Cardiac Arrest at the airport, with an easy but important ECG for everyone to recognize
 Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - September 23, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Arrest at the airport, with an easy but important ECG for everyone to recognize
 Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - September 23, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 60s with palpitations, chest discomfort, and multiple misdiagnoses by both EM and Cardiology!!
 Written by Pendell MeyersA woman in her 60s was shopping when she suddenly experienced palpitations and chest " discomfort. " She denied outright chest pain or dyspnea. She walked across to the street to my Emergency Department. She had no known prior history of dysrhythmias or heart disease, but had known hypertension, breast cancer, diabetes, and obesity. She has had episodes of palpitations in the past, followed by holter monitor workups which did not reveal any cause of palpitations. However, her symptoms today feel worse than prior episodes, and she has never felt the " chest discomfort " wit...
Source: Dr. Smith's ECG Blog - September 21, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A man in his 50s with anterior ST elevation and a " tall T wave in V1 "
Written by Pendell MeyersTake a look at this ECG from a 57 yo M without any context first:What do you think? Imagine he presented with chest pain.There is normal sinus rhythm. QRS shows high voltage, likely representing LVH. There is STE in V1-V4 measuring up to 3-3.5 mm, and STD in V5-6. V2 has saddleback morphology, and V3 has a straight ST segment. V4 has slightly convex ST segment.Findings that would potentially favor OMI: large absolute amount of STE, large proportion of STE to QRS in V1-2, STD in areas like V5-6 that would be considered reciprocal to V1-2 area, straight ST segment in V3 and slightly convex in V4.Find...
Source: Dr. Smith's ECG Blog - September 19, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Narrow Complex Tachycardia at a Rate of 220
40-something yo who is on flecainide and diltiazem had suddenonset chest pain, palpitations, shortness of breath and diaphoresis:Rate is 220.  What do you think?It is fast, narrow, and regular, without P-waves.  So it isnot atrial fib andnot VT.  It is a regular narrow complex tachycardia.  There is a lot of ST depression -- this is ischemia caused by the very fast rate and is an indication for emergent electrical cardioversion.What is the DDx?  ----PSVT (which includes AVNRT and orthodromic AV reciprocating tachycardia) [AVRT uses an accessory pathway, a " bypass trac...
Source: Dr. Smith's ECG Blog - September 17, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Syncope in a young man
 Written by Pendell MeyersLet's say a young person presented with exertional syncope. They are now at baseline, asymptomatic, normal vital signs, and they have this ECG at triage:What do you think?Below are two other variations of this patient's resting ECG from different time periods:Answer: Arrhythmogenic Right Ventricular CardiomyopathySee the end of the post for review and details on ARVC and it's ECG findings, but suffice to say that this patient has sinus rhythm, small epsilon wave in some of his ECGs, and R waves in V1-V3 with TWI.Here is a close up of V1-V3:Notice the very subtle micro-voltages at the J point....
Source: Dr. Smith's ECG Blog - September 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A man in his late 40s with chest pain
 Written by Pendell MeyersA man in his late 40s with no known medical problems was at work when he suddenly experienced midsternal chest pain radiating down both arms. Approximately 1 hour after onset of symptoms he was triaged at the ED, with ongoing chest pain, normal vitals, and this triage ECG:What do you think?Twice, months apart, I sent this ECG to Dr. Smith without any context or other information (I do this many times per day, with many normal or false positive cases mixed in). The first time he responded " acute ischemia but not active occlusion " . The second time he responded " LVH and subend...
Source: Dr. Smith's ECG Blog - September 13, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A man in his 70s with chest pain, shortness of breath, and acute huge anterior ST elevation
Written by Pendell MeyersA man in his 70s presented to the ED complaining of various symptoms including chest pain and shortness of breath. He had a very hard time explaining his symptoms, and it was very hard to obtain an accurate history. It was unclear to us how long the patient had been experiencing symptoms, but I feel confident that he was actively having symptoms at the time of my evaluation. He did seem to admit to using cocaine, possibly yesterday evening, but unclear. His vitals were within normal limits except mild tachycardia.Here was his triage ECG:What do you think?I texted it to Dr. Smith with no information...
Source: Dr. Smith's ECG Blog - September 9, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A 76 Year Old Female With Recurrent Syncope, Lightheadedness, Palpitations and Negative Stress Test
Written by Lucas Goss MD, peer reviewed by Meyers, Smith, BraceyA 76 year old female with a history of arial fibrillation not on anticoagulation, non-obstructive CAD found on coronary CTA 2 years prior, HTN, HLD, recurrent lightheadedness, and syncope status post loop recorder placement, presented for another episode of feeling lightheaded, diaphoretic, and feeling like she “was going to die.” She was discharged just the day prior for her second hospitalization for similar episodes. She was actually at the pharmacy to pick up her medicines the day after discharge when this episode occurred, and pharmacy staff s...
Source: Dr. Smith's ECG Blog - September 4, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Some ECG simply require pattern recognition, followed by a bit of investigation
Brooks Walsh @BrooksWalsh helped with this post One of my partners showed me this series of ECGs, without any info:I said: " It's a normal variant.  Young black male, right? "He said, " Yes, but look at this one recorded 2 hours later. It is different " :There is T-wave inversion in V4 that was not there before.I said: " Yes, small changes can happen even with normal variants. "  And there might be a slight difference in lead placement.  On the 2nd ECG, V4 is farther to the right -- notice there is more S-wave than on the first and the R/S ratio is smaller.  There...
Source: Dr. Smith's ECG Blog - August 30, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Wide and weird
Written by Clare Gunn MD, peer reviewed by Smith, Meyers, BraceyA 74-year-old female presented to the ER after a trip and fall (unclear if purely mechanical or due to possible unsteadiness) causing her to cut her leg. Due to chronic anticoagulation for atrial fibrillation, she could not stop the bleeding, so she came the ED.  On arrival she is found to be hypoxemic requiring four liters of oxygen via nasal cannula. While getting her leg wound repaired, the patient was also evaluated for hypoxemia and tachycardia and was found to have this ECG:What do you think?Here was her most recent prior ECG on file for comparison:...
Source: Dr. Smith's ECG Blog - August 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

