A man in his early 40s with chest pain a " normal ECG " by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?
This study looked at less than 1000 cases, which is not nearly enough (see below for analysis) and they used cardiologists as the gold standard (a very poor gold standard), NOT presence or absence of Occlusion MI (which we have done in all of our ECG studies, and must be ascertained by 1) TIMI 0/2 flow on angiogram or 2) culprit + TIMI 3 flow and very high troponin. So this study is worthless and must be ignored. I have here 38 cases of " Computer Normal " ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized ...
Source: Dr. Smith's ECG Blog - May 23, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
An elderly patient with syncope, dyspnea, and weakness, but no Chest Pain, and mild hyperkalemia
An elderly patient had a fall from probable syncope, and could not get up. He complained of weakness and shortness of breath, but no CP. Vital signs were normal.Here is the first ED ECG:COMPUTER INTERPRETATION:Electronic Atrial Pacemaker. Marked ST Elevation, ***ACUTE MI***What do you think?First, the QRS is incredibly wide!You should ask for more history. Whenever a patient does not have chest pain, the pre-test probability of OMI is diminished. Of course SOB, jaw pain, shoulder pain, etc can be a result of OMI, but the pretest probability is less and so you must scrutinize fur...
Source: Dr. Smith's ECG Blog - May 21, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
45 yo with jaw pain radiating to left shoulder for 6 hours
This case was provided by Steven Souchtchenko, a recent graduate of our Hennepin Healthcare EM/IM residency (i.e., a former trainee of mine).CaseA 45 yo man with no previous cardiac history presented to an ED not associated with a cath lab. He complained of jaw pain radiating to left shoulder for 6 hours. He stated he had had a brief similar episode the evening prior.Here is his ED ECG.What do you think?When this was shown to me I immediately said " Proximal LAD OMI " . Then I ran it through theQueen of Hearts AI app and she said " OMI with high confidence " .I showed it to Pendell, who said: " Clear...
Source: Dr. Smith's ECG Blog - May 18, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his late 30s with acute chest pain and ST elevation
Sent by Dan Singer MD, written by Meyers, edits by SmithA man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Here is his triage ECG:What do you think?Dr. Singer sent this to me with just the information: " ~40 year old with acute chest pain " . I immediately responded: " cool fake! Not OMI. Do you have a prior? There is a reasonable chance of pericarditis in this case, or this could be a baseline. " It could easily be mistaken for a South African flag pattern anterolateral OMI, with STE in I, aVL, V2. But importantly there is no reciprocal STD in III (which would...
Source: Dr. Smith's ECG Blog - May 16, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
What is this strange looking ECG in a young woman?
I was reading EKGs on the system and saw this one,with no other information.What was my interpretation of these apparently abnormal precordial leads?Smith: Normal variant ST Elevation and T-wave inversion, probably in a young African American male.The Queen of Heart PM Cardio Bot also states: " Not OMI with High Confidence "Additionally, as Ken notes below, the limb leads are reversed.I later went into the chart:This was recorded in a young African American female with altered mental status (severe agitation) due to an unidentified intoxicant. She rapidly awoke and was discharged home. Electrolytes wer...
Source: Dr. Smith's ECG Blog - May 13, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day
This was sent by a colleague.A 34 yo woman with a history of HTN, h/o SVT s/p ablation 2006, and 5 months post-partum presented with intermittent central chest pain and SOB. She had one episode of pain the previous night and two additional episodes early on morning the morning she presented. Deep breaths are painful and symptoms come and go. She had one BP that was measured at 160/120, uncertain when and what the BP was at other moments. Home meds were labetalol and nifedipine. There are T-wave inversions in precordial leads. The patient is pain free, so it is qu...
Source: Dr. Smith's ECG Blog - May 10, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 70s with acute chest pain and paced rhythm.
Sent by Pete McKenna M.D. Edits by Meyers and SmithA man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain.Triage ECG:What do you think?This is diagnostic of proximal LAD occlusion. This is a huge anterolateral OMI. Deadly. I cannot be anything else.Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. There is concordant ST elevation in I, aVL with reciprocal concordant STD in inferior leads, as well as excessiv...
Source: Dr. Smith's ECG Blog - May 8, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
An Unusual Bradycardia
==================================Case Presentation by KEN GRAUER, MD (5/5/2023): — Edits by Drs. Meyers& Smith ...==================================Dr. Smith was reading ECGs — and he sent myself and Dr. Meyers the tracing shown in Figure-1. At the time we did not yet know the history ...What do YOU think?Figure-1: The initial ECG in today ' s case. No history yet ...Our Initial Thoughts on the ECG in Figure-1:Dr. Meyers said the following: " I see 2 different atrial foci — one sinus and one ectopic. There is AV block — but unclear why. T...
Source: Dr. Smith's ECG Blog - May 5, 2023 Category: Cardiology Authors: ECG Interpretation Source Type: blogs
A woman in her 60s with large T-waves. Are they hyperacute, hyperkalemic, or something else?
Case written by Brandon Friedman M.D., edits by MeyersA woman in her 60s with a history of chronic atrial fibrillation on Eliquis, ESRD on hemodialysis, type-II diabetes mellitus, prior CVA, hypertension, and hyperlipidemia presented to the emergency department with multiple complaints after missing dialysis. She described a feeling of general unwellness, diarrhea, right-sided abdominal pain, bilateral leg pain, bilateral leg swelling, and diffuse itching. She missed her last two dialysis appointments, with her last session occurring one week prior to presentation. On initial assessment, she was found to be tachycard...
Source: Dr. Smith's ECG Blog - May 1, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A 50-something with acute chest pain, a computer " Normal " ECG, and a HEART score of 3 (low risk)
A 50-something with no previous cardiac history and no risk factors presented to the ED with acute chest pain (pressure) that radiated to the left arm. An ECG was immediately recorded:Computer read: Normal ECGWhat do you think?There is ST depression in V1-V3. We showed that this isdiagnostic of OMI (of the posterior wall). Moreover, there is ST elevation in V6 (which is getting close to the location of posterior lead V7). Thre is also absence of S-wave in V6, which is not entirely abnormal, but is suggestive of OMI (when this finding is in V2 or V3 in the setting of STE in V2 or V3, we call...
Source: Dr. Smith's ECG Blog - April 29, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 20-something with intermittent then acute chest pain
This was sent to me by a partner:" Curious what you think of this one we had overnight. Healthy male under 25 years old with a pretty good story for acute onset crushing chest pain relieved with nitro. He had another episode the day before after exerting himself. No pericardial effusion on ultrasound. "What do you think?First, many on Twitter said " Pericarditis " . This is NOT pericarditis, which virtually NEVER has ST depression any where except aVR. When there is ST depression (as in aVL, V2, V3), then top on the differential is OMI or myocarditis.See our publication: ST depression in ...
Source: Dr. Smith's ECG Blog - April 25, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
50 year old with acute chest pain, with ‘normal’ ECG and falling troponin
Written by Jesse McLaren, with comments from SmithA 50-year old patient on the medical wards developed acute
chest pain, with an ECG labeled (see computer interpretation at the top) and confirmed as normal. What do you
think? There ’s normal sinus rhythm, normal conduction, normal axis,
normal R wave progression, and normal voltages. Lead aVL jumps out as abnormal
because there is a discordant T wave inversion and mild ST depression. This is reciprocal to inferior
mild ST elevation and hyperacute T waves (wide based, bulky, and symmetric, and in III taller than
the QRS complex), and adjacent to ST depression in...
Source: Dr. Smith's ECG Blog - April 21, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Compare these two ECGs. Do either, neither, or both show anything important?
One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve SmithTake a look at these two ECGs below from two patients in the ED, first without any clinical context. Full case details and outcomes are below.Case 1:Case 2: Case 1:What do you think?This was sent to Dr. Smith by SamGhali (@EM_RESUS) with zero other info. Smith ' s response was: " OMI Mimic. "Later, this info was supplied by Sam:This
ECG was recorded in a 23-year-old African American man with a history
of psychiatric illness, acute alcohol/drug intoxication, brought in by
police officers status post being ...
Source: Dr. Smith's ECG Blog - April 17, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 60s with acute chest pain and high voltage
Sent by Anonymous, written by Pendell MeyersA man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. There was associated diaphoresis, but no dyspnea, nausea, or vomiting. He reported having covid 2 weeks ago, but had seemingly fully recovered.Triage 1104:What do you think?The triage ECG was sent to me with no history (I did not have access to baseline ECGs), and I said that I thought this was just LVH causing the an...
Source: Dr. Smith's ECG Blog - April 14, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A 40-something woman with acute pulmonary edema -- see the Speckle Tracking echocardiogram.
A 49 year old woman with h/o COPD only presented with sudden dyspnea. She had acute pulmonary edema on exam. PrehospitalConventional algorithm interpretation: ANTERIOR INFARCT, STEMITransformed ECG by PM Cardio:PM Cardio AI Bot interpretation:OMI with High ConfidenceWhat do you think?There is STE and hyperacute T-waves in V2 and V3, with significant STE in I and aVL, and inferior reciprocal STD.This is proximal LAD Occlusion until proven otherwise.On arrival, lung ultrasound confirmed pulmonary edema (B lines). An ECG was recorded:ED ECG 1:The findings are still present but not nearly as profound now...
Source: Dr. Smith's ECG Blog - April 12, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
