A man in his 40s with chest pain and T wave inversion
Written by Pendell Meyers with edits by SmithA man in his early 40s with history of HTN presented to the ED for feeling lightheadedness and mild " beating " chest pain off and on last night, but resolved at the time of ED presentation. He still felt some lightheadedness during evaluation. He stated that he used ecstasy yesterday prior to the onset of symptoms. Vitals were within normal limits on arrival.Here is his ED ECG on arrival:What do you think?Sinus rhythm. The narrow QRS with relatively high voltage is overall most consistent with a young healthy heart, less likely pathologic LVH (including HOCM). There a...
Source: Dr. Smith's ECG Blog - January 22, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Which ACS had more myocardial damage? The one that meets STEMI criteria, or the one with the'normal' ECG?
Discussion According to the current paradigm based on ECG millimeter criteria, the first patient had STEMI  requiring emergent reperfusion while the second did not have STEMI so could have been treated with delayed reperfusion. But the second patient had a totally occluded artery leading to a large MI despite rapid reperfusion, and admitting them as “NSTEMI” with next day angiography could have been fatal. According to the discharge summaries, which seemed to be based on culprit lesions that received rapid reperfusion, both patients had “STEMI” despite the first never having a rise in trop...
Source: Dr. Smith's ECG Blog - January 18, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.
 Written by Pendell Meyers with edits by SmithNOTE: Please check outMy Commentat the very bottom of this post — in which I amplify discussion by Drs. Meyers& Smith on somesubtle-but-important ECG findings on theinitial ECG—KenGrauer, MD —A man in his 60s called EMS apparently for shortness of breath. EMS found him in distress and hypoxemic requiring 4 L nasal cannula to maintain oxygen saturation greater than 93%.Here is his triage ECG:What do you think?An old ECG was available on file, from 2 years ago:RBBB, otherwise normal.The triage ECG is diagnostic of life threatening hyperkalemia (sodium c...
Source: Dr. Smith's ECG Blog - January 16, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Would your radiologist make this diagnosis, or should you record an ECG in trauma?
A very young man had severe blunt trauma with severe head injury.As part of his evaluation, he had a " pan-scan " which of course includes a chest abdomen pelvis CT.Here is one slice of his chest:What do you see?Let's look at a closer view, and also made easier to see using Spectral CT:And one more:The very dark area at the septum and the apex of both ventricles is transmural ischemia.  There is no contrast making it into this area which should be perfused by the LAD.Here is a color image of the same:Notice the extremely dark area at the apex and apical part of the septum.The radiologist was Dr. Gopal Punjab...
Source: Dr. Smith's ECG Blog - January 14, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

Wide Complex Tachycardia with Huge ST Elevation. What is going on?
This 70-something woman with no significant past history (no previous ECGs or cardiac history) presented by EMS with fairly acute chest pressure and shortness of breath, with nausea and diaphoresis.  " Like an elephant sitting on my chest. "  She had no history of atrial fibrillation and was not on any anticoagulants.She stated that she had had a similar episode a couple weeks earlier, lasting 24 hours, with rapid heart beat but without chest pain, that spontaneously resolved.  She thought she was having a panic attack.  Since then she has had " little spurts " of the same thing...
Source: Dr. Smith's ECG Blog - January 12, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 50s with abdominal pain and a computer read of ***Acute MI ***
 Submitted by Dr. Arjun J V, Written by Pendell MeyersA man in his 50s with history of diabetes presented with acute onset abdominal pain and nausea.Here is his ECG at triage:What do you think?Sinus bradycardia. The QRS is narrow but very abnormal with significant LVH. There are widespread, dramatic, and discordant ST and T wave deviations which are due to the LVH. Look at leads III and aVF here for a particularly important lesson for your eyes. In these leads, the QRS does not actually have radically large QRS voltage, but yet there is substantial (easily meeting STEMI criteria) ST elevation which is due to LVH ...
Source: Dr. Smith's ECG Blog - January 8, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