ST Depression Seen While scrolling through ECGs -- What is it?
This is a good one for residents and students! I was reading ECGs on the system and saw this one.What do you think?When I subsequently went into the chart, what do you think I was looking for?This ECG is all but diagnostic for Digoxin effect.  There is atrial fibrillation, which explains why the patient would be prescribed Digoxin.  There is scooped ST depression in multiple leads, nearly pathognomonic of Digoxin, and the ST depression in accompanied by a short QT interval.So to confirm, I went to the chart and, sure enough, he was on digoxin.  These findings are seen at therapeutic levels. The ECG...
Source: Dr. Smith's ECG Blog - August 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Crushing Chest pain, Tachycardia, and Very Elevated Blood Pressure in a 40-something Man.
A 40-something male called 911 for 2 hours of crushing, non-radiating, chest pain at about 11 AM.  He reported a similar episode last year when his blood pressure was very out of control and that again he has not taken his BP meds for 2 months.  He stated he had drunk 12 cans of Mountain Dew (high caffeine content) overnight. On exam, he was very anxious,  holding his chest, breathing normally.  Chest pain was worse with palpation.  His BP was 250/150 with a heart rate of 150.Here are 2 prehospital ECGs, 6 minutes apart:Heart rate 156.  ST Elevation. Large T-wavesThe computer re...
Source: Dr. Smith's ECG Blog - August 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 60 year old man with chest pain -- many fascinating aspects to this ECG
Written and submitted by Lucas Goss MD, peer reviewed by Smith, Meyers, BraceyA 60-year old man with history of CAD and prior stents to the LAD and ramus presented with acute chest tightness and shortness of breath. He arrives to the ED at about 1 hour and 15 minutes after onset of pain, and his triage ECG is shown below:ECG#1 (no baseline available for comparison):What do you think?Sinus rhythm with PVCNo evidence of hyperkalemiaQT within normal limitsNegative P-wave in V2, so at least V1 and V2 are placed too highSTE in V2-V5, as well as lead II, III, aVFTerminal QRS distortion (TQRSD) in V3 and perhaps almost also V4&nb...
Source: Dr. Smith's ECG Blog - August 19, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A 52 year old female with chest pain
Written by Pendell Meyers, edits by Steve SmithA 52 year old female with history of hypothyroidism and smoking presented to the ED with an episode of chest pain that began suddenly around 1500 while sitting down at work. She states it felt like a central chest pressure that radiated to her jaw. The pain had been persistently present since since 1500 (seen at 1615 in the ED), but had waxed and waned in severity, with the initial onset of pain being the worst. She had dyspnea and diaphoresis when the pain began. Coworkers called EMS who administered aspirin and NTG, which the patient says did not relieve her pain. During ini...
Source: Dr. Smith's ECG Blog - August 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A 60-something male presents with crushing chest pain
 I was reading ECGs on the system and saw this one:What do you think?I recognized this immediately as a variant due to some combination of Benign T-wave Inversion, Early repolarization, or LVH.  1. There is ST Elevation in V2-V52. There is very high R-wave voltage in V4-V63. The leads with STE and T-wave inversion have very distinct J-waves.4. The T-wave inversion is in leads V3-V6 (in contrast to Wellens', in which they are V2-V4)5. There is high S-wave voltage in V2, with proportional ST elevation (consistent with LVH)6. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves, or J-waves onlyI w...
Source: Dr. Smith's ECG Blog - August 13, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Why do we liberally record ECGs? And what do you think the angiogram showed?
Discussion:This ECG is Aslanger's pattern, and the angiogram is exactly what you expect with this ECG pattern, including the inferior OMI attributed to circumflex (more often than RCA).This pattern was recently published in J Electrocardiology: Aslanger and others (including Smith).  A new electrocardiographic pattern indicating inferior myocardial infarction.  https://pubmed.ncbi.nlm.nih.gov/32526537/This newly recognized ECG pattern is defined as:(1) any STE in III (with reciprocal STD in aVL), but not in other inferior leads, (2) STD in any of leads V4 to V6, (but not in V2) with a positive...
Source: Dr. Smith's ECG Blog - August 10, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

