG is pathognomonic for severe hyperkalemia.  Wide QRS, large R-wave in aVR, Brugada-like ST Elevation in V1-V3 with inverted T-waves, extremely peaked T-waves (in many leads).I went to the chart to find the case:56 y.o. type 1 diabetic presented for evaluation of hyperglycemia. He had stopped t...
Source: Dr. Smith's ECG Blog - April 25, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Guess the culprit with ST Elevation in posterior leads
A middle aged man had off and on chest pain for 2 weeks, then 2 hours of more severe and constant pain.Here was his ED ECG, which was identical to the prehospital ECG.  He did not get prehospital activation.What do you think?There is sinus rhythm with ST depression in I, II, aVF and V2-V6.  It is maximal in V3 and V4.  This usually means posterior MI,whether the T-wave is upright or not.There is also some ST elevation in aVR, which must be present whenever there is ST depression in I and II (a lead between I and II is (-) aVR, opposite aVR; if ST segments in I and II are negative, then theymust also be negat...
Source: Dr. Smith's ECG Blog - April 24, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A quick and easy, but interesting, case: why 3 different QRS morphologies?
One of my residents who is very smart sent me this ECG.Patient had "nonspecific chest symptoms worried she had pneumonia. She does not have pneumonia. "Here is the ECG:What do you think?The resident wrote:She has 3 different QRS morphologies:,1. One that looks narrow2. One that looks LBBB3. One that looks RBBB. Cardiology called them PVCs in their note, and I think the RBBB looking morphologies are PVCs with compensatory pause, but the LBBB ones clearly are not.Here is my interpretation:At a normal heart rate, the patient has left bundle branch block. But this left bundle has a long refractory period. Thus, ...
Source: Dr. Smith's ECG Blog - April 22, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Why doesn't the name " OMI " say anything about the ECG, in contrast to STEMI? Because sometimes the ECG isn't always enough, no matter who interprets it.
Written by Pendell MeyersA man in his 60s with history of prior CAD with PCI, HTN, HLD, and aortic insufficiency presented with acute chest pain radiating to the left arm. He had been walking on a treadmill for approximately 5 minutes when the symptoms began abruptly. He had associated shortness of breath, diaphoresis, and dizziness.He arrived by private vehicle with relatively normal vitals signs and this initial ED ECG:What do you think about the patients clinical presentation? About the ECG?The patient: the treating team was completely convinced of ACS (or less likely another catastrophe such as dissection) by his sympt...
Source: Dr. Smith's ECG Blog - April 20, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

60-something with wide complex tachycardia: from where does the rhythm originate?
p.p1 {margin: 0.1px 0.0px 0.1px 0.1px; font: 9.0px Helvetica}An elderly woman with history of coronary disease presented with CP and SOB and hypotension by EMS.  EMS had attempted adenosine x 2 without success.Here is her ED ECG:Here is the ED physician's interpretation:IMPRESSIONUNCERTAIN REGULAR RHYTHM, wide complex tachycardia, likely p-waves.LEFT BUNDLE BRANCH BLOCK [120+ ms QRS DURATION, 80+ ms Q/S IN V1/V2, 85+ ms R IN I/aVL/V5/V6]Comparison Summary: LBBB and tachycardia are new.What do you think?Smith:  This is indeed a regular wide complex tachycardia.  I do not see P-waves.  Retrograde P-w...
Source: Dr. Smith's ECG Blog - April 15, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 60s with chest pain. The ST segments and T waves are ALWAYS interpreted in the context of their QRS.
Written by Pendell MeyersA man in his 60s with history of CAD, CABG, HTN, DM, and smoking presented with chest pain,and shortness of breath over the past 1 hour, and a mild cough over the past few days, of course asking for COVID testing.Here is his ECG on presentation (shown to me with no information):What do you think?Raw Findings: - RBBB (some will also say LPFB) - Negative T-waves in V1-V3 - STD in V1-V6, I, aVL - STE in aVR - V2 has strange QRS morphology that does not seem to fit in the progression between V1 and V3, possibly lead misplacementInterpretation:In the context of RBBB, it is norma...
Source: Dr. Smith's ECG Blog - April 13, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

PVCs and AV Block in a Young Adult?
===================================MY Comment by KEN GRAUER, MD (4/9/2020):===================================The patient is a man in his 30s with a long history of smoking — who presents to the ED with a history of severe dizziness, near syncope, and chest discomfort over the past few days. His initial ECG and long lead II rhythm strip is shown in Figure-1.QUESTIONS:How would you interpret the ECG and rhythm strip shown in Figure-1?Is it likely that AV block is the cause of his symptoms?Figure-1: The initial 12-lead ECG in this case (See text).My THOUGHTS: There are 2 par...
Source: Dr. Smith's ECG Blog - April 9, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