What does LBBB look like in severe hypothermia? Is there a long QT? Is the QT appropriate for the temperature?
This patient was found down in a Minneapolis winter.  He was very cold with frostbitten fingers and toes.  He was alert but encephalopathic and delirious and very agitated and could not be adequately calmed with olanzapine and lorazepam, so we intubated him.  The first reliable temperature could only be obtained with a Foley thermistor, and it was 26.5 degrees C (79.7 F).His BP was 76/60.  K was 2.8 mEq/L.Here was his first ECG:There is sinus bradycardia with left bundle branch block (LBBB), with proportional ST-T, and VERY long QT and a PVC.  I measure the QT at 800 ms. Notice that there are ...
Source: Dr. Smith's ECG Blog - January 6, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

7 steps to missing posterior Occlusion MI, and how to avoid them
This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by SmithCaseYou ’re shown an ECG from a patient in the waiting room with chest pain. What do you think?Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. There ’s primary ST depression in the precordial leads maximal in V3-4, and an inverted T wave in V2. There’s also a down-up T wave in aVL with a tiny bit of ST depression (which suggests inferior MI), but without associated inferior findings.  Step 1 to missing posterior MI is relying on the STEMI criteria. A prosp...
Source: Dr. Smith's ECG Blog - January 3, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

CJEM Open Access OMI Quality Improvement Publication
Just published in the CJEM:From STEMI to occlusion MI: paradigm shift and ED quality improvementJesse T. T. McLarenH. Pendell MeyersStephen W. SmithLucas B. Chartier (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - December 31, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Should we activate the lab? A simple but important lesson
Written by Pendell MeyersA man in his 60s called EMS for sudden chest pain and shortness of breath. He was found in moderate respiratory distress, hypertensive, diaphoretic, and hypoxemic. He was given aspirin, nitroglycerin, and placed on noninvasive positive pressure ventilation during transport. Medics recorded a 12-lead and transmitted it to the provider, asking if they wanted to activate the cath lab.Here is the ECG:What do you think?Sinus rhythm. In this EMS ECG, as is true for many EMS ECGs, the machine cuts off the S wave voltage at 10 mm. You can see this visually by the subtle but noticeable squared-off waveform ...
Source: Dr. Smith's ECG Blog - December 31, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Hyperacute T-waves -- missed. Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) may be due to transient thrombotic Occlusion MI.
Coronary thrombosis (twice in the same patient!!) without a stenosis or even a culpritDo not miss the last image at the bottom that shows the series of T-waves in V4-V6I recently had a discussion with an incredibly smart and fantastic ECG and Cardiology expert.  He was skeptical that you can have OMI with Wellens waves without having a major stenosis on angiogram.I told him I've seen it on occasion and that this happens due to thrombosis of non-obstructive lesions that lead to complete occlusion but that thencompletely lyse and do not show stenosis by the time of the angiogram.  I said that even if there is not a...
Source: Dr. Smith's ECG Blog - December 29, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Did the posterior leads help here? Why not just get good at STDmaxV1-V4?
 Written by Pendell MeyersA middle aged woman presented with chest pain and dyspnea. Her exam and vitals were within normal limits. Here is her triage ECG:What do you think?There is sinus rhythm with a relatively normal QRS (except for the substantial positive QRS component in V2). There is STD in V2-V4, with no QRS explanation, and downsloping ST morphology in V2 and horizontal morphology in V3-4. Thus, there is posterior OMI until proven otherwise, because of STD maximal in V1-V4. There is also subtle evidence of inferior OMI, with slight STD and TWI in aVL with suspiciously full upright T waves in the III and ...
Source: Dr. Smith's ECG Blog - December 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Dynamic ST Depression in precordial leads. Does this transient STD signify subendocardial ischemia?
This case was written up by one of our fantastic 3rd year residents, Michael Fischer.  Edits by Smith.A mid 60s male with past history of 2 prior STEMI(+) OMIs s/p stenting (most recently ~2 years ago) had onset of substernal chest pain after he came inside from smoking a cigarette. He reported becoming diaphoretic and also having pain in his L hand. After approximately one hour, he called 911.  Medics arrived and recorded a prehospital ECG:Sinus rhythm.  Deep QS-waves in inferior leads. Tall R-wave in V2, but no definite ST shifts or hyperacute T-waves.He was given aspirin and sublingual nitr...
Source: Dr. Smith's ECG Blog - December 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Collapse, Ventricular Tachycardia, Cardioverted, Comatose on Arrival. OMI is a clinical diagnosis.
A middle-aged woman cried out, then collapsed.  She had bystander CPR.  First responders palpated a pulse.  Paramedics found her to be in Ventricular Tachycardia.  She underwent synchronized cardioversion.On arrival, she had this ECG:What do you think?There is sinus rhythm. The ECG shows unequivocal ST Elevation in I and aVL, with reciprocal inferior ST Depression, and also STE in V3-V6.  There is unequivocal subepicardial (transmural) ischemia on this ECG.  This is probably a proximal LAD occlusion, right?Not so fast!!This patient dropped to the ground, and in spite of VT with a pulse (not VF...
Source: Dr. Smith's ECG Blog - December 20, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man his 50s with chest pain. What happens when you treat with morphine rather than with reperfusion?
 Written by Pendell MeyersA man in his late 50s presented to the ED with 3 days of left chest pain radiating into the jaw and neck. He described it as " heartburn. " The pain radiates into his left arm and causes numbness and tingling from time to time. The history does not state what changed on day 3 that made him finally present to the ED; the history has no details as to whether the pain was off and on, or fluctuating, or whether the pain become persistent soon before arrival (these are key details and would help with many important questions we will have below!). Vitals were normal, and his triage ECG is...
Source: Dr. Smith's ECG Blog - December 17, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain and RBBB with right axis deviation, and downsloping ST Elevation. What is downsloping ST Elevation?
 4916132A 50-something male smoker with h/o Diabetes, but with no cardiac history presented by ambulance with acute chest pain.  It was described as severe, pleuritic, with radiation to bilateral shoulder blades, and associated with shortness of breath. Constant.  He had never had this before.His chest wall was exquisitely tender and palpation exactly reproduced his pain.He had this prehospital ECG.What do you think?There is a right bundle branch block, and also right axis deviation due toleft posterior fascicular block.  An old ECG was available that did not have BBB of any kind, but a more r...
Source: Dr. Smith's ECG Blog - December 15, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Bradycardia with a Wide Complex. Sometimes 2 pathologies are present. Which?
An elderly woman was found to be bradycardic.  She was awake with a BP of 120/70.Here is her prehospital ECG:What do you think?I thought this was likely due to hyperkalemia.  I do not see P-waves.  It appears to be sinus arrest with ventricular escape.  The ST deviations could be ischemia, but are very often the result of hyperkalemia.First ED ECG:Pretty much the sameShe was given multiple doses of Calcium gluconate.  6 grams as I recall.  And another ECG was recorded 9 min later:3rd 2.5 hours laterThere are some possible P-waves here, but if they are, there is complete AV block as well, ...
Source: Dr. Smith's ECG Blog - December 12, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