An Adolescent with dizziness and near syncope
Submitted by Maura Corbett, PA-C, written by Alex Bracey, with some comments by Smith and MeyersA teenage male presented to the emergency department with the complaint of dizziness with near-syncope. He was stable and able to provide a history and mentioned that he was asymptomatic while seated but dizzy and weak when attempting to stand. An ECG was recorded:What do you think? There iscomplete (third degree) heart block with wide complex bradycardicescape.  The morphology is that of LBBB and so the escape is originating from the right bundle.The possible etiologies of this ECG are:- Structural/congenital heart di...
Source: Dr. Smith's ECG Blog - August 7, 2021 Category: Cardiology Authors: Bracey Source Type: blogs

How much ST depression in V2 and V3 is acceptable before you suspect ischemia?
A 60-something woman with h/o bioprosthetic MV replacement and COPD, who is not on anticoagulants (bioprosthetic valves generally do not require anticoagulation), presented after 14 hours of left sided chest pain with radiation down left arm.  It woke her up at 0200.  She states that now it is worse with deep inspiration and associated with SOB.  Here is her triage ECG:What do you think?Here I magnify leads V2-V4:There is almost 1 mm ST depression at the J-point, relative to QRS onset, in lead V3.  We don't really know about lead V2 because it was placed too high (Negative P-wave shows that it was ...
Source: Dr. Smith's ECG Blog - August 3, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Pancreatitis with Bizarre T-wave inversions and a normal echo. Is it takotsubo?
I was shown this ECG and told that the patient is suffering from another bout of chronic pancreatitis.  I was told there was no chest discomfort or SOB. What do you think?I said " this looks like takotsubo " .With this ECG and the presumptive diagnosis of pancreatitis, takotsubo stress cardiomyopathy is by far most likely.  It is possible that it is due to ACS, but thebizarre diffuse T-wave inversions with a very long QT are nearly pathognomonic of takotsubo.  (They can also be seen in apical hypertrophic cardiomyopathy, but this patient did not have any such history and previous ECGs were dif...
Source: Dr. Smith's ECG Blog - July 31, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Computer says " normal, " troponin undetectable.
This was written by @BrooksWalsh, with one comment by SmithA middle-aged guy comes in with chest pain. No known cardiac disease, and he ’s healthy enough that he was hiking in some hilly terrain when he developed the symptoms..He comes into the ED, and they get an ECG which shows …… and is read by the computer as:Very reassuring, especially in the context of evidence that a computer interpretation of “normal” is “unlikely to have clinical significance that would change triage care. ” (HINT: this paper is very flawed, as Litell, Meyers and Smith point out in this article:&nbs...
Source: Dr. Smith's ECG Blog - July 26, 2021 Category: Cardiology Authors: Brooks Walsh Source Type: blogs