A man in his 30s with chest pain
Written by Pendell Meyers, case submitted by Tom FieroA man in his 30s walked into the ED complaining of chest pain. His triage ECG was done at 11:30 (no prior was available):What do you think?Sinus tachycardiaNormal QRS complex pattern, with borderline low voltageVery slight STE in leads V2-V5Proportionally large and fat T-waves in V4-5 with straightening of the ST segmentsT-waves also concerning in II, III, aVF, with inappropriately negative T-waves in aVLUsing the LAD OMI vs. BER formula:3 Variable: 27.34 (positive for OMI, using STE60V3=1.5mm, QTc=444, RWV4=2.0mm)4 Variable: 23.01 (positive for OMI, using QRS amplitude...
Source: Dr. Smith's ECG Blog - March 29, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A patient with abdominal pain associated with alcohol withdrawal and alcoholic ketoacidosis
While at work, one my partners showed me this ECG of a 50-something woman with abdominal pain associated with alcohol withdrawal and alcoholic ketoacidosis.  There was no reported chest pain or SOB.What do you think?I said it " looks like takotsubo.  Electrolytes might contribute.  Are they back yet? (they were not).  I do not think this is a coronary event. "He asked why.I responded: " bizarre T-waves, with T-wave inversion and extremely long QT.  The computer measures the QT at 506 ms, but it really is more like 560-580 ms, with a QTc of 600-620 ms.  This is not at all typical...
Source: Dr. Smith's ECG Blog - March 25, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 32 year old woman with chest pain has a prehospital ECG
:What do you think?Is it really " due to ventricular hypertrophy, " as the computer says?This was texted to me and my response was:" Leads are reversed.  Correct them and I think you will find a STEMI (or OMI).  Either inferoposterior or posterolateral. "Analysis:The QRS is negative in I, II, and aVL and positive in aVR, all of which makes for a bizarre axis.  Normally you can determine if it is truly lead placement by looking at P-waves, which should be upright in lead II.  Here it is difficult to see them.  But another way is to see if the QRS is negative in the lateral precor...
Source: Dr. Smith's ECG Blog - March 18, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A Clinical Scenario to Recognize- Irregular WCT
===================================MY Comment by KEN GRAUER, MD (3/12/2020):===================================A young adult presented to the ED with the “heart awareness” and the ECG shown in Figure-1 — but with no more than slight shortness of breath. BP ~ 130/70.QUESTIONS:What is the cardiac rhythm?How certain are you of your diagnosis?Is the clinical scenario consistent with what you might expect for this rhythm?Figure-1: The initial ECG in the ED (See text).ANSWERS: This young adult appears to be hemodynamically stable  — since his BP ...
Source: Dr. Smith's ECG Blog - March 11, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Does ST Elevation in lead aVR indicate acute coronary occlusion?
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 - March 9, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?
This middle-aged man with no cardiac history but with significant history of methamphetamin and alcohol use presented with chest pain and SOB, worsening over days, with orthopnea.BP:143/99, Pulse 109, Temp 37.2 °C (99 °F), Resp (!) 32, SpO2 95%On exam, he was tachypneic and had bibasilar crackles.Here was his ED ECG:There is sinus tachycardia (rate about 114) with nonspecific ST-T abnormalities.There is a large peaked P-wave in lead II (right atrial enlargement)There is left axis deviation consistent with left anterior fascicular block.There are nonspecific ST-T abnormalities.There is no evidence of infarction or i...
Source: Dr. Smith's ECG Blog - March 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 40-something with chest pain. Is this inferior MI?
This was sent by a Saleh Hatem, an avid reader of the blog.The patient presented with chest pain:There is a narrow complex tachycardia.Is there inferior ST Elevation?Here was my interpretation:What appears to be ST Elevation in inferior leads is really a P-wave that is contiguous with the QRS. (The next bump over is a T-wave that looks like a P-wave!).Since the P-wave is not inverted, it is NOT retrograde, and therefore it is a native sinus beat.  This sinus beat does conduct, but there is severely prolonged PR interval (severe first degree AV block), with a PR interval of over 400 ms.So: Sinus tachycardia with severe...
Source: Dr. Smith's ECG Blog - March 4, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 60s with chest pain. Could you have prevented his cardiac arrest?
Written by Pendell MeyersA man in his 60s with HTN and AF presented with chest pain that started about 1 hour ago and started to subside during transport via ambulance. Vitals were normal except for a heart rate of 49 bpm at triage.Here was his EMS ECG recorded just before arrival:What do you think?Sinus bradycardia with clear but subtle evidence of inferior OMI. The T-waves in III and AVF are certainly hyperacute, as they are fat and wide compared to their small, normal QRS complexes and are corroborated by the inappropriate T-wave inversion in aVL. Lead II would probably also be proven to be hyperacute in comparison to a...
Source: Dr. Smith's ECG Blog - March 2, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Are these Wellens' waves?
In conclusion, the presence of negative T waves in both leads III and V1 allows PE to be differentiated simply but accurately from ACS in patients with negative T waves in the precordial leads. "Witting et al. looked at consecutive patients with PE, ACS, or neither. They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6% of controls.  This does not contradict the conclusions of Kosuge et al., who studied a select population of patients who were known to haveeither PE or ACS -- that is, all were indeed ill.  Of those select patie...
Source: Dr. Smith's ECG Blog - February 28, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