What is this ST Depression? (Hint: there are 2 etiologies)
Discussion from above article by Manne JRR.Atrial repolarization wave (Ta wave) is usually not perceptible on the ECG as it has low magnitude of 100 –200 microvolts and is usually concealed by the ensuing QRS complex [1]. Occasionally, they are seen as shallow negative deflections right after the P wave in conditions with prolonged PR interval, but they are best seen in patients with complete heart block, when the Ta waves and QRS complexes are uncoupled [2]. In contrast to the QRS complex and T wave which under normal conditions have the same polarity, the polarity of the P wave is always opposite to that ...
Source: Dr. Smith's ECG Blog - December 9, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 50s with acute chest pain, now resolved, has 2 undetectable troponins. CT Coronary Angiogram?
 Written by Pendell MeyersA man in his 50s presented to the ED with chest pain described as pressure, without radiation, acute onset about three hours prior to arrival. He had had stuttering less severe versions of this pain all week that usually went away after a few minutes. He also had diaphoresis and dyspnea. He had extensive family history of CAD with CABG's in the mid 50s for multiple relatives, but he had no personal known history of CAD. It is unclear whether he had pain at the time of triage, but notes describe that his pain had subsided by the time of EM physician evaluation:Triage at approximately 2130...
Source: Dr. Smith's ECG Blog - December 6, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Do these Serial Prehospital ECGs show OMI?
A 50-something male with a history of hypertension called 911 after sudden onset chest pain in the middle of his chest radiating up to his neck. He reports that earlier in the day he had some chest pain that came on while he was teaching that subsequently resolved with rest.  + Diaphoresis and SOB, no radiation to the shoulders. He had 3 prehospital ECGs recorded:What do you think?The 1st ECG is may appear normal, but is ischemic.  There is a very tiny amount of ST depression in V2, but there is definitely a bit of STD in V3 and V4.  The 2nd ECG has clear STD in V2-V4 and slightly larger inferior T...
Source: Dr. Smith's ECG Blog - December 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Even when the story is obvious, with intractable pain, the STEMI paradigm can cause preventable delays
 Written by Pendell MeyersA man in his early 60s presented with acute chest pain rated 10/10 with associated nausea and vomiting with known history of multivessel CAD. He presented at 2300 with onset of symptoms at 2230. He was awoken from sleep by the symptoms, which were identical to prior MI for which he received a stent years ago. On arrival his heart rate was 43 bpm and blood pressure 91/62. Atropine and IV fluid was given.Here was his triage ECG:What do you think? Baseline below for comparison, but try first without it.His baseline ECG was available on file:The presentation ECG shows diagnostic evidence of poste...
Source: Dr. Smith's ECG Blog - December 1, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A Pathognomonic ECG. What is it? (Hint: 2 diagnoses in one)
I was reading through the list of EKGs and saw this one.  What is it diagnostic of? (hint: 2 diagnoses in one)There is a very long, flat, ST segment, resulting in a long QT (most long QT is due to a wide T-wave, not a long ST segment).  This is diagnostic of hypocalcemia.  There are also peaked T-waves of hyperkalemia.  This is a common combination in dialysis patients.The ionized calcium was 2.29 mg/dL (normal is 4.40-5.20).  The K was 6.2 mEq/L.Here are the symptoms she had (very typical for hypocalcemia):Dialysis patient with left upper extremity numbness and tingling, lightheadedness, perioral ...
Source: Dr. Smith's ECG Blog - November 29, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 40s with epigastric pain and a dynamic ECG
 Case written and submitted by Dr. Arjun J V, peer reviewed by Meyers, Smith, GrauerA 49 year male patient was brought to our ED at around 9 PM on with complaints of epigastric pain since that afternoon. The patient had the same complaints on and off for many years which would resolve on taking OTC antacids. However, this time the pain was persistent and included new diaphoresis, so he presented to an outside facility where this ECG was recorded:What do you think?There is sinus rhythm with a narrow QRS complex with normal axis. There is slight PR depression in III, followed by some STE with upright T wave. Lead aVL sh...
Source: Dr. Smith's ECG Blog - November 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Any ST depression in V2 and V3 is posterior OMI until proven otherwise, especially if downsloping
A middle aged male presented after onset, approximately 50 minutes prior, of constant crushing 10/10 substernal chest pain, radiating into right arm associated with shortness of breath. He had never felt this way before. There was a history of HTN but he was not taking any medicines.Prehospital ECG was recorded approximately 20 minutes after pain onset and 20 minutes prior to ED arrival:There are somewhat large T-waves in II and aVF and a sagging ST segment in aVL, suggestive of inferior OMI.  There is some minimal downsloping ST depression in V2 and V3, which is suggestive of posterior OMI. The ECG isnot di...
Source: Dr. Smith's ECG Blog - November 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Shark fin post arrest: do you understand the ECG?
Case submitted by Dr. Daryl Williams, written by Pendell Meyers, peer reviewed by Smith and BraceyA physician bystander witnessed a middle-aged or slightly elderly man suddenly collapse while walking down the street, very close to the hospital. The physician immediately started CPR and called EMS. EMS arrived quickly and found the patient to be in VFib. After several shocks the patient achieved ROSC.A minute or so after arrival to the ED, he went back into VFib and was immediately shocked back out into sinus rhythm.His EMS ECG during initial ROSC was available for the ED team:Here is his ED ECG:What do you think?Both ...
Source: Dr. Smith's ECG Blog - November 22, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 60s with syncope and vomiting. Does she need a pacemaker?
 Written by Pendell Meyers with some edits by Steve SmithA woman in her 60s on chemotherapy presented to the Emergency Department for a syncopal episode just prior to arrival. She was walking to the bathroom when she suddenly felt nauseous and passed out. EMS was called by the patient's daughter, and en route to the ED she vomited twice. On arrival to the ED, she adamantly denies chest pain but says she's " just still not feeling well. " She had no prior known cardiac disease.Triage at 0755:The rhythm is most either atrial fibrillation with complete heart block and resulting junctional escape, or atrial flut...
Source: Dr. Smith's ECG Blog - November 19, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

New Review: Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms
 New Review, full text: Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - November 18, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Toothache, incidental Wide Complex Tachycardia
Discussion by our ElectrophysiologistSmith: “I thought that the wide complex tachy (WCT) could be AVRT or VT” EP: " Antidromic AVRT morphology would essentially be the same as “VT” originating from ventricular the insertion site of the accessory pathway. Therefore, traditional criteria for SVT with aberrancy do not apply to antidromic AVRT (except, that negative concordance can never be AVRT!) "  Smith: “But then when the patient converted and had PVCs of exactly the same morphology as the WCT, that it must be VT and not AVRT ” EP: " In cases ...
Source: Dr. Smith's ECG Blog - November 17, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Is this ST depression due to OMI or due to subendocardial ischemia? This is critical to distinguish, and this is a trick case!
We just today published this very important article in the Journal of the American Heart Association:Ischemic ST ‐Segment Depression Maximal in V1–V4 (Versus V5–V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia)full text: https://www.ahajournals.org/doi/pdf/10.1161/JAHA.121.022866However, if the patient has atrial fibrillation with RVR, one must first cardiovert and then re-assess.  STD Max V1-V4 can be due to subendocardial ischemia (not OMI) when there is tachycardia, especially if due to atrial fibrillation with RVR.I have long noticed this (but ha...
Source: Dr. Smith's ECG Blog - November 15, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 19 year old with panic attacks. On the previous ECG, the diagnosis was missed, as it frequently is!
This young woman presented with recurrent anxiety attacks with chest pain and dyspnea.  She was otherwise healthy except for history of cholecystitis and cholecystectomy one year prior.I saw her in triage and ordered an EKG:What do you think?  How did I interpret this?There is a short PR interval.  The eye is taken immediately to the ST depression and T-wave inversion in multiple leads.  But as I pointed out in this recent post (I thought the ECG diagnosis was obvious. But many missed it. So I'm showing it.) when there are ST-T abnormalities, one must look at the entire PQRST and look for reasons t...
Source: Dr. Smith's ECG Blog - November 12, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

With all those Q-waves, this can't be acute OMI, right?
Author's note: This post is guest-written byBrooks Walsh, an emergency physician with an interest in emergency electrocardiology and echocardiography, along with Steve Smith. I'm grateful for Steve's review and additional comments.The case is not recent, and non-relevant details have been changed to make this case unidentifiable.The case: A week of chest painAn older gentleman was brought to the ED, complaining of burning abdominal pain. The pain had started about a week ago, but had worsened the day he came to the ED.An ECG was obtained:The ST elevation in the inferior leads does not clearly meet standard STEMI criteria. ...
Source: Dr. Smith's ECG Blog - November 10, 2021 Category: Cardiology Authors: Brooks Walsh Source Type: blogs

Collapse, pulse present, ECG shows inferior OMI. Then there is loss of pulses with continued narrow complex on the monitor ( " PEA arrest " )
An elderly woman was witnessed to collapse.  911 was called and when EMS arrived, she was unresponsive with shallow respirations, a GCS of 3, pulse of 70 and BP of 78/67 by cuff pressure.3 prehospital ECGs were recorded:There is an obvious inferior OMI/STEMI, right?The patient then had a PEA arrest while on the cardiac monitor, and CPR was started.On arrival, all the usual things were done for cardiac arrest.Transthoracic cardiac POCUS was of low quality, and so after intubation aTEE probe was inserted.Aside: here is a recent report of our experience with over 550 TEE exams in the Hennpin ED: Feasibility, utility...
Source: Dr. Smith's ECG Blog - November 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Agitation, Confusion, and Unusual Wide Complex Tachycardia. What is it, why did it occur, and how to treat?
A 50-something male ran a 10 mile race, after which he complained of a headache.  The next day, he collapsed and had a witnessed seizure.He arrived agitated and the monitor showed a wide complex tachycardia.  He was very hypertensive and tachycardic.A 12-lead ECG was obtained:What is it?  What therapy?There are wide complex QRS's with 2 different morphologies:1. RBBB configuration with an axis of about 135 degrees (lower right axis toward III)2. IVCD (neither RBBB nor LBBB) with a " Northwest " (upper right) axis toward aVRThere appear to be 3 possible P-waves, but they are not consistent and not d...
Source: Dr. Smith's ECG Blog - November 6, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

PEA cardiac arrest, ROSC, and no STEMI on ECG. Randomized trials say emergent reperfusion is not indicated, right?
This study had a fatal 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 whom they suspected had Occlusion MI (OMI), even if they did not have STEMI. These physicians did not want a patient with an OMI that was not a STEMI to be randomized to no angiogram.  This strong suspicion is supported by their data: ...
Source: Dr. Smith's ECG Blog - November 4, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

What are these bizarre bigeminal PVCs??
Case 1This ECG was texted to me last week with the question: " What is this?? "What do you think?My answer:" This is a pre-torsades EKG. Watch out!  Every other beat, a PVC, has anextremely long QT.  In my experience, patients with ECGs like this are at very high risk of TORSADES. I have seen this several times. " OutcomeIt came from a patient who had been falling much, had a K of 2.8, and is on methadone but taking too much.  The patient then received K and Mg.  Torsades did not ensue.  The ECG findings resolved after metabolism of methadone and K replenishment.&...
Source: Dr. Smith's ECG Blog - November 1, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A deadly alcohol binge: a man in his 30s with chest pain and initial high sensitivity troponin I within normal limits
Submitted and written by Emergency Physician Dr. Arjun J V, with some minimal edits by Smith and MeyersA man in his 30s was rushed into our ED on a Sunday morning with continuous chest pain for 2 hours. The patient was drowsy but following simple commands and was pointing to his left chest where it hurt with a single finger. He said the pain started after he tried to vomit forcefully. He also had the odor of alcohol to his breath. The patient voluntarily told the team he had half a bottle of whiskey the previous night and he was uncomfortable ever since he woke up. He did, however, consume alcohol on a regular basis but ne...
Source: Dr. Smith's ECG Blog - October 29, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Acute Pulmonary Edema, PEA Arrest, LBBB, First degree AV Block, and STD maximal in V3, V4
An elderly woman had sudden SOB and 911 was called.  Medics found her with labored breathing and 75% saturations.  She was put on high flow oxygen.  After placing her in the ambulance, she had a PEA arrest.  She was intubated and ventilated, and given compression decompression CPR with theResQPod andResQPump.Aside:these 2 devices were invented by researcher Keith Lurie, who is in the Department of EM here at Hennepin; this isthe only method of CPR ever proven in a randomized trial to improve outcome in cardiac arrest see this ResQTrial, published in Lancet in 2011:Treatment of out-of-hospital cardi...
Source: Dr. Smith's ECG Blog - October 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

An elderly man who dies 12 hours later - could he have been saved?
Sent by Anonymous, written by Pendell Meyers and Steve SmithAn elderly man with good neurologic baseline but history of CABG presented to the ED with acute lightheadedness, shortness of breath, and chest pressure radiating to both arms. He had just recently been admitted for similar symptoms which had been diagnosed as an NSTEMI, and he received a stent to the ostial LCX one week ago. At that time his EF was 30%. He returned to the same hospital where he had just received his LCX stent.Here is his first ECG at triage, with chest pain temporarily resolved:He then had spontaneous return of chest pain while in the ED, wi...
Source: Dr. Smith's ECG Blog - October 22, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