Hypotension, altered mental status, and aVR sign - activate the cath lab?
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. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - July 21, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

See many morphologies of non-ischemic ECGs from the same patient
 I was reading ECGs on the system when I saw this one (ECG-1):What do you think?My read was " ST Elevation that is NOT ischemic " .  I suspected this strongly because it just doesn't " look right " for a STEMI, in spite of the clear STE in V3 and V4.  This STE appears to be due to LVH, even though the STE in V4 is concordant to the QRS.  There were previous ECGs for comparison, so I looked at them:The patient had presented 4 days earlier with chest pain and had several ECGs recorded:Time zero (ECG-2):Scary looking STE, but has features of benign STE, especially in V5 and V6...
Source: Dr. Smith's ECG Blog - July 19, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

What is this rhythm? Is there AV block?
Case written and submitted by Elzada Sercus M.D., peer reviewed by Pendell Meyers, Steve Smith, and Ken GrauerA 31-year-old female with a history of low blood pressure and episodes of lightheadedness developed near syncope on postpartum day one after an uncomplicated c-section. She has no other past medical history and does not take any medications. She has no family history of sudden cardiac death or premature coronary artery disease. Given the patient's near syncope, an ECG was obtained and when the patient was placed on continuous telemetry monitoring was found to have frequent PVCs. She did not experience any palpitati...
Source: Dr. Smith's ECG Blog - July 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Which Modified Sgarbossa Rule does this meet? And what is the Rhythm?
A reader sent this ECG and asked " Steve, can this be hyperK? "  He sent no clinical information.What do you think?My answer: " This is inferior OMI. "  There is LBBB and an with a false negative Modified Sgarbossa. "The rhythm is also interesting, but does not affect the diagnosis of OMI:there are also no P-waves before the QRS complex.  The wide complex suggests an idioventricular rhythm, in fact it is an accelerated junctional rhythm followed by Left Bundle Branch Block (LBBB).  Idioventricular rhythm would have a slower QRS onset, similar to VT (and it can't be VT also becau...
Source: Dr. Smith's ECG Blog - July 13, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A child with biphasic T waves in V1-V2
 Case submitted by Dr. Mike Runyon, written by Meyers, Grauer, and SmithA child between the ages of 5 and 10 was brought in by parents for new onset recurrent episodes that were interpreted as most likely panic attacks. Before arriving at that diagnosis, the providers wanted to make sure all other diagnosable causes were ruled out. An ECG was ordered and is shown below.What do you think?This was sent to me asking " What do you make of the T waves in V1 and V2? "I responded:" These T waves don't match any pathology I know of. I think they are likely just a meaningless normal variant. I've seen some like ...
Source: Dr. Smith's ECG Blog - July 10, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain and ST Elevation.
 A 42 year old presented with chest pain.  Here is his triage ECG:What do you think?' This is a classic pattern of ST Elevation that everyone should recognize.  There are QS-waves in V1-V4, with slight ST elevation in V1-V3.  (QS-wave means a Q-wave with no R-wave at all, in contrast to a QR-wave or qR-wave).  This is" Left Ventricular Aneurysm (LVA) " morphology and is due to Old Completed (Transmural) Anterior MI, which often results in an LV aneurysm and manifests on the ECG as " persistent ST elevation after old MI. "The T-wave may be upright or inverted.  See...
Source: Dr. Smith's ECG Blog - July 7, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 64 year old man with chest tightness
Submitted and written by Kaley El-Arab MDPeer reviewed by Pendell Meyers, Alex Bracey, Stephen Smith A 64-year-old male with past medical history of coronary artery disease with prior MI s/p stent to RCA (2008), hypertension, dyslipidemia, and diabetes presented with acute onset of chest pain.  Around 15:00 while at work he developed left-sided chest tightness that lasted for a few hours, then eventually went away, but returned the same evening around 22:00 when it woke him from sleep. He reportedly tried to “walk it off” which relieved the pain transiently. When the pain returned it was more severe a...
Source: Dr. Smith's ECG Blog - July 5, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

This ECG Pattern Told the Story When the Patient Could Not
 Submitted by Spencer Lord MD, written by Alex Bracey with edits by Meyers and SmithA patient presents as a transfer from an outside facility. On arrival, he appeared air hungry, volume overloaded, and agitated. EMS was not available for a history at the time and the patient was unable to provide any details regarding his circumstances. During the initial minutes of his resuscitation the following ECG was performed:This ECG is pathognomonic. What is it?Sinus bradycardia with first degree AV blockWide, bizarre QRS complexes with STE in V1 and aVRPeaked T waves in I, II, V4-V6QRS duration is nearly 200 ms.There is a lar...
Source: Dr. Smith's ECG Blog - July 2, 2021 Category: Cardiology Authors: Bracey Source Type: blogs

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)
This is a case from many years ago that I discovered recently.  The patient has heart failure as a result of this event.A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away.  There was SOB at the start and increased work of breathing.  He had been drinking 5 beers.  He does not seek medical attention often.  He called 911.  Medics recorded this ECG:There is a lot of artifact, but you can clearly see ST depression in V2 and V3....
Source: Dr. Smith's ECG Blog - June 27, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Neck and Jaw Pain in a patient with a Pacemaker. Sgarbossa Negative. But How about the Modified Sgarbossa Criteria?
I was at home on a late Saturday evening when this first ED ECG was texted to me:Atrial and Right Ventricular Paced Rhythm(most pacing is RV pacing --- there is increasing use of biventricular pacing)What do you think?  What did I say?" It looks like Occlusion Myocardial Infarction (OMI).  If the clinical presentation is consistent with acute MI, Activate the Cath Lab. "I added this to my text response:  " The EKG meets the Smith modified Sgarbossa criteria, so I think there is no choice but to take a look at his coronary arteries, but for some reason I do not feel convinced in my own&nbs...
Source: Dr. Smith's ECG Blog - June 21, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Acute Chest pain. All P-waves are not conducting. Is it OMI?
A 50-something male complained of acute onset chest discomfort about 30 minutes PTA while at rest with radiation described as numbness to the back of his neck and both arms.  He denied history of CAD, but he reported that he has history of smoking, hyperlipidemia, and pre-diabetes. He reports some shortness of breath and anxiety.Here is his first ED ECG, ECG 1:What is the rhythm?  Are there any signs of OMI?There is an annotated version below, and Ken Grauer does a laddergram of this one at the bottom of the post.Notice that there is high degree AV block.  This is the essential feature.  Acute...
Source: Dr. Smith's ECG Blog - June 17, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life
Case submitted and written by Dr. Jesse McLaren (@ECGcases), ofEmergency Medicine CasesReviewed by Pendell Meyers and Steve SmithAn 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. The paramedics found the patient with ROSC and a GCS 7, and an ECG showing LBBB with possible lateral ST elevation. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. On arrival, GCS was 13 and the patient complained of ongoing chest pain. Vitals were HR 58 BP 167/70 R20 sat 96%. Below is the first ED ECG, labeled LBBB by the machine. Are there any indicat...
Source: Dr. Smith's ECG Blog - June 11, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A man in his 50s with chest pain and shortness of breath
Submitted by Ali Khan MD, written by Pendell MeyersA man in his early 50s presented with exertional chest pain and dyspnea. He had family history of early CAD. Otherwise, no clear risk factors. Vitals were within normal limits. No prior ECG was available. Here is his triage ECG:What do you think?This is yet another subtle inferior (and likely also posterior) OMI. There is a small and narrow QRS complex with reasonable axis and R wave progression, therefore the QRS cannot explain any abnormalities of the ST segment and/or T waves. The T waves in II, III, and aVF are subtly too large for their QRS, and the most importan...
Source: Dr. Smith's ECG Blog - June 6, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A man in his 50s with schizophrenia, hypoglycemia, and vague chest pain and shortness of breath for a few days
Written by Pendell Meyers with edits by Steve SmithBystanders called EMS for a man in his 50s " not acting right. " Medics found a man with altered mental status, immediately measured a blood glucose of 42 ng/mL, and administered glucose.  There was immediate improvement in his mentation, but it was " not back to normal. " Now that the patient was able to give some history, he was able to complain of chest pain and shortness of breath off an on for " a few days. " The impression that I get from the documentation is that the patient was still felt to be somewhat altered, and the histo...
Source: Dr. Smith's ECG Blog - May 30, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