70 year old woman with non-exertional non-radiating chest discomfort
This was sent by a reader:" I would really appreciate your thoughts on this ekg progression. 71 yo F, only risk factor hyperlipidemia, has isolated chest discomfort, non-exertional and non-radiating. "Sinus rhythm with one PVC.What do you think?Smith response:This ECG has symmetric (hyperacute) T-waves in V2-V4.  It is diagnostic of LAD occlusion.If you're uncertain, use theformula: https://hqmeded-ecg.blogspot.com/2017/11/12-cases-of-use-of-3-and-4-variable.htmlI applied it here after measuring a QTc of 440 ms.The value comes to 19.73 (greater than 18.2 is quite good for Diagnosis of LAD occlusion...
Source: Dr. Smith's ECG Blog - February 26, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

What are these wide complexes? If unclear by explanation, the laddergram helps to understand.
An 18 y.o. female who presented for chest pain. Patient reports productive cough and headache x 4 days. She notes persistent sternal chest pain worse at night and waking her from sleep. She also notes intermittent abdominal pain, describing as a " tightness " ." Sinus arrhythmia with variable right bundle origin PVCs "Is this accurate?No.This is sinus bradycardia with a slightly accelerated right ventricular escape, such that sometimes:1.  the sinus beat is conducted before any ventricular escape (beats 7)2.  the ventricular beat starts at almost the exact same time as the P-wave, and the P-wa...
Source: Dr. Smith's ECG Blog - February 20, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

32 yo with right sided chest pain. Zero ST Elevation, but that does not matter.
DiscussionIn hindsight I feel there are very few alternative causes for an ECG like this other than an acute LAD occlusion. I believe this is one of those'subtle STEMI'cases where neither the ECG nor the symptoms are very obvious or severe and the usual evolution is not seen.I think of these cases as'insidious infarcts'and I have seen this in all infarct territories and I do not think they are particularly rare. Essentially the patient is fairly comfortable and the ECG is not obvious but the patient ended up with Q waves, huge troponins and we missed the opportunity to reperfuse the artery when it counts. These patients te...
Source: Dr. Smith's ECG Blog - February 18, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 53 yo woman with cardiogenic shock. Believe me, this is not what you think.
This was sent by a reader.A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock.pH was 6.9 and K was normal.Here was the ECG:There is sinus tachycardia.This is " Shark Fin " morphology.Shark Fin has also been called:"Giant R-wave""Triangular QRS-ST-T waveform"Usually shark fin is in one coronary distribution and represents massive ST elevation that is as high as the peak of the R-wave and thereforefuses the R-wave and ST segment.So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution.It is often confused wi...
Source: Dr. Smith's ECG Blog - February 16, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 50s with " gas pain "
Written by Pendell Meyers, sent by AnonymousA man in his 50s with history of type 2 diabetes, HTN, and HLD presented with one day of off and on chest / upper abdominal pain. It had awoken him from sleep earlier, and he described it as " gas pain, " located in the upper epigastrium and radiating upwards. Vitals were within normal limits. The patient presented with active pain, diaphoretic and ill appearing.Here was his triage ECG (sorry for the quality, unable to obtain better images from sender):Last ECG on file is below for comparison. First try this ECG without the baseline, then with. What do you think?Previou...
Source: Dr. Smith's ECG Blog - February 14, 2020 Category: Cardiology Authors: Pendell Source Type: blogs