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

New Paper: Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute OMI.
Just published online today by Meyers and Smith.@PendellMThis is our best and most important work ever. Another nail in the STEMI/NonSTEMI coffin. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute OMI. Full text:https://www.sciencedirect.com/science/article/pii/S2352906721000555 (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - April 12, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

An 80-something with weakness, cough, and CP. Should this ECG provoke a Prehospital Cath Lab activation?
An 80-something called 911 for chest pain, generalized weakness, and cough.Here is his prehospital ECG:The medics were worried about this ECG and activated the cath labSmith: As in many prehospital ECGs with large voltage,the tracing goes off the image, making assessment of voltage impossible.  Thus, it is impossible to assess the ST Segments and T-waves, which should always be assessed in proportion to the size of the QRS.  I call this " proportionality " and in a non-ischemic ECG, the repolarization should always be proportional to the depolarization.  Since we can't see the true s...
Source: Dr. Smith's ECG Blog - April 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Paroxysmal Atrial Fibrillation with RVR, hypotension, volume depletion, good EF, AND pulmonary edema. Strange. Why? What to do?
A 30-something woman presented with a few days of feeling ill.  She had a history of paroxysmal atrial fibrillation, bio-prosthetic mitral valve, and tricuspid valvuloplasty, and was on Coumadin.Records showed she is usually in sinus rhythm and has normal LV function.She presented hypotensive (systolic pressure 80), with diffuse B lines, flat IVC, good LV function, and an irregular, fast heart beat.Here is here ECG:Atrial fib with RVR and some probable ischemic ST depression in V3-V6Here is her POCUS:What do you think?  There is asmall LV with good function and alarge left atrium, andmoderately large RV.Ther...
Source: Dr. Smith's ECG Blog - April 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Prehospital Cath Lab Activation for inferior STEMI -- do you agree?
A 40-something male complained of 3 days of chest pressure.  He called 911.  He had some pulmonary edema and hypoxia.Here is the prehospital ECG:The computer says ***STEMI***Based on this and the presence of chest pain, the medics did a prehospital activation of the cath lab.What do you think?Interpretation: There is clear atrial flutter.Look at the spikes in V1 at a rate over 300, which are flutter waves.  The flutter wave in the inferior leads mimics ST Elevation.  An ED ECG was recorded:Confirmed Atrial FlutterAgain, notice the flutter waves manifest are sharp spikes in V1There is 2:1 conduction...
Source: Dr. Smith's ECG Blog - April 2, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 40s with a highly specific ECG
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. that when T-wave inversions in the right precordial leads and in lead III are indeed present, then PE may indeed by more common. ...
Source: Dr. Smith's ECG Blog - March 30, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Nonspecific symptoms with RBBB and New ST Elevation. Anterior STEMI, right? What does the echo show?
A 50-something male with a history of COPD and substance use disorder who presented with generalized weakness and exacerbation of chronic back pain that is now radiating to his neck, and headache. He also developed nausea, alternating " hot and cold flashes " , and generalized weakness the previous evening. He became anxious about his symptoms and then used crack cocaine as well as drank alcohol last night. His symptoms have persisted since then. He states he has felt short of breath since last night. He denies any chest pain, though notes he has a " odd " sensation in his chest...
Source: Dr. Smith's ECG Blog - March 28, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

20-something with anxiety. Pulse is 169. Then 229. Then 169. Then 229. Latent conduction vs. Concealed Conduction. 3 Pathways.
A young woman in her third trimester of pregnancy had complained of panic attacks on multiple occasions.  She presented to the ED this time, instead of to a clinic, for the same complaint and her pulse was palpated at " very fast " .Side note: Many panic attacks are diagnosed as SVT by 3 year followup. In other words, the patient was wrongly diagnosed and treated for psychiatric disease for up to 3 years.Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537-543.&n...
Source: Dr. Smith's ECG Blog - March 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Does this ECG represent acute ischemia?