I thought the ECG diagnosis was obvious. But many missed it. So I'm showing it.
I was reading ECGs in the system and came across this one:What do you think?Computer diagnosis: --ST DEVIATION AND MARKED T-WAVE ABNORMALITY, ANTEROLATERAL ISCHEMIA --ST DEVIATION AND MODERATE T-WAVE ABNORMALITY, CONSIDER INFERIOR ISCHEMIA I thought the ECG diagnosis was obvious, but no comment was made by the providers who ordered it.  That could be because they never saw it, as the patient eloped before full evaluation.  But then I showed it to multiple smart providers and not a single one saw it.  So I thought it would be good to show it to blog readers.Everyone went straight to the ST...
Source: Dr. Smith's ECG Blog - October 18, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 50s year old man with lightheadedness and bradycardia
 Written by Pendell Meyers with edits by Smith and GrauerA man in his 50s with history of end stage renal disease on dialysis, prior bradycardia episode requiring transvenous pacemaker, diabetes, and hypertension, presented to the ED for evaluation of acute onset dizziness and lightheadedness starting several hours prior to arrival. These symptoms prevented him from going to dialysis, and his last session was three days ago. EMS found him with a heart rate of 30 bpm but normal blood pressure. He received 0.5 mg atropine with increased in heart rate to the 60s with improvement in symptoms. He denied chest pain or short...
Source: Dr. Smith's ECG Blog - October 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A New Seizure in a Healthy 20-something
A 20-something year old who is the picture of good health presented with a new onset seizure.  A witness described what sounded like a 3 minute tonic-clonic seizure.  Her seizure workup was negative and she was scheduled for an outpatient MRI and EEG.Because she was persistently tachycardic, an ECG was recorded.  At the time her K was 3.2 mEq/L:Here is the interpretation by the computer, confirmed by the over-reading physician:JUNCTIONAL TACHYCARDIAINTRAVENTRICULAR CONDUCTION DELAY [130+ ms QRS DURATION]ABNORMAL ECGP-R Interval 116 msQRS Interval 158 msQT Interval 422 msQTC Interval 485 msP Axis 25...
Source: Dr. Smith's ECG Blog - October 14, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Hyperkalemia: is it the cause of this AV Block, ST Elevation, and T-wave inversion?
I was texted this ECG:What do you think?This was my response: " Yikes. Pacer and Cath Lab!! "He asked: " Could this all be due to hyperK? "I said: " Always possible. But it does not look like it.  Among the reasons I do not think it is all due to potassium is that the QRS is not wide. "  Also, there are obvious signs of OMI, and though these can sometimes be mimicked by hyperkalemia, the K must bevery high.ECG analysis:Sinus tachycardia with third degree AV block and a junctional escape.  QRS is 100 ms.  There areinferior Q-waves with inferior ST Elevation of OMI,...
Source: Dr. Smith's ECG Blog - October 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 60s woken from sleep by epigastric pain. Would you have been able to correctly diagnose him?
Written by Pendell MeyersA man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. He called EMS who brought him to the ED. He had active chest pain at the time of triage at 0137 at night, with this triage ECG:I sent this ECG, without any text at all, to Dr. Smith, and he replied: " LAD OMI with low certainty. V3 is the one that is convincing. " After his response I sent him the baseline ECG (below), still with no context at all except that this was his prior ECG:Dr. Smith replied: " Now high certain...
Source: Dr. Smith's ECG Blog - October 5, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 60s with misdiagnosed palpitations, part 2: Case follow up!
 Written by Pendell MeyersThis post will be follow up information on the patient from this recent case linked below. Make sure to read that one first, then see what happened to this patient in this post below!A woman in her 60s with palpitations, chest discomfort, and multiple misdiagnoses by both EM and Cardiology!!Here is the ECG:Here is the explanation:We see a regular, narrow, monomorphic tachycardia, for which the full differential would include sinus tachycardia, SVT (an umbrella term including many different rhythms), and atrial flutter. This ECG has a large negative atrial wave just before the QRS complex...
Source: Dr. Smith's ECG Blog - October 4, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!
In this study, Smith and others show that the initial high sensitivity troponin is often below the 99th percentile in true STEMI (+) OMI (and sometime even below a very low threshold).[1] Wereski, R., Chapman, A. R., Lee, K. K., Smith, S. W., Lowe, D. J., Gray, A.,& Mills, N. L. (2020). High-Sensitivity Cardiac Troponin Concentrations at Presentation in Patients With ST-Segment Elevation Myocardial Infarction. JAMA Cardiology, 5(11), 1302 –1304. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - October 2, 2021 Category: Cardiology Authors: Bracey Source Type: blogs

Massive ST Elevation in a 38 year old with Syncope
This ECG was texted by a former resident with the words " 38 year old, syncope while urinating.  Negative troponin. "What do you think?There is massive ST Elevation of 5 mm (at the J-point, relative to the PQ junction) in lead V2.  There is 3 mm in lead V1 and 2.5 in lead V3.  But there is also 57 mm QRS in V2 and a 19 mm R-wave in V4.  The QT interval is not very long.My response was this:" I have seen this pattern before and it is very unlikely to be OMI. "  I did not know what " troponin negative " referred to [single troponin?  below the level of detectio...
Source: Dr. Smith's ECG Blog - September 29, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

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