When the ECG is more revealing than the HPI
 Written by Alex Bracey with edits from Pendell Meyers and Steve SmithA woman in her 60s presented to the ED as a referral from an urgent care for weakness. When I interviewed her, she reported that she had experienced several months of shortness of breath and fatigue, which had worsened in the last several days. She had also experienced new dyspnea on exertion, along with a non-productive cough and fatigue. The only medical problem she was aware of was hypertension treated with hydrochlorothiazide. An ECG was performed as follows:Sinus tachycardiaConvex, upward ST elevation in V1-V4 with subsequent T wave inversionRi...
Source: Dr. Smith's ECG Blog - May 30, 2021 Category: Cardiology Authors: Bracey Source Type: blogs

Why is there ST Elevation in lead V2? Think Lead Placement.
 I was shown this ECG of a 40-something intoxicated male with altered mental status.  The provider was very worried about LAD occlusion.What do you think?There is ST Elevation in lead V2, but there is also an RSR'wave which creates a kind of saddle ( " saddleback pattern " ).  This is rarely due to anterior MI.  There is also tachycardia, which unless a patient has cardiogenic shock, is also uncommonly due to ACS.  And, of course, without chest pain, the pretest probability is very low.RSR'and saddleback can be due to leads being placed too high, but since the P-wave is upright ...
Source: Dr. Smith's ECG Blog - May 27, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Atrial Fibrillation w Rapid Ventricular Response and ST Depression Maximal V1-V4: Not always subendocardial.
A patient presented a few years ago with chest pain, but also cough, low grade fever, and malaise.  She had one prehospital saturation at 88%, but otherwise all vital signs and labs were normal, without tachycardia, elevated BP or anemia.  She was never in any distress.She had this prehospital ECG:What do you think?There is diffuse ST depression, in I, II, III, aVF and V3-V6.  It is diagnostic of ischemia.  It is maximal in V5 and II, with reciprocal STE in aVR, and is thus most consistent with subnendocardial ischemia (Posterior OMI would have maximal STD in V1-V4, and Posterolateral OMI would have STD...
Source: Dr. Smith's ECG Blog - May 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

What are these ST elevations, ST depressions, and tall T waves diagnostic of?
 Written by Pendell MeyersLet's see this presentation ECG without any context first (no baseline ECG was available)What do you think? What will you do?The ECG is diagnostic of severe hyperkalemia. There is sinus tachycardia, the beginning of QRS widening, tall pointy peaked T waves with little area compared to their height. There is STE in V1-V3, aVR, and aVL, with STD in II, III, aVF, V4-V6. The appearance in V1 is similar to the Brugada morphology (as is often the case in hyperkalemia and Na channel blocker effects causing STE). Together these ST elevations in the right precordial leads and aVL are classic pseudoSTE...
Source: Dr. Smith's ECG Blog - May 14, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Typical Chest Pain: Would you activate the cath lab? Would you advocate if the interventionalist was not interested?
A 50-something woman complained of acute chest pain radiating to the left arm, onset while driving.  It would briefly improve with NTG.Here is the first ED ECG:What do you think?When I saw this, I immediately said: " This isAslanger's Pattern. " 1. Inferior OMI, with STE in lead III only, and reciprocal STD in aVL.2. Diffuse subendocardial ischemia (ST depression, STD, in I, II, V3-V6) with reciprocal STE in aVR.Aslanger's pattern is a combination of inferior OMI and diffuse subendocardial ischemia.  The subendocardial ischemia produces an ST depression vector toward leads II and V5 (with reciproca...
Source: Dr. Smith's ECG Blog - May 10, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 30s with greater than 12 hours of chest pain
 Written by Bobby Nicholson MD, with edits by MeyersA man in his early 30s presented at 7:35am to the ED with chest pain (7/10) beginning suddenly at 7:30pm the night prior. The note did not specify whether the pain had been truly constant for 12 hours, or whether it had been intermittent. He had associated nausea, vomiting, hot flashes, chills, dyspnea, and cough. He had uncontrolled type 1 diabetes and smoking history. Vitals were normal. Physical exam was unremarkable. No prior ECG was on file.At 0742, this ECG was obtained in triage:What do you think?Raw Findings:  - Sinus rhythm - QRS is narrow wit...
Source: Dr. Smith's ECG Blog - May 7, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Let's Use Aslanger's simplified formula on this case (simplified Smith LAD occlusion/early repol formula)
Discussion:An interpretation of " normal " could, of course, deceive many providers.AnalysisThis could be normal variant ST Elevation in V2 and V3.  There is 1.5 mm STE in at the J-point in lead V2 (relative to QRS onset, otherwise known as PQ junction).  There is 1.0 mm in V3.So this is a normal amount of STE in V2 and V3, defined by Universal Definition of MI as up to 2.0 mm in men over age 40.  So there is definitely no STEMI, and the STE is normal.  So the computer is correct in calling it normal.But after reading this blog, you all know that most OMI do NOT meet STEMI criteria. ...
Source: Dr. Smith's ECG Blog - May 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

See this: Occlusion/Reperfusion/Re-occlusion/Reperfusion/Re-occlusion/Reperfusion
A 60-something y.o. male presented with intermittent left-sided chest and shoulder pain that is achy in nature and lasted a few minutes or sometimes just a few seconds. " The symptoms come and go, not associated with any exertion or history of trauma. Patient does have a history of hypertension and has been taking his medications.  Prehospital EKGs appeared consistent with anterior tombstone ST elevation with pain. " Prior to arrival the patient was given full dose aspirin, as well as nitroglycerin, which relieved his pain, after which T wave inversions were noted in the anterior precordi...
Source: Dr. Smith's ECG Blog - May 3, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

