Is this Septal STEMI/OMI? Many examples of Septal STEMI/OMI
 This ECG was texted to me with the implied question " Is this a STEMI? " :What do you think?I responded that it is unlikely to be a STEMI.  Why?1. There is a saddleback.  I have only seen 2 Saddlebacks with LAD occlusion.  Links to these two are below.2. There is high voltage. It does not quite meet LVH criteria, but all I can say is that it has " the look "3. The QS-wave in V2 is associated with a biphasic P-wave.  This P-wave indicates that the leads were placed too high.  When the V1, V2 leads are placed too high, a frequent result is a QS-wave in V2.4. The QT is s...
Source: Dr. Smith's ECG Blog - October 28, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Fascinating case of dynamic shark fin morphology - what is going on?
 Case submitted by Magnus Nossen MD from Norway, written by Pendell MeyersA man in his 50s with no pertinent medical history suffered a witnessed cardiac arrest. EMS found the patient in VFib and performed ACLS for 26 minutes then obtained ROSC. 12 minutes later, the patient went back into VFib arrest and underwent another 15 minutes of resuscitation followed by successful defibrillation and sustained ROSC. In total, he received approximately 40 minutes of CPR and 7 defibrillation attempts. Here is his first ECG recorded after stable ROSC:Originally recorded in 50 mm/s (the standard in Norway), here converted to ...
Source: Dr. Smith's ECG Blog - October 26, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A 40-something male complains of worrisome chest pain and possible " fever "
This was sent by an EM colleague at Highland Hospital in Oakland.  His name is " Deep " A 40-something male complained of chest pain and SOB that began 2 hours prior at work and was becoming progressively worse.  He had additional nausea and vomiting and complained of fever.  The pain was constant, pressure-like, substernal, without radiation, and was 10/10 in intensity.  He stated that his wife had been diagnosed with Covid 3 months prior and that he, too, had been tested but never received the results. BP was 213/128.  Apparently no temperature was recorded as the patient...
Source: Dr. Smith's ECG Blog - October 23, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

What happens if you do not recognize this ECG instantly?
Written by Pendell MeyersA young man in his 20s with history of end stage renal disease and dialysis presented for acute chest pain. His last dialysis was 4 days ago. He was very hypertensive and short of breath, but oxygen saturation was normal.Triage ECG:What do you think?Pathognomonic for severe, life threatening hyperkalemia. QRS widening, PR interval prolongation (I believe those are P waves best seen in V1 and V2, but it matters not), and peaked T waves are apparent.  There is also a large R-wave in aVR, which is typical of severe hyperkalemia.Prior ECG on file from 12 days ago:Baseline LVH with repolarization a...
Source: Dr. Smith's ECG Blog - October 21, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Acute coronary occlusion seen in paced *and* non-paced ECGs
This was written by Brooks Walsh@BrooksWalsh, an emergency physician in Connecticut.A paced ECGThe family of a very elderly person called EMS when they became short of breath. The patient had a number of comorbidities, including a pacemaker.EMS obtained a number of ECGs, including this one:Could a cath lab activation be justified with this ECG?Well, yes, it should be!The classic- and modified-Sgarbossa criteria for determining acute MI in the context of a paced rhythm are likely already well appreciated by readers of this blog. This ECG is a great illustration of those rules, particularly the criterion that ST elevation th...
Source: Dr. Smith's ECG Blog - October 19, 2020 Category: Cardiology Authors: Brooks Walsh Source Type: blogs

A 70-Something Woman with a Very Wide Tachycardia
 ===================================MY Comment by KEN GRAUER, MD (10/4/2020):===================================Today ’s patient is a 70-something year old woman who presented to the ED for possible acute Covid-19 symptoms. She was conscious, but appeared acutely ill at the time the initial ECG was obtained in the ED (Figure-1). The computer interpretation read, “Extreme wide complex tachycardia”. How would YOU interpret the cardiac rhythm in ECG #1?Should you treat with Adenosine? Amiodarone? Immediate cardioversion? — or — Would you first do ...
