Off and on chest pain for 24 hours in a 50s year old man
Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell MeyersA man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath. His pain was initially mild, then became severely worse several hours prior to presentation, but then eased off again and was minimal on arrival. There was no associated diaphoresis, nausea, vomiting, arm pain, jaw pain, syncope, lightheadedness or other acute symptoms.Initial vitals: Temp 36.7 C, BP 161/79, RR...
Source: Dr. Smith's ECG Blog - April 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
The OMI Quizzes
There are 4 quizzes here on OMI ECG diagnosis:BeginnerNoviceIntermediateAdvancedThe first link on the page is to an ECG guide as a primer on OMI ECG diagnosis.These quizzes were written by Gregory Yates (an " FY 2 doctor " in the UK), Maddy Kahle (who is just finishing her 4th year of medical school at the U of MN), and aided by Romi Lee (another U of MN med student).All quizzes were of course reviewed by Smith and Meyers.Here is the Page:http://www.getthegas.co.uk/quiz/ecg/You can also sign up to get thePM Cardio OMI app. It is AI that was trained by Pendell and Smith to diagnose OMI on the ECG. It is pr...
Source: Dr. Smith's ECG Blog - April 7, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
RBBB and LAFB. Is it trifascicular block? The complexities of Wenckebach, with Ken Grauer analysis.
This patient presented with complications of his dialysis fistula.Medical history:History of Ischemic Heart DiseaseHistory of Congestive Heart FailureDiabetes Mellitus requiring treatment with insulinPre-operative serum creatinine>2 mg/dLHe had this ECG recorded:What do you think?There is AV 2nd degree AV Block (Mobitz I, Wenckebach) with RBBB and LAFBThe physicians recognized the RBBB and LAFB, but not the Wenckebach. They compared to a previous ECG and thought they were identical. Here is the previous ECG from 2 months prior for pre-op for cataract surgeryThis appears to be atrial fibrillation with RBB...
Source: Dr. Smith's ECG Blog - April 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
70-year-old with acute chest pain, STEMI negative: just an old infarct?
Submitted by Dr. Dennis Cho (@DennisCho),
written by Jesse McLaren A 70-year-old with no cardiac history
presented with 2 hours of chest pain radiating to the neck, associated with
shortness of breath. What do you think?There ’s normal sinus rhythm, first-degree
AV block, normal axis and voltages. R wave progression is abnormal: there are Q
waves in aVL/V2-3 and loss of R wave in V2. This is accompanied by minimal ST
elevation in aVL/V1-V2 and more pronounced inferior reciprocal ST depression, and minimal ST depression V5-6.
This is diagnostic of OMI, either proximal LAD or first diagonal. Q wave, old
infarct?B...
Source: Dr. Smith's ECG Blog - April 4, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
I was reading EKGs on the system and came across this one......
I am always looking for EKGs that show either subtle OMI or OMI mimics.Which did I think this was?I suspected that this was amimic. It is hard to say why. There is " inferior " ST depression, reciprocal to high lateral ST Elevation. The precordial leads have ST Elevation but also high voltage and look like possible LVH. I was not certain that it did not represent OMI, but was pretty sure.So I went to the chart and found that it was not different from previous ECGs and the patient ruled out for MI by serial troponins.This is a very difficult ECG and so I wanted to know how the PM Cardio Bot would per...
Source: Dr. Smith's ECG Blog - April 2, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 50-something with chest pain. what to do? And get the PM Cardio app for your own use here!
This was sent to me by a friend.It is from a 50-something with chest pain:What do you think?This was marked as " Not a STEMI " by the physicians. It is not a STEMI, but it isdiagnostic of an LAD OMI (Occlusion MI). There is subtle ST Elevation in V1-V4 and hyperacute T-waves in V2-V6.There is also subtle but diagnostic INFERIOR ST Elevation, with reciprocal ST Depression in aVL.I uploaded this to our new PM Cardio AI Bot app. We call the app the " Queen of Hearts "First, it transforms it to a digital file and standardizes the image. Here is the result:Next, it interprets the digital data:A...
Source: Dr. Smith's ECG Blog - March 31, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Is this Rhythm Puzzling to You?
==================================My Comment by KEN GRAUER, MD (3/30/2023):==================================The ECG in Figure-1 was sent to me without the benefit of any history. I thought the rhythm illustrated a number of essential concepts for clinicians dedicated to Emergency Care.Do YOU know what the rhythm is?IF this arrhythmia is puzzling to you — READ ON! I illustrate how to make the diagnosis within less than 15 seconds.Figure-1: The initial ECG in today ' s case. This tracing was sent to me without the benefit of any history. ...
Source: Dr. Smith's ECG Blog - March 30, 2023 Category: Cardiology Authors: ECG Interpretation Source Type: blogs
A 40-something with 100 minutes of chest pain
I was reading ECGs on the system, and saw this one:What do you think?I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI.However, it is difficult to recognize for an interpreter who is does not have special expertise in OMI ECG diagnosis. We taught an AI system fromPM Cardio to recognize patterns of subtle OMI (beware: this version of the app is not available to the public yet). We named the AI app the " Queen of Hearts " This is what the Queen said about this ECG:" OMI with High Confid...
Source: Dr. Smith's ECG Blog - March 27, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
85 year old with chest pain, STEMI negative, then normal troponin but with relatively large delta: discharge?
Conclusion:This patient should NEVER have been ruled out by troponin.And the ECG findings, which are diagnostic of OMI, were also missed.Thus, this is the protocol Fred Apple and I developed for Hennepin for the Abbott Architect:==================================My Comment by KEN GRAUER, MD (3/24/2023):==================================I like this case by Dr. McLaren — because it allows us to highlight a very important fault of the outdated STEMI paradigm that is all-too-often forgotten — namely, Being sure to obtain and clinically correlate at least 2 serial ECGs&...
Source: Dr. Smith's ECG Blog - March 24, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Watch what happens when you teach others how to find OMI
Submitted by Dr. Caio Aguiar from Brazil, written by Pendell MeyersIt is immensely rewarding to receive these emails, like I received from Dr. Aguiar last week:" Last year I had a couple of lessons with you while on my internship.I finished my residency of Emergency Medicine and I ’m working at a great Emergency Department here in Brazil.Since then, I started looking for OMI EKG findings and not just STEMI.So, I ' m a follower of your blog, and I think I have a interesting case that I attended yesterday. "Case" Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Risk Factors: High Cholesterol. Vitals S...
Source: Dr. Smith's ECG Blog - March 21, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A 50-Something Male with 2 hours of Chest discomfort
This ECG was texted to me in real time, but I did not notice the message until about an hour after it came. " 50 + yo. Concerning history, known CAD "Recorded 2 hours after pain onset:What do you think?This was my response:" This looks like a worrisome EKG. It looks like an Occlusion MI (OMI), but I am not 100% certain. But by now you must have a repeat ECG. Can I see it? "Pendell Meyers had an identical response when I sent it to him.PM Cardio AI algorithm said " OMI with high confidence "Explanation: There is subtle ST Elevation in inferior leads, with a hyperacute T-wave in III, reciprocal STD in aVL with an ...
Source: Dr. Smith's ECG Blog - March 19, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 50s with chest pain and dyspnea
Submitted by anonymous, written by Pendell MeyersA woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. She had a prior history of " NSTEMI " one month ago, during which she had a coronary angiogram reportedly showing no stenosis in any coronary artery. Her vitals were within normal limits.Here is her triage ECG:PM Cardio Version (see original screenshot I received below)Original image. What do you think?Here is the prior ECG on file (from 1 month ago, when she was having " NSTEMI " with high sensitivity troponin peaking at 200 ng/L):What...
Source: Dr. Smith's ECG Blog - March 17, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?
Conclusions.The efficacy of transthoracic cardioversion for converting atrial fibrillation to sinus rhythm was enhanced by pretreatment with ibutilide. However, use of this drug should be avoided in patients with very low ejection fractions. (N Engl J Med 1999;340:1849-54.) Smith comments from the full text: They included patients who had had a fib for less than 48 hours They excluded patients with a fib for longer than 48 hours unless they proved, by TE echo, to not have an atrial thrombus OR unless they anti-coagulated them for 3 weeks first *Therefore, our patients who have been in afib< 48 hours, or who h...
Source: Dr. Smith's ECG Blog - March 13, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Severe Chest Pain on ED Arrival, after Wellens' waves Seen on Prehospital ECG
A 40-something woman called 911 in the middle of the night for Chest pain that was intermittent. On arrival, she complained of severe pain.The medics had recorded this ECG and were uncertain whether it was recorded during chest pain:Let ' s get a better image with use of thePM Cardio app:What do you think?There is deep T-wave inversion in proximal LAD territory (V2-V4, I, aVL) that is all but diagnostic of Wellens ' . This is acute ACS, but it almost always seen in a pain free state. Since the patient has active pain now, if this is indeed Wellens, ' she must be re-occluded at this moment. An ED...
Source: Dr. Smith's ECG Blog - March 13, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 50s with chest pain
Sent by anonymous, written by Pendell MeyersA man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. Vitals were within normal limits.Here is his triage ECG at 0343:What do you think?Meyers interpretation: Diagnostic of LAD OMI, with hyperacute T waves in a large LAD distribution including precord...
Source: Dr. Smith's ECG Blog - March 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