This patient with " NSTEMI " was not allowed to go to the cath lab. Then the ED provider obtained an emergent coronary CT angio. What do you think it showed?
 Submitted by Shakita Crichlow MD, edits by MeyersA female in her 60s presented with chest pain off and on starting the day before presentation. The chest pain was left sided, pressure-like, intermittent, without aggravating or alleviating factors, and associated with mild shortness of breath. She become worried when she took her blood pressure at home and found it to be 200 systolic, so she decided to come to the ED at that point. Here is her initial ECG:What do you think?Raw findings: - Sinus rhythm - STE in leads II, III, and aVF, reaching at least 1.0 mm in III and aVF - Large Q wave in lead II...
Source: Dr. Smith's ECG Blog - April 30, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Fever, tachycardia, hypotension, hypoxia and " SVT "
This 40-something presented with hypoxia, BP 60/30, pulse 195, and Temp of 40 C.He had what appeared to be SVT on the monitor.Here is his 12-lead:Narrow complex tachycardia at a rate of 184.This was interpreted by the computer and the over-reading physician as " SVT "While it is SVT, the supraventricular part is sinus.  Usually when we say SVT, we are referring to areentrant rhythm.  This is why I prefer the term PSVT (Paroxysmal SVT), to distinguish sinus or other automatic SVT from re-entrant SVT.First, when there aregenerators of sinus tachycardia, such as hypoxia, fever, and hypotension, sinus tachy...
Source: Dr. Smith's ECG Blog - April 28, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 40s with palpitations and chest pressure of unusual etiology
Submitted and written by Magnus Nossen MD from Norway, with some minor edits by Meyers and SmithA female in her 40s with no known cardiac disease presented to the ED with palpitations and presyncopal episodes recurring over several years, usually lasting 1-5 minutes, sometimes associated with chest discomfort, and increasing in frequency over the past few months. Previously she had an echo and 5 days ambulatory ECG performed at a private clinic, both normal. The suspected arrhythmia had evaded capture. She then purchased a smart watch with the possibility for ECG recording. She presented to the emergency room with pri...
Source: Dr. Smith's ECG Blog - April 25, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

This is really good Prehospital, ED, and Cardiology care. Inferior de Winter's T-waves.
A 50-something y.o. male with history of previous acute MI and stent was shoveling snow.  Shortly thereafter he had the onset of tight chest pain across the front of his chest, without radiation, but associated with diaphoresis and nausea without vomiting. It felt similar to his prior heart attack 9 years ago. He called EMS immediately. Here is his first prehospital ECG: What do you see?There is ST depression maximal in V3, and also in inferior leads.  There is minimal T-wave inversion in aVL, by itself a soft sign of inferior MI.  Are the T-waves large?  Does this inferior ST depression ...
Source: Dr. Smith's ECG Blog - April 21, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

This case was flagged as a false positive cath lab activation. Why? And do you agree?
Conclusions/Summary " Indication: Chest pain with dynamic EKG changes concerning for ACS "--CAD with moderate stenosis of ostial left main.--CAD with long segment of serial stenosis of proximal to mid LAD.--Successful PCI of proximal to mid LAD with placement of 3.5 x 38 and 3.5 xLAD: Large caliber vessel.There is a long segment of serial 50-80% stenosis noted in the mid portion of the vessel. The LAD is severely tortuous and there is large caliber diagonal after an acute bend in the mid vessel. The distal and apical segments are without significant stenosis. Lesion on Mid LAD was stented...
Source: Dr. Smith's ECG Blog - April 19, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 60s with diaphoresis, vomiting, and inferior STE
Written by Pendell MeyersA man in his 60s appeared altered and diaphoretic and vomiting to a bystander, who called EMS. EMS personnel agreed that he was altered, possibly intoxicated, and seemed to deny all complaints that EMS inquired about. Vital signs were within normal limits.EMS performed an ECG:What do you think?Raw findings: - Sinus rhythm - Normal QRS, axis straight down at lead aVF - STE in leads II (2.0 mm), III (1.5 mm), aVF (2.0 mm) - STD in aVL (1.0 mm) - STD in V1 (0.5 mm), STD in aVR (0.5 mm)Subjective interpretation of those findings:It is slightly tough to decide whether this is in...
Source: Dr. Smith's ECG Blog - April 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Getting It Right Despite the Wrong Paradigm
Written by Alex Bracey, edits by Meyers and SmithA 50 something year old male presented to the ED as a transfer from an outside hospital with chest pain. As EMS gave report I looked through the transfer packet for the initial ECG:Sinus bradycardia with loss of R-wave progression and hyperacute T-waves in V2-V5, slight STE in aVL and I without meeting STEMI criteria. There is a down-up T-wave in lead III, which is a very specific reciprocal finding in high lateral OMI. Very highly suspicious of OMI. Applying the 4-variable formula for detection of subtle anterior OMI would yield: STE60V3 = 2.5, QTc = 360, RV4 = 3, QRSV2 = 5...
Source: Dr. Smith's ECG Blog - April 12, 2021 Category: Cardiology Authors: Bracey Source Type: blogs