Source: Dr. Smith's ECG Blog - October 17, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Dynamic ST Elevation
A 70-something male with 3 CAD risk factors developed intermittent left sided chest discomfort 29 hours prior.  It began again 2 hours prior to first ECG.  Pain was 7/10 radiating to left arm with SOB and diaphoresis.Here was the prehospital ECGSinus rhythm. Slight ST depression in I, aVL, and V4-V6, consistent with ischemia.These medics were smart and well trained, and so they recorded another several minutes later due to persistent symptoms:New ST Elevation in V4-V6, with obliteration of the S-waves.There is also new subtle STE in inferior leadsThey arrived in the ED and another ECG was recorded:Chest pain stil...
Source: Dr. Smith's ECG Blog - October 14, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Cardiologist declines taking patient to the cath lab. Patient dies.
Sent by anonymous, written by Pendell MeyersA middle aged man presented with acute shortness of breath. Apparently he denied chest pain. Here is his first ED ECG:What do you see?Findings: - Sinus tachycardia - Poor R wave progression - STD in leads V3 and V4 - there is almost an appearance of STE in V6, but it is not definite - there is also slight STE in aVL with slight reciprocal STD in inferior leads Impression: Diagnostic of posterior OMI [and the subtle lateral involvement (aVL) supports this] until proven otherwise. STD maximal in V1-V4 (in this case V3-V4) is in my opinion the sing...
Source: Dr. Smith's ECG Blog - October 11, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Not all new T-wave inversion signifies ischemia. Also, what is this irregular rhythm?
 This ECG was texted to me with the question" Wellens'? "The computer read was: Atrial Fibrillation, marked ST Elevation. ***Acute MI***The QT interval is short (377 ms, QTc = 399 ms)This is NOT atrial fibrillation: There is sinus arrhythmia with an accelerated junctional rhythm that competes with the sinus node and results in some AV dissociation (no AV block!).  This is completely benign.I responded: This STE with T-wave inversion looks like a normal variant for an African American.  I would check the troponin, but I do not think it is pathologic.Here is the history: The patient wa...
Source: Dr. Smith's ECG Blog - October 9, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Cardiologists need to keep an open mind and be capable of listening to, and learning from, the Emergency Physician
Conclusion: This represents the largest study of patients with VPR and angiographically-proven ACO. The MSC were highly sensitive and specific for the diagnosis of ACO in patients presenting to the ED with VPR and symptoms of acute coronary syndrome.===================================MY Comment by KEN GRAUER, MD (10/4/2020):===================================Today ’s case provides a superb example of how acute OMI can sometimes be definitively recognized even in the presence ofpacing. Unfortunately, this was not recognized by the cardiology team despite...
Source: Dr. Smith's ECG Blog - October 4, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Patient with STEMI (-) OMI is now pain free. Is there need for emergent cath lab activation?
I was reading through a stack of ECGs to put in the formal interpretation, and came across this one:This was my interpretation without having any clinical information:" There is suspicion forevolving infarction in inferior, lateral, and posterior walls. " ( " Evolving " means that it has been going on for some time, is not very acute, probably subacute) Then I went into the patient's chart:This was a 50-something female who presented from an outside hospital in the very early hours with " NSTEMI. " The patient started having pain the previous evening.  She reported that she was leavi...
Source: Dr. Smith's ECG Blog - October 1, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

" It isn't a STEMI, " so cath lab refusal (again). Were they right?
Sent by Anonymous, written by Pendell MeyersAn elderly female called EMS for acute epigastric pain. EMS arrived and recorded this ECG on the way to the hospital:This case was sent to me with only the details above, and my response was: " It's posterolateral (and probably also inferior) OMI until proven otherwise. I'd also give a little calcium because it's slow, wide, and a couple leads have almost pointy Ts. But I don't really think it's hyperK. This one is OMI. Either LCX or RCA, or perhaps an Obtuse Marginal that supplies those regions. "Interpretation: There is an absence of sinus activity, including an ...