 I was shown this ECG, without any clinical data:What do you think?My answer:" I think it is a baseline ECG, not ischemic. "Why did I say that?  Because of the very high voltage.  Whenever you see voltage like that, ST-T abnormalities which at first appear to be ischemic are probably simply secondary to the abnormal depolarization and due to LVH or some other baseline disease.And so it was indeed the patient's baseline ECG:  The patient had presented for nonspecific symptoms and had the ECG recorded.  So they searched for a previous ECG.  Here it is from 20 months prior. &n...
Source: Dr. Smith's ECG Blog - March 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 50s with acute chest pain and diffuse ST depression
Submitted by Alex Bracey, with edits by Meyers and SmithA man in his 50s with history of type B aortic dissection with prior TEVAR experienced acute onset chest pain at rest and presented to the Emergency Department. Here is his ECG on arrival:What do you think?Here is a prior ECG on file (presumed baseline):There is sinus rhythm with minimal STD in V5, V6, II, III, aVF. There is the tiniest amount of STE in aVL, but the T wave is not hyperacute (instead there is a terminal inversion). I would call this ECG consistent with subendocardial ischemia, but also the question of possible high lateral OMI (for which I am not ...
Source: Dr. Smith's ECG Blog - March 19, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

80-something year old with acute chest pain. 3 visits. Fascinating Ultrasound progression
An 80-something year old man with history of metastatic cancer had acute onset of chest pain and called 911.Here is his prehospital ECG:What do you think?The computer read ***Anterior STEMI*** along with RBBB.Smith interpretation: There is Right Bundle Branch Block (RBBB).  There is 1 mm of STE in inferior leads and also in lateral precordial leads.  As a general rule, RBBB should not have ST Elevation (there are some infrequent patients with RBBB who have non-ischemic STE, usually discordant to the negative S-wave, as in this case).  Moreover, the T-waves appear hyperacute.I would activate the cath lab base...
Source: Dr. Smith's ECG Blog - March 15, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Trust a computer read of " Normal ECG " at your peril!
This case was contributed byBrooks Walsh, an emergency physician in Connecticut.Don't trust the " Normal ECG "It's important to periodically reemphasize that the computerized ECG interpretation  can miss critical findings. Some authors have suggested that ECGs interpreted as " normal " by the computer are "unlikely" to be significant. However, " unlikely " is doing a lot of the heavy lifting in that conclusion!The challenge of emergency medicine, after all, is to churn though the sea of benign presentations, looking for that " unlikely " crucial diagnosis. If you ...
Source: Dr. Smith's ECG Blog - March 13, 2021 Category: Cardiology Authors: Brooks Walsh Source Type: blogs

De Winter's T-waves are Not a Stable ECG condition. Upright T-waves in Posterior OMI are Distinct from de Winter's waves.
This was just published in JAMA Internal Medicine:The de Winter Electrocardiogram Pattern Evolving From Hyperacute T WavesIt reminded me that many believe, due to the assertions in the original de Winter's article, that de Winter's waves are stable.  In fact, the title was "Persistent precordial ‘‘hyperacute’’ T-waves signify proximal left anterior descending artery occlusion. "  The authors based this idea of persistence mostly on their perception, not on a rigorous evaluation involving frequent serial ECGs of all patients with de Winter's T-waves. But de Winter's wave...
Source: Dr. Smith's ECG Blog - March 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 53 year old with chest pressure has a diagnostic EKG (EKG 1). What is it? Chest pressure resolves (EKG 2)
A 50-something male had onset of pain approximately 30 min prior to arrival and was still present on arrival.  The pain was described as a pressure with radiation to his back. No nausea or SOB. No diaphoresis. He had never had this pain before.Computer and physician read:SINUS RHYTHMMODERATE ST DEPRESSION [0.05+ mV ST DEPRESSION]What do you think?After looking, compare with the patient's previous ECG (next), and then see what you think.There is ST Elevation in V2 and V3Previous ECG from 3 months prior, during a visit for angioedema:This ECG is normal, with a bit of normal ST elevation in V2 and V3The first ECG above:&...
Source: Dr. Smith's ECG Blog - March 3, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain with ventricular paced rhythm - will you be able to rise above the STEMI paradigm and figure out what to do?
 Submitted by Marie Wofford MD and Mark Kastner MD, edits by Smith and MeyersAn 86 year old with prior history of CAD and PCI, aortic stenosis, pacemaker, atrial fibrillation on warfarin, hypertension, etc., presents with sudden onset mid back pain radiating to the left shoulder and chest. His vital signs were within normal limits with the exception of tachypnea at 22/min. The EMS ECG is shown below:What do you think?The ECG shows ventricular paced rhythm (the pacer spikes are barely visible to me in lead V2), resulting in almost LBBB morphology (LBBB morphology would require upright usually monophasic R waves in I an...
Source: Dr. Smith's ECG Blog - March 1, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

When there is less than 1 mm of ST depression, can you make the diagnosis of posterior OMI?
DiscussionApproximately 10% of OMIs will involve the posterior wall, most of which also have concomitant involvement of the lateral and/or inferior walls (though usually not meeting STEMI criteria). Isolated posterior OMI, however, manifests as STD without associated STE since the subepicardial myocardial ischemia that would normally generate STE on overlying leads is occurring in the opposing or negative vector compared to the recording ECG leads. The majority of isolated posterior OMIs will be due to occlusion of the LCX, RCA, or a variety of their posterior branches.The 4th Universal Definition of Myocardial Infarc...
Source: Dr. Smith's ECG Blog - February 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Saw this ECG while reading through a stack. Lots here: myocardial stunning, MRI viability, P2Y12 inhibitors and CABG.
I had just finished passing the shift off to my partner and the next shift of residents.  It was 11:30 PM.  I turned to the computer system to finish reading any EKGs from the shift and I saw this one, which had been recorded after the end of my shift at 11:11.Usually these are brought immediately by the tech to the faculty physician.  I'm not certain whether another faculty had seen this or not.What do you think?I immediately saw the ST depression in V2 and V3 of at least 1.5 mm.  There is also minimal STD in II, III, aVF.  When you see this inferior STD, you should not think "...
Source: Dr. Smith's ECG Blog - February 26, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Sudden CP and SOB with Inferior ST Elevation and in STE in V1. Is it inferior and RV OMI?
A 60-something had been having chest " soreness " on and off for one month when she presented with sudden chest discomfort and dyspnea starting about an hour prior to arrival.Here is the triage ECG.It was texted to me along with concern for inferior ST Elevation and STE in V1, possible inferior and right ventricular OMI:There is a negative P-wave in lead II.  You'll notice that the P-wave is abnormal everywhere.  This is an ectopic atrial rhythm, and it is low in the atrium such that the atrium is depolarized AWAY from lead II and is inverted.  In any ECG, there might be an atrial re...
Source: Dr. Smith's ECG Blog - February 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 30-something with inferior ST Elevation. OMI? Pericarditis? Normal Variant ST Elevation?
This study showed that ANY ST depression in lead aVL is highly sensitive for inferior OMI, and that zero patients with pericarditis had this feature.Of the 154 patients with catheterization laboratory diagnosis of inferior STEMI, 154 patients (sensitivity, 100%; CI, 98%-100%) had some degree of ST depression in lead aVL (at least 0.25mm).  In addition, all 154 patients demonstrated T-wave inversion in lead aVL (sensitivity, 100%; CI, 98%-100%).  Of the 49 pericarditis patients, zero (0%) had any ST-segment depression in lead aVL (CI, 0%-7%), and 7 (14%) of 49 (CI, 7%-27%) had T-wave inversion in aV...
Source: Dr. Smith's ECG Blog - February 16, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his early 40s with chest pain: STD in V1-V4, but posterior lead are negative
This study by Shah et al. shows that the STD of subendocardial ischemia (in contrast to posterior OMI) is maximal in V5 and V6.Shah A, Wagner GS, Green CL, et al. Electrocardiographic differentiation of the ST-segment depression of acute myocardial injury due to the left circumflex artery occlusion from that of myocardial ischemia of nonocclusive etiologies. Am J Cardiol [Internet] 1997;80(4):512 –3. Available from: https://europepmc.org/article/med/9285669However, STD in V1-V4 can occasionally be due to subendocardial ischemia.  If posterior leads also show ST depression, then subendocardial ischemia is probabl...
Source: Dr. Smith's ECG Blog - February 14, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

What to do when Atrial Fib with RVR will not Electrically Cardiovert. And how do you measure the QT in Atrial Fib?
This middle-aged male patient has a history of paroxysmal atrial fibrillation, and on this day of admission had sudden onset of palpitations and he knew it was atrial fib again.  He presented only a few hours after onset.  He complained of severe chest pressure.  Here is his ED ECG:Atrial Fibrillation with very rapid ventricular rate which varied from 130-170.  There is somemoderate ST depression in V4-V6 which islikely due to ischemia.What is the QT interval?  Is the computer's measurement correct?  How do you correct the QT in atrial fib?  And does it matter?Because he wa...
Source: Dr. Smith's ECG Blog - February 12, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 50-something with cocaine chest pain and ST Elevation in V1 - V3
CONCLUSIONS -- SUMMARY Moderately increased left ventricular wall thickness.Normal left ventricular size and systolic function with an estimated EF of 68%.No regional wall motion abnormality.Dynamic intracavitary gradient, peak 34 mmHg at rest and mmHg with Valsalva.Indeterminate left-sided diastolic parameters.  The hypertrophy is somewhat more prominent at the apex. This, in conjunction with the dynamic intracavitary gradient, raisesconcern for hypertrophic cardiomyopathy. Learning PointsRight precordial ST Elevation: Septal STEMI vs. LVH:Here is a typical case of massive LVH, with secondary ST Elevat...
Source: Dr. Smith's ECG Blog - February 9, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 60 year old with chest pain
I saw this in a stack of ECGs and recognized it immediately. What do you think?There is ST depression in the context of a normal QRS.  In other words, the ST depression is not secondary to LVH, LBBB, RBBB, RVH, WPW, or LV aneurysm.ST depression with a normal QRS has a small differential:1. Ischemia2. Hypokalemia3. Digoxin4. Normal variant.5. Anyone have any others?Ischemia has a relatively long QT intervalDigoxin results in a short QT interval.Digoxin is also associated with atrial fibrillation, as we see here.Digoxin ST depression has a " scooped " appearance.  It has been likened to Salvador Dali...
Source: Dr. Smith's ECG Blog - February 6, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Another diagnostic ECG of a potentially deadly condition
 Written by Pendell MeyersA middle aged woman with no significant past medical history presented with epigastric abdominal pain with vomiting off and on for the past few days. Today her symptoms returned and intensified, so she came to the Emergency Department. Her vital signs were only significant for mild bradycardia.What do you think? It is basically pathognomonic.Here is her triage ECG:Here is her baseline ECG on file from several months prior:The presentation ECG shows sinus bradycardia with a normal QRS complex followed by diffuse down-sloping ST depression with extremely long down-up T waves. This is diagnostic...
Source: Dr. Smith's ECG Blog - February 2, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain, ST Elevation, and tachycardia in a 40-something woman
A prehospital cath lab activation for STEMI came through with the information that the 40-something woman had chest pain and a pulse of140.We were immediately skeptical that the patient had a STEMI because of the high heart rate.  She would have to be in cardiogenic shock with a massive STEMI for that.  Certainly possible, but when the heart rate is so high, be skeptical.The patient arrived with this ECG:Here the heart rate is obviously no longer 140What do you think?ECG: it certainly appears to be an anterior STEMI, but it is important to realize that right ventricular ischemia from either inferior and RV STEMI ...
Source: Dr. Smith's ECG Blog - January 30, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Wellens' syndrome: to stent or not? IVUS negative, Symptoms persist, Stress Testing, Instantaneous Wave Free Ratio, and Fractional Flow Reserve.
A 55 y.o. male with no cardiac PMHX presented for 2 weeks of exertional chest pain, worsened on the day prior to presentation.  On the day of presentation, the chest discomfort was particularly intense, and associated with diaphoresis and nausea.  It was resolved (pain free) when the ECG was recorded:This ECG was read as " nonspecific " by the providers.  What do you think?These is classic Wellens'pattern A (biphasic, terminal T-wave inversion), and it isWellens 'syndrome (Angina, resolved -- pain free -- with preserved R-waves and Wellens'pattern A T-waves).  The morphology of these...
Source: Dr. Smith's ECG Blog - January 28, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Acute Chest pain which then resolves spontaneously
A 50-something woman presented with sudden onset of left sided chest pain while driving, radiating down left arm, in addition to feeling diaphoretic, dizzy, and lightheaded. She presented immediately to the ED and had this ECG recorded:QTc was 432 msWhat do you think? One of our fellows and a resident were worried about the ST Elevation in V3-V5, and but they were uncertain if it was possibly normal variant STE.They calculated the formula at21.05, which very strongly suggests acute LAD occlusion.  18.2 is the most accurate cutoff value, but at 19.0 it is very very specific.  21.05 is nearly always ...
Source: Dr. Smith's ECG Blog - January 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Typical chest pain and hypotension, Activate the Cath lab?
I was texted this ECG with the info that the patient " clinically looked like he was having a myocardial infarction " :What do you think?There is atrial and ventricular pacing.  Both spikes are best seen in V1 and V2 (as always, if you click on the image, it enlarges).  The QRS is very very wide.  On the image below, I have drawn lines in every lead from the QRS onset (blue) and QRS end (red).  I measure the QRS duration at about 280 ms.  Of course, all ventricular paced rhythm is wide, but not often this wide.  One must always consider hyperkalemia when the QRS is very wide, but the...
Source: Dr. Smith's ECG Blog - January 17, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 47-year-old man with abdominal pain and heart rates approaching 300 bpm
 Written by Pendell MeyersA 47-year-old man with known WPW syndrome presented to the ED complaining of left abdominal pain, diarrhea, and chills. He denied palpitations, but is found to have a heart rate of 170 bpm at triage. He states that he occasionally has episodes of tachycardia which usually lasts about 1 hour, which he was instructed to " ride out at home unless they persist. "  Other than his heart rate, his other vitals were within normal limits, and the patient did not show any signs of compromised cardiac output or distress.Here is his initial ECG:What do you think?The ECG shows an irregularl...
Source: Dr. Smith's ECG Blog - January 13, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A wide complex tachycardia
Submitted by Van Wall M.D., Written by Pendell MeyersLet's go back to the basics for a common and classic scenario.A middle-aged patient presents with shortness of breath and palpitations. The patient was stable without signs of low cardiac output or distress. Her ECG is shown below (first see what you think without using the baseline): What do you think?There is a (minimally) wide complex, regular monomorphic tachycardia at a little faster than 150 bpm. I measure the QRS duration at almost exactly 120 ms. The differential would include ventricular tachycardia, any cause of narrow complex regular tachycardia plus adde...
Source: Dr. Smith's ECG Blog - January 11, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Acute chest pain, ST Depression in V2 and V3, relief with Nitroglycerine, " normal " coronaries, and apical ballooning. Is it takotsubo?
This was submitted by Michael Fischer, one of our outstanding2nd year EM residents at Hennepin Healthcare.CaseA previously healthy female in her 40s presented 1 hour after abrupt onset 10/10 crushing chest pain that started while brushing her hair that morning. The pain radiated to her bilateral jaw and right shoulder, and did not seem to be exertional or pleuritic in nature.  Here is her pre-hospital ECG: What do you think?Smith: V2 and V3 have some minimal ST depression with downsloping.  This is highly suggestive of posterior MI.This was read by EMS as non-specific. Aspirin 324mg was given by EMS. Ni...
Source: Dr. Smith's ECG Blog - January 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs