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

ECG with Aslanger's Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory.
A 52 y.o. male presented with persistent central chest pressure, without radiation, SOB or diaphoresis, which began at rest approximately one hour prior to arrival.  He had never had pain like this before.  He felt slightly nauseous earlier but no vomiting.  He is denying any back pain or abdominal pain.  An ECG was recorded during pain:What do you think?This shows significant ST depression in I, II, and V4-V6, with reciprocal ST Elevation in aVR.  This suggests diffuse subendocardial ischemia.  However, along with that subendocardial ischemia, there is also STE in lead III with...
Source: Dr. Smith's ECG Blog - January 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain after motor vehicle collision with an abnormal ECG - blunt cardiac injury? OMI? normal variant?
Discussion:Significant cardiac trauma occurs in approximately 10% of patients with severe blunt chest trauma. Isolated coronary artery dissection from blunt trauma is a very rare event. Traumatic dissections are most often seen in the LAD, followed by the RCA and LCX. It is thought that this is due to the relative anterior position of the LAD. The ECG is a report from the myocytes of their condition. They do not know the etiology of acute complete ischemia. No matter if its typical ACS, traumatic dissection causing acute occlusion, or spasm, it is the same result to the myocytes, and the same findings can be present o...
Source: Dr. Smith's ECG Blog - December 30, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!
DiscussionFlutter waves are well known to mimic ST deviations, as well as to hide true ischemic ST deviations from the interpreter. In many cases of flutter waves mimicking ST deviations, the expert electrocardiographer can see the morphology of the flutter waves as the cause of apparent STE or STD. Likewise, in some cases of ischemia concealed by flutter waves, the ischemia can be seen despite the flutter waves, whereas in other cases the dysrhythmia must be terminated before the ischemia can be clearly distinguished. Even when flutter waves conceal true ST segment deviations, the cause and effect relationship may be...
Source: Dr. Smith's ECG Blog - December 26, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

ST Depression Maximal in V1-V4 and Angio shows 3 Vessel Disease. Is it posterior? Which is the culprit?
A 70-something woman had acute chest pain.The ECG was texted to me with the words: " Acute chest pain. Could this be posterior MI? What do you make of the ST depression in V4-V6? "What do you think?My response: " The ST depression is maximal in V1-V4.  This is most consistent with a posterior MI.  If it sounds clinically like acute MI then this is good for activating the cath lab. "Her response: " Yeah, I did activate.  But the cardiology fellow told me he was sure it would not be a posterior MI because of diffuse ST depression.  He suggested that we should have consulted cardio...
Source: Dr. Smith's ECG Blog - December 23, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Bradycardia, Crushing Chest pain, and Pulseless VT Arrest
A 50-something woman with h/o hypertension and hyperaldostonism presented with severe crushing chest pain and bradycardia.  EMS found the patient with a decreased level of consciousness.  En route to the ED, the heart rate was 30-60 with systolic BP in the 150s and the patient was talking and answering questions.  They recorded a prehospital ECG:What do you think?The patient arrived awake and had another ECG recorded:What do you think?The ED physicians correctly identified hyperkalemia and pseudoSTEMI (bradycardia, STE in V1 and V2, very peaked T-waves with a narrow bse and very flat (even downsloping) ...
Source: Dr. Smith's ECG Blog - December 21, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman with near-syncope, bradycardia, and hypotension
 Written by Pendell MeyersA 59-year-old woman with diabetes, hypertension, prior stroke, and peripheral vascular disease presented with multiple near-syncopal events over the past 2 days, as well as ongoing back pain. EMS found her bradycardic in the 40s and administered atropine with no response. She was mentating and had a reasonable blood pressure (around 90s systolic), so they decided not to pace prehospital. On arrival the patients blood pressure was 79/50 mm Hg. She was still awake and alert. Here is her first ECG (no baseline available):What do you think?Findings: - junctional bradycardia (no P waves,...
Source: Dr. Smith's ECG Blog - December 18, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Extreme widespread ST depression, with ST Elevation in aVR. What do you think?
ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - December 16, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 45 year old smoker presents with palpitations, is discharged, and is found dead 2 days later
A 45 year old smoker presented with palpitations.  He had no other medical problems.  There was no syncope.  He was on no medications.Unfortunately, no other information is available, but that is enough to provide an learning point.Here is the EKG:Do you see anything worrisome?There are PVCs, and these might be the cause of the palpitations (whether they are indeed the source of the palpitations could easily be ascertained by asking the patient if the palpitations are still present during the ECG).  However, there are wide QS-waves (0.8 ms) in III and aVF, and they have afragmented QRS (extra spike...
Source: Dr. Smith's ECG Blog - December 14, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Our newest OMI publication, in JEM - Comparison of the STEMI vs. NSTEMI and Occlusion MI vs. NOMI paradigms of acute MI
Conclusions:STEMI( –) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(–) OMI.If your understanding of ACS stops at the STEMI vs. NSTEMI concept, then this figure below appears at first glance to justify and summarize your practice: But in reality, the paradigm keeps an important population hidden from your understanding: the NSTEMI patients with OMI. Their peak troponins were similar to the obvious STEMIs, ...
Source: Dr. Smith's ECG Blog - December 10, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