Source: Dr. Smith's ECG Blog - September 27, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

40 Something Man with Palpitations and Grouped Beating: Is it Wenckebach?
FromDr.Smith:A 40 something male complained of palpitations.  See the ECG below and how Ken Grauer dissects this grouped beating.===================================MY Comment by KEN GRAUER, MD (9/27/2020):===================================The 12-lead ECG and accompanying long lead II rhythm shown in Figure-1 was obtained from a 40-something year old man who was found to have a fairly slow and irregular heart rate. He was hemodynamically stable at the time this tracing was done. Imagine this is the only history available.What is the rhythm? Is this Wenckebach?Clinically  —...
Source: Dr. Smith's ECG Blog - September 25, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Repost: Syncope, Shock, AV block, RBBB, Large RV, " Anterior " ST Elevation in V1-V3
I came across this post from 2015 while answering a question on Twitter, and decided to repost it:http://hqmeded-ecg.blogspot.com/2015/12/syncope-shock-av-block-large-rv.htmlSyncope, Shock, AV block, RBBB, Large RV, " Anterior " ST Elevation in V1-V3An elderly male had a syncopal episode. 911 was called. When medics arrived, the patient was alert and following commands. In the presence of the medics, he lost consciousness and became apneic and underwent 30 seconds of chest compressions, after which he started moaning and was again able to communicate and follow commands.  No shock was ever del...
Source: Dr. Smith's ECG Blog - September 23, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 60s with chest pain and prominent J waves
Case submitted by Dan Singer MD and Ryan Barnicle MD, Written by Pendell MeyersA woman in her 60s with history of smoking presented to the ED with left sided chest pain radiating to the left arm and back, starting at about 1330. She described the pain as a " heaviness, " without exacerbating or alleviating factors. Her pain at the time of arrival was 10/10.Here is her triage ECG (no prior for comparison):What do you think?Findings: - Sinus rhythm at around 100 bpm - Grossly normal QRS complex - 1.0 mm STE in lead III, and just a hint of STE in aVF (both of which have to be measured just after signi...
Source: Dr. Smith's ECG Blog - September 22, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Implementation of Abbott Architect High Sensitivity Troponin I in the ED
This was recorded by Stephen W. Smith to help clinicians implement the Abbott Architect High Sensitivity Troponin Assay.This describes the way we have decided to implement the assay, our algorithms, and the research behind the algorithms, primarily from our own UTROPIA studies, of which there are many.  (These studies were authored by Yader Sandoval, Fred Apple, and by me, Smith).  Very important data also comes from the High STEACS group in Scotland, led by Nick Mills.We believe these are reasonable pathways based on the data available, butalways remember that you must use your clinical judgment and ECG.  Y...
Source: Dr. Smith's ECG Blog - September 20, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Interventionalist at the Receiving Hospital: " No STEMI, no cath. I do not accept the transfer. "
Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? Yes. We don't know how many though.I was texted these ECGs by a recent residency graduate after they had all been recorded, along with the following clinical information:A 50-something with no cardiac history, but with h/o Diabetes, was doing physical work when he collapsed. He was found in ventricular fibrillation and defibrillated, then brought to a local ED which does not have a cath lab.Here is the initial ED ECG:This is pretty obviously and inferior posterior OMI, right?There is slight inferior ST Elevation, with reciprocal ST depr...
Source: Dr. Smith's ECG Blog - September 20, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Cardiac arrest with anterior-inferior STEMI: Guess the value of the initial ED high sensitivity Abbott troponin I
A ~40 year old woman started having chest discomfort.  She called 911 after an uncertain amount of time.  EMS arrived and recorded thisprehospital ECG:Obvious Anterior and Inferior STEMI, consistent with LAD occlusionAfter recording this ECG, the patient went intoventricular fibrillation.She was rapidly defibrillated.The cath lab was activated by the paramedics.She arrived complaining of chest pain, with a BP of 110/70.An ED ECG was recorded:It looks worse stillAside: Should the patient receive antidysrhythmics to prevent recurrent VT/VF?  See discussion below on both beta blockers and other anti-dysrhythmic...