" Pay me now, or pay me later "
This patient presented with acute pulmonary edema without chest pain.A bit of history prior to showing the ECG:The patient had been hospitalized at a different hospital for pneumonia and NonSTEMI for a week. The troponin I had peaked at 40 ng/mL, and echo showed multiple wall motion abnormalities and EF of 35%.  The patient suffered third degree heart block with bradycardia and required permanent pacemaker placement.  A troponin that high is usually associated with Occlusion.I reviewed the ECGs from that hospital and they donot show OMI.  But many ECGs in patients with OMI do not reveal the OMI, even when I ...
Source: Dr. Smith's ECG Blog - December 10, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Abbott High Sensitivity Troponin Algorithm at Hennepin Healthcare
To see the full lecture with the data, click hereAlgorithmRule Out MIRule In MI (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - December 8, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

The Diagnosis of OMI does not depend on the ECG. But if you recognize it, that's great.
An elderly woman presented with 4 days of waxing and waning epigastric/substernal chest pain, worse on the day she presented.  She described the pain as a constant chest pressure, 6/10, without radiation to left arm, jaw or back, and without change in with breathing or movement.Here is her ED ECG:This was read as non-specific.  What do you think?I found this case while looking through a stack of ECGs, without clinical information.  I immediately thought " Acute LAD occlusion. "  Why?  There are QS-waves in V2-V4.  These suggest old anterior MI, or subacute MI.  But as ...
Source: Dr. Smith's ECG Blog - December 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 49 year old man with chest pain. Is it OMI? is it pseudonormalization?
Written by Pendell Meyers Before we get to the whole case, let's interpret this ECG without any other context except to say that this is a 49 year old man with acute onset chest pain:What do you think? This will be called " ECG2 " .Here is the whole case:A 49 year old man with no medical history presented with acute onset chest discomfort for several hours which improved to 2/10 severity at the time of arrival to the emergency department. Here is his triage ECG (ECG1) at 1750:What do you think? Form your opinion, then see the baseline ECG below and see if your opinion changes.A baseline ECG was availabl...
Source: Dr. Smith's ECG Blog - December 4, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

The cardiologist disagreed with cath lab activation. What do you think?
This was sent by a reader who is obviously a very astute clinician.A middle aged male presented after 4 days of intermittent chest pressure which suddenly became worse and radiated down his left arm.  Here was his initial ECG:What do you think?The emergency physician recognized that the " inferior ST depression " was reciprocal to high lateral OMI (very subtle STE in aVL).  There is some minimal downsloping ST depression in V3 and V4, further confirming the diagnosis.She activated the cath lab at the referral institution (she is at a smaller hospital without a cath lab).The patient suddenly had muc...
Source: Dr. Smith's ECG Blog - December 2, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Lecture on Head Up CPR by the Expert: Johanna Moore
 https://drive.google.com/file/d/17HKyT2l0_AmjvGlegXZA6u2x14LIJPER/view (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - December 1, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 40s with acute chest pain
Case written by Neha Ray MD, Brandon Fetterolf MD, and Pendell Meyers MDA woman in her 40s with a history of rheumatoid arthritis, anemia, and thrombocytopenia presented to the ED with acute onset chest pain starting around 5am on the morning of presentation.  It woke her from sleep. The chest pain was midsternal, severe, sharp, and constant. On the previous night she had had a mild version of the same pain that she thought was heartburn (esophageal reflux). She reported some radiation to the left arm. She also reports 3 episodes of non-bloody vomiting over the course of the morning. She had a recent admission fo...
Source: Dr. Smith's ECG Blog - November 29, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain, ST Depression maximal in V2-V4, and a Blood Pressure of 238/118.
A Middle-aged male had sudden onset severe substernal chest pain that woke him from sleep.His BP was 238/118 on arrival.Here is his first ED ECG:What do you think?There is ST depression maximal in V2-V4, which normally would be all but diagnostic for posterior MI. However, the extremely elevated BP makes it likely thatthis STD is really subendocardial ischemia from high oxygen demand.  (There are also incidentally large U-waves -- the K was 4.1).It is best to first manage the BP and then repeat the ECG.So the physician did just that.  He obtained a chest CT to rule out aortic dissection (which was negative)....
Source: Dr. Smith's ECG Blog - November 27, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Barcelona Rule on Left Bundle Branch Block: Lots of Issues.
ConclusionDespite the profound methodological flaws, there may be utility of some  components of the Barcelona algorithm vs. those of the MSC. If such individual components are confirmed by external validation studies, perhaps a rule with better overall performance could be formulated. Most importantly, we must understand that no ECG rule will likely ever identify all AMI in either LBBB or normal conduction, and so seek to maximize the potential of the ECG to identify Occlusion MI.  References:1.   Di Marco, A.et al. New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infa...
Source: Dr. Smith's ECG Blog - November 25, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A Fall and a Rhythm to Recognize
CONCLUSION: The above bullets point out too many findings to be by chance. Therefore, these consistent relationships that are highly unlikely to be by chance tell us — there must be some type of conduction going on in this irregular, long-lead rhythm strip.PEARL #2: It is sometimes very helpful to “step back” a little bit from the tracing — to gain an overall perspective of the pattern of a complex rhythm. PROVE THIS to yourself. Go BACK to my unlabeled Figure-1— and take another look at th...
Source: Dr. Smith's ECG Blog - November 24, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

The resident made the diagnosis immediately. The faculty was not as certain.
This was sent by one of our G2 residents, working at a different hospital." A 50-something male with a history of hyperlipidemia but no known cardiac history woke up with sudden onset substernal pressure and nausea/vomiting and diaphoresis. "EMS recorded this ECG: What do you think?" The medics were concerned by the story and they saw some ST Depression in the inferior leads and so they gave ASA and nitro with some relief. On arrival to ED we got a 12-lead ECG and looked at the prehospital EKG. " Here is that first ED ECG:Resident: " My interpretation was STD in II, III, and aVF with...
Source: Dr. Smith's ECG Blog - November 21, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Anterior ST Elevation and a Finding that was Overlooked
===================================MY Comment by KEN GRAUER, MD (11/19/2020):===================================I ’d like to revisit one of Dr. Smith’s ECG Blog posts from 2012 for 2 Reasons:Reason #1: It highlights the challenge of assessing anterior ST elevation in a certain type of patient.Reason #2: There is one more easy-to-overlook but important finding on the ECG that was not initially detected.TAKE a LOOK at the ECG in Figure-1. This is the initial tracing from this patient who presented to the ED with new chest pain and dys...
Source: Dr. Smith's ECG Blog - November 19, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

A woman in her 60s with VFib arrest and no STEMI on her post-ROSC ECG.
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 didnot 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: only 22 of...
Source: Dr. Smith's ECG Blog - November 17, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A Covid patient with cough and Fever. Why does the ST-T wave look so abnormal?
I was reading through a stack of ECGs and saw this one.  What is going on here?At first glance, it looks like a low atrial rhythm, with a negative P-wave in inferior leads.  There appear to be inferior QS-waves and and intraventricular conduction delay (computer measure QRS at 120 ms).There appear to be very strange down up T-waves.On closer inspection, the P-wave in V1 appears biphasic, which should not happen in a low atrial rhythm.Then we see that there is another P-wave inbetween, superimposed on the T-wave, in V1.Then we see that in lead II, the negative P-waves have another negative P-wave between...
Source: Dr. Smith's ECG Blog - November 15, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Extreme shock and cardiac arrest in COVID patient
This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED.  He was moderately hypoxic.  He had the following EKG recorded:Low voltage, suggests effusion.(see Ken's discussion of low voltage below)There is a QS-wave in V2.There is minimal, probably normal STE in V2-V6.A bedside cardiac ultrasound was normal, with no effusion. He had troponins ordered, and the first returned at 72 ng/L (Abbott Architect hs cTnI; URL for males = 34 ng/L).  An elevated troponin in a COVID patient confers about 4x the risk of mortality than a normal one.He was admitted on oxygen and was&nb...
Source: Dr. Smith's ECG Blog - November 12, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 30-something Man with Chest Pain and this ECG
 ===================================MY Comment by KEN GRAUER, MD (11/10/2020):===================================A 30-something man presented in agony holding his chest. He thought the pain was due to esophageal reflux. The patient ’s initial ECG in the ED is shown in Figure-1.The rhythm is sinus. There appears to be ST elevation in each of the inferior leads. (The computer interpretation said, " Marked ST elevation; Consider inferior Injury " ...).QUESTION: Would YOU activate the cath lab? Figure-1: The initial ECG in this...
Source: Dr. Smith's ECG Blog - November 10, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs

This skill can be taught and learned
 I was texted this ECG by a former resident, who just just graduated (there are 2 images of thesame ECG, as they are not of high quality):What do you think?It came with the message: " Thanks for the good training, Steve! "I responded: " Sweet!  This would have been missed by almost anyone. "  It is diagnostic ofLADOMI (but not STEMI!). OMI= Occlusion Myocardial Infarction.This physician said he had been handed the ECG just before starting a shift, while being told it is a woman with chest pain, and he immediately activated the cath lab based on just that information + the ECG.As...
Source: Dr. Smith's ECG Blog - November 8, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Deepening T-wave inversion one week after STEMI. Is it new Ischemia/infarction?
I (Smith) was asked to look at this ECG (ECG-4).  What do you think?I said there is an inferior and lateral myocardial infarction, with Q-waves, and it is recent.They added some history: the patient had a STEMI 1 week ago.They then showed me the most recent previous ECG (ECG-3), recorded 1 day after intervention for that inferior STEMI.  They were worried that the T-waves were much deeper inECG-4 than inECG-3, and that this was therefore evidence of recurrent MI.ECG-3The T-waves are inverted in II, III, and aVF, as well as V4-V6.They are less deep than in ECG-1Notice also that the T-wave in V2 is larger on E...
Source: Dr. Smith's ECG Blog - November 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Fatigue and Weakness and a computer interpretation of STEMI
This case was sent by David Carroll, a 2nd year EM resident, and his attending physician Brad Caloia.A 60-something male presented to the ED with weakness and fatigue.  He was diagnosed with a viral syndrome anddischarged.  He returned later and had a lab and ECG workup.  He had no cardiac history.  There was no chest pain or shortness of breath.Here is his ECG:The computer interpretation:Rate: 93 | PR 146 | QRSD 112 | QT/QTc(Bazett) 353/439Normal sinus rhythmAnterolateral infarct, acute / ***ACUTE MI*** What do you think?Dr. Carroll astutely realized something was amiss: what is it?There...
Source: Dr. Smith's ECG Blog - October 30, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

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