Source: Dr. Smith's ECG Blog - September 18, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 60-something Woman with Chest Pain and a Wide QRS
CONCLUSION to the Case: The interventionalist finally took the patient to the cath lab. There was 100% occlusion of the RCA, which was stented.================NOTE: My sincere THANKS to Emmanuel Reisman (New York) for sharing the tracings and this case with us!================SmithQuickComments:Ken,Great case and great discussion!The modified Sgarbossa criteria are only 84% sensitive (if you use 20%) in our studies (Meyers Validation study), and if used on a consecutive group of chest pain patients with LBBB, it would probably be lower.  So indeed we need to look beyond these criteria in order to NOT mi...
Source: Dr. Smith's ECG Blog - September 16, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

A 58 year old collapses in the hot sun
A 58 yo male was out working in the hot sun for 2-3 hours. He stated he almost passed out, and bystanders called 911. They give him water with salt, as he thought he was dehydrated.When medics arrived, he was alert, sweating, and felt weak.  He walked to the ambulance for evaluation.  He denied headache, chest pain, nausea / vomiting and dyspnea. He had no cardiac history, meds, or risk factors. Vitals were obtained, and placed on cardiac monitor, including this 12 lead prehospital ECG: QTc =  320 ms; (QTc = 374 ms)The computer measures the ST Elevation at the J-point for you.Here it is 4.08 mm in ...
Source: Dr. Smith's ECG Blog - September 14, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 50s with 2 hours of chest pressure
 Case submitted by Anonymous, written by Pendell MeyersA man in his 50s with history only smoking presented to the ED with chest pressure for the past 2 hours. His vitals were within normal limits except BP 163/109. No prior ECG was available. Here is his triage ECG:What do you think?This is probably obvious to regular readers of this blog, but it is NOT obvious to most emergency providers and cardiologists.Findings include: - Sinus rhythm - Normal QRS complex - Hyperacute T waves in leads II, III, and aVF - reciprocal STD and T wave inversion in aVL - STD in V2-V4 (max in V3) - Like...
Source: Dr. Smith's ECG Blog - September 12, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

An 18 year old with chest pain and diffuse ST Elevation
An 18 year old complained of chest pain.Here is his ECG:  What do you think?Comment on ECGMany immediately think this is pericarditis.  But, in fact, this is the patient's baseline early repolarization, seen on a previous ECGs when he presented for a seizure (not chest pain). Most diffuse ST elevation is normal variant.  --There isdiffuse ST Elevation.  --There are well-formednotchesat the J-point in all leads with ST Elevation.  The STE is called normal variant.  The notching qualifies the ECG as true early repolarization (which is now defined as distinct from normal varia...
Source: Dr. Smith's ECG Blog - September 10, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Is there Wenckebach? An Elderly Patient with a Fall
===================================MY Arrhythmia Case by KEN GRAUER, MD (9/9/2020):===================================PREFACE: Recognition of the presence (or absence) of AV block is a common problem in emergency medicine. This case puts beginners, intermediate interpretersand experienced interpreters " to the test " in working through the etiology of this interesting rhythm.================================================The ECG that is shown in Figure-1 was obtained from an elderly patient, who was admitted to the hospital for a fall. The patient was found to be severely anemic — but w...
Source: Dr. Smith's ECG Blog - September 8, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Young Man with a Heart Rate of 257. What is it and how to manage?
A 30-something was in the ED for some minor trauma when he was noted to have a fast heart rate.  He acknowledged that he had palpitations. but only when asked.  He had a history heavy alcohol use.  Blood pressure was normal (109/83).Here is his 12-lead:There is a wide complex tachycardia with a rate of 257, with RBBB and LPFB (right axis deviation) morphology.The Differential Diagnosis is: SVT with aberrancy(#)     [AVNRT vs. WPW (also called AVRT*)]    Atrial flutter with 1:1 conduction, with aberrancy    VT coming from the anterior fascicle (fascicular...
Source: Dr. Smith's ECG Blog - September 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A patient with chest pain and ST Elevation in V1 and V2
A 56 year old male complained of chest pain and called 911.They recorded a prehospital ECG:As you can see, at the top it says ***Meet ST Elevation MI Criteria***The medics activated the cath lab prehospital.It is a pathognomonic ECG.What is it?This is hyperkalemia, severe.  Surprisingly, there appear to be P-waves, which are often extinguished when the K is so high.Severe hyperkalemia often presents with STE in V1 and V2, often with a Brugada-like morphology (tall R in V1, or rSR'; downsloping ST segment; negative T-wave.  There is a very wide QRS and very peaked T-waves.  Especially in V4 and V5, T-waves ar...
Source: Dr. Smith's ECG Blog - September 4, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

OMI Manifesto lecture in less than 20 minutes, via H & R Reloaded conference
Written by Pendell MeyersHere's my latest and most condensed version of the OMI Manifesto lecture, which I recently gave for the fantastic H and R Reloaded conference.Enjoy and feel free to give feedback on how it can be improved!  MY THOUGHT (Ken Grauer, MD): This superb 17-minute talk by Dr. Meyers tells it all!Our July 31, 2020 post links to the most recent supportive evidence favoring the OMI-NOMI paradigm (Article by Aslanger, Smith et al). I ’ve added to that post key ECG findings among those that suggest acute OMI despite not satisfying the millimeter...
Source: Dr. Smith's ECG Blog - September 2, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

21 year old woman with CP, SOB, then syncope, and with ST depression with T-wave inversion in V1-V3
In this study, except for troponin elevation,Gestalt was the best predictor.The article does not specify the QT correction methodWhy is right ventricular hypertrophy (RVH) not found in this large study of syncope?  Probably because it is not common enough to be identified in a general syncope study.  Not every high risk factor will be identified in such studies, but it is obvious that RVH is a dangerous condition and that, if identified on ECG, needs further workup.  Why were so few ECG findings predictive?Because most abnormal ECG findings were considered adverse outcomes in their own right and not eva...
Source: Dr. Smith's ECG Blog - August 31, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 31 year old with Diabetes and HTN complains of bilateral arm tingling and headache
This ECG was texted to me with the message " A 31 year old with Diabetes and HTN complains of bilateral arm tingling and headache. "There is high lateral ST Elevation and inferior reciprocal ST depression.There is also STE in V2.The computer calls it a STEMI.What do you think?STE in I, aVL and V2 is a pattern associated with "Mid-anterolateral OMI, " which is seen with OMI of the first Diagonal.  See more of Mid-anterolateral OMII wrote back: " I think this is a false positive due to LVH.  PseudoSTEMI.  I can't tell you exactly why.  It just looks like it.  ECGs are of...
Source: Dr. Smith's ECG Blog - August 29, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

3 days of shoulder and chest pain, and now cardiogenic shock
I was texted these ECGs." Bad chest pressure with severe left shoulder pain 3 nights ago.  Then SOB and nausea the next day.  Now appears to be in cardiogenic shock. "(Later review showed systolic BPs in the range of 55 to 83.  So she was quite hypotensive.)First recorded at time zero:There is sinus rhythm. Rate of only 70 suggests some beta blockade.The QT is very long.There is T-wave inversion in inferior leads, suggestive of reperfused or subacute MI.There is a Q-wave in III, so this may be subacuteThere is ST depression in V2-V4.20 minutes:Again, very long QT.Now, T-waves are upright in inferio...
Source: Dr. Smith's ECG Blog - August 27, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 60s with 6 hours of chest pain, dyspnea, tachycardia, and hypoxemia
Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
Source: Dr. Smith's ECG Blog - August 23, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Dynamic ST Change in a mid-50s Man with Chest Pain
===================================MY Comment by KEN GRAUER, MD (8/21/2020):===================================The patient is a mid-50s man who presented to the ED for new-onset chest pain of ~1 hour duration. His symptoms awakened him from sleep. He was still having chest pain in the ED at the time ECG #1 was done (Figure-1).QUESTION:HOW would YOU interpret his initial ECG that is shown in Figure-1?Figure-1: The initial ECG in this case (See text).MY THOUGHTS on ECG #1: Although significant baseline artifact is seen (especially in the limb leads) — the...
Source: Dr. Smith's ECG Blog - August 21, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Chest pressure and T-wave inversions. Not what you might think.
A 40-something male had been in the ED for many hours for altered mental status due to alcohol, when he became more alert and complained of chest pain.They recorded an ECG:What do you think?The clinician called me over due to worry about Wellens'pattern, and showed this to me.Here was my response: " I do not think this is Wellens.  These are not ischemic T-wave inversions. This is Pseudo-wellens, probably due to LVH.  It is maximal in V3-V6 and there is a lot of QRS voltage.  It is possible that it is Wellens, and so you should order 2 serial high sensitivity troponins, but I think he will rule out. &qu...
Source: Dr. Smith's ECG Blog - August 18, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

35-year old with Palpitations and a Very Complicated Rhythm
CONCLUSION: Mobitz I with an overall appropriate ventricular response is not an indication for pacing. But there are a number of signs suggesting this patient may have underlying heart disease — so despite this patient’s young age (35) — additional evaluation is indicated (ie, at the least an Echo, 24-hour Holter monitoring, lab, perhaps other tests).=================================SUGGESTION for Viewing the Laddergrams that Follow:IF you did not recognize that the rhythm in Figure-4 is 2nd-degree AV block, Mobitz Type I —&n...
Source: Dr. Smith's ECG Blog - August 16, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Chest discomfort, Sinus Tachycardia, Q-waves, ST Elevation, and Intermittent Wide Complex Tachycardia. Activate the Cath Lab?
This ECG was texted to me with no other information:Computer Diagnosis:SINUS TACHYCARDIAINCOMPLETE RIGHT BUNDLE BRANCH BLOCK [90+ ms QRS DURATION,TERMINAL R IN V1/V2, 40+ ms S IN I/aVL/V4/V5/V6]LEFT ANTERIOR FASCICULAR BLOCK [QRS AXIS
Source: Dr. Smith's ECG Blog - August 12, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A middle aged female with " heartburn " and a " normal ECG " per the computer
This is a re-posting of a Tweet by Robert Jones (@RJonesSonoEM), reproduced with permission, written by Pendell MeyersA middle aged female with history of smoking presented to the ED with " bad heartburn. "Here is her prior baseline ECG (first), and her ED ECG (second):Baseline:ED ECG:What do you think? Do you agree with the computer's interpretation of " Normal ECG " ?This was posted on Twitter and Dr. Smith (and several others) replied that it shows OMI. Dr. Smith said " No " (meaning " No, I do not agree with the computer " ). " New ST elevation in V4-V6. New distortion of S ...
Source: Dr. Smith's ECG Blog - August 7, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Management of MI can be similar to stroke: Use CT angiogram. Don't depend only on STE on ECG for reperfusion?
This study suggests that it is possible with high accuracy (91% Negative Predictive Value) to exclude a ≥50% coronary stenosis by means of CTA (Computed Tomography Angiography). And indeed — it would be helpful in patients with NSTE-ACS to know that emergent cath is not needed because CTA was done in the ED and came back negative.According to the central illustration (above) — 88% (666/758 patients) of those with either a non-diagnostic or positive CTA result had significant coronary disease (presumably treated by reperfusion).Average time in this study to co...
Source: Dr. Smith's ECG Blog - August 7, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 40s with chest pain reproducible with palpation
Written by Pendell Meyers, submitted by George KonstantinouA man in his early 40s with history of smoking and hypertension presented to the ED with substernal and right sided chest pain of 8 hours duration. The pain had first started after a stressful event and had waxed and waned several times over the 8 hours. The pain was reproducible with palpation on the right side of the chest.Here is his initial ECG:Notice the leads configuration (this ECG comes to us from Greece).There is sinus rhythm with very small STE in V2-V3. The T waves in V2-V5 are very concerning for hyperacute T waves with increased area under the curve. C...
Source: Dr. Smith's ECG Blog - August 3, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Computer and transferring physician say " normal. " What do you think?
Conclusion  — I did not know for certain if the T wave inversion in lead aVL of ECG #1 was abnormal — but it could be!Also as noted by Dr. Smith — the T wave in lead V2 is inverted. While the T wave may normally be inverted in lead V1 in adults — most of the time, the T wave should not be inverted in lead V2. Adding to my suspicion that this was indeed an abnormal finding is the distinct ST segment straightening in lead V2, that continues on in lead V3.Finally — there are the subtle findings in the inferior leads. I was not as concern...
Source: Dr. Smith's ECG Blog - July 31, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article
Data:OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article by Emre Aslanger, with some help from Smith" ACOMI " = Acute Coronary OMIDIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study)Free full text:https://www.sciencedirect.com/science/article/pii/S2352906720303018 (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - July 30, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A Woman with New Dyspnea. Is the extreme left axis deviation, with negative T-wave in lead III, suggestive of RV strain?
===================================MY Comment by KEN GRAUER, MD (7/26/2020):===================================The ECG in Figure-1 was obtained from a middle-aged woman who presented to the ED with new-onset shortness of breath.QUESTION: Is the inferior lead T wave inversion indicative of RV (Right Ventricular) Strain from acute PE (Pulmonary Embolism)?Figure-1: ECG obtained from a middle-aged woman who presented to the ED with new dyspnea (See text).MY THOUGHTS on ECG #1: As always — I favor a systematic approach to ECG interpretati...
Source: Dr. Smith's ECG Blog - July 27, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

Prehospital ECG of a 50-something male with Syncope and Chest Pain
This case was sent by an excellent medic:A 50-something yo male started to chop wood when he experienced a short syncopal episode followed by 8/10 chest pain.  Ground EMS arrived, administered ASA and sublingual nitro to which he passed out again.Flight crew was called to transport for signs of shock/syncopal episodes, not ACS.Ground crew had recorded this prehospital ECG:Sinus rhythm with one PVC (first complex)And anything else?These are hyperacute T-waves diagnostic of LAD occlusion.  They begin at V3, and there is no inferior ST depression, so this is probably a mid-LAD occlusion.  The hyperacute T-waves...
Source: Dr. Smith's ECG Blog - July 25, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A Complication of the COVID Era
Submitted and written by Gia Coleman MD and Roshan Givergis DO, edits by Meyers and SmithA woman in her 30s was found crawling in the streets, altered on arrival to the ED. Here is her presenting ECG:How would you interpret this EKG and what is on your differential?At first glance, it appears to be a sinus rhythm with PR prolongation at a rate of about 75 bpm. The QRS may appear narrow but is in fact slightly wide (see figure below). The computer measured it to be 136 ms.Perhaps the most striking finding in this EKG is the almost complete loss/flattening of the T waves. The computer calculated the QTC to be 427. Looking cl...
Source: Dr. Smith's ECG Blog - July 23, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Subtle ECG Findings of Left Anterior Descending Artery (LAD) Occlusion -- LAD Occlusion MI (OMI)
I just gave this Zoom lecture to U Mass on Subtle ECG Findings of Left Anterior Descending Artery (LAD) Occlusion -- LAD Occlusion MI (OMI)Subtle ECG Findings of LAD Occlusion - Steve Smith fromStephen Smith onVimeo. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - July 21, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Updated 1 hour lecture: The False STEMI-NonSTEMI Dichotomy
I just gave this Grand Rounds at U Mass by Zoom on:The False STEMI - NonSTEMI Dichotomy.You can view the entire 1 hour lecture here:The False STEMI-NonSTEMI Dichotomy - Steve Smith fromStephen Smith onVimeo. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - July 21, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A case of misinterpreted troponins, in spite of a very suspicious ECG....
This 50-something male with previous history of MI presented for intermittent CP and SOB for 2 days. CP lasted for hours at a time, was described as pleuritic, without radiation, but relieved by nitro. He was given nitro and full dose aspirin by EMS.  Prehospital ECG was similar to first ED ECG.Here is the ED ECG for ED visit #1:It is very abnormal, with potentially ischemic downsloping ST depressionThere were 3 ECGs during an ED visit for chest pain one month earlier.  Let's call that ED visit zero.Here is the last EKG from ED visit zero:There is minimal ST depression without the downsloping.Here ...
Source: Dr. Smith's ECG Blog - July 20, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

What is a useful next step in the evaluation of this patient with Chest pain and this ECG?
Written by Pendell Meyers, submitted by Daryl Williams, edits by Steve SmithA man in his sixties with prior CAD and CABG experienced chest pain and pressure off and on for three days. He saw his primary doctor during this time who had suspected GI related symptoms and increased his PPI medication. On the third day it became more intense and had associated radiation to his neck and left arm, and this reminded the patient of his prior MI symptoms, so he presented to the Emergency Department. It is unclear how long he had constant symptoms during those three days.Here is his triage ECG (no prior was available in our system):W...
Source: Dr. Smith's ECG Blog - July 18, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Chest Pain and Ischemic ST Depression — but there is no Cath Lab available. Thrombolytics?
===================================MY Comment by KEN GRAUER, MD (7/14/2020):===================================This middle-aged man with hypertension and hyperlipidemia presented to the ED with 2 hours of new-onset chest pain — and the ECG shown in Figure-1. The patient was hemodynamically stable. No prior tracing was available for comparison.HOW would you interpret the ECG shown in Figure-1?Immediate cath lab activation was not an option in this hospital. Should acute thrombolysis be used?Figure-1: The initial ECG in the ED (See text).My THOUGHTS on EC...
Source: Dr. Smith's ECG Blog - July 14, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

A young woman in her early 20s with syncope
Written by Pendell MeyersA 20 year old female with an episode of syncope was triage to my low acuity zone one morning. Her vitals were within normal limits except for her heart rate of 109 bpm.I immediately went to evaluate her, without looking in the chart first. I found a well appearing young lady in the room with her parents who witnessed the event. She stated that she was sitting on a shallow ledge in a pool when she became lightheaded, so she got up out of the pool and then briefly syncopized next to the pool in front of her parents, who were able to catch her preventing any trauma. She returned to normal within 30 se...
Source: Dr. Smith's ECG Blog - July 11, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain and Inferior T-wave Inversion. Does this patient need emergent cath lab activation?
This ECG was texted to me, initially with no information:What do you think?There are QS-waves in III and aVF.  There is a qR in lead II.  There is minimal STE, upsloping, with T-wave inversion in lead II.  Leads III and aVF only have deep, fairly symmetric T-wave inversion.My interpretation and reply (paraphrase):There is subacute inferior MI and there has probably been prolonged pain.  The initial troponin will be high.  With T-wave inversion, it is possible that the artery has opened, but with subacute MI, the T-wave may be invertedeven with persistent occlusion.  If there is persistent pain...
Source: Dr. Smith's ECG Blog - July 8, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

An Very Elderly Male with Epigastric pain, " ischemic ECG " and Interesting Imaging.
CONCLUSION: Prior to reviewing the literature for discussing this case — I had not fully appreciated the impact of the mechanism of cardiac compression as a causative factor in: i) altering QRS morphology; ii) precipitating supraventricular and/or ventricular arrhythmias (including VT, which can be sustained) — and, iii) producing ST-T wave changes (ST elevation and/or depression) that may mimic old or new infarction.CT imaging (as shown by Dr. Smith) clearly suggests there was compression of cardiac structures in thi...
Source: Dr. Smith's ECG Blog - July 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs