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
What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.
If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation?This is a trick question, as you will see below. But you can make a diagnosis here, and Pendell and I do this all the time when reading ECGs from databases. I sent this to Pendell without any information at all, and he replied " Postero-lateral Reperfusion. "The T-waves in V2-V4appear hyperacute, suggesting LAD occlusion,BUT there is also T-wave inversion that is typical morphology forreperfusion in V5 and V6.Thus, one must think of reperfusion. When there is reperfusion and there are large T-waves in...
Source: Dr. Smith's ECG Blog - March 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 30-something with Chest pain and SOB
In conclusion, the presence of negative T waves in both leads III and V1 allows PE to be differentiated simply but accurately from ACS in patients with negative T waves in the precordial leads. "See this post for more detail on the ECG in pulmonary embolism. Still more cases are here.==================================My Comment by KEN GRAUER, MD (1/19/2023):==================================How good is the ECG for the diagnosis of acute PE? The answer is — it depends! Sometimes the ECG is excellent, in that it immediately tells you " high probability for massive acute PE ...
Source: Dr. Smith's ECG Blog - March 4, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Our OMI Toolbox Application is out now !
We are happy to announce that our " OMI Toolbox " application has just released and ready for your use. As myocardial infarction (MI) and many other diagnoses (for example left ventricular hypertrophy, prior MI etc.) can cause ST-segment elevation (STE) on electrocardiogram (ECG), the distinction between them may be hard and complicated. Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO). For this purpose, only one set of diagnostic or differentiating criteria (STEMI criteria) is not enough, therefore a bunch of different tools are needed to make a&nbs...
Source: Dr. Smith's ECG Blog - March 3, 2023 Category: Cardiology Authors: Emre Aslanger Source Type: blogs
Anaphylaxis, chest pain, and ST elevation in aVR
Sent by anonymous, written by Pendell MeyersA man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis. Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms.During active chest pain an ECG was recorded:Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF. R...
Source: Dr. Smith's ECG Blog - March 1, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
What are these hyperacute T waves, with STE and T-wave inversion in aVL, and STD in inferior leads?
I was reading EKGs on the system and came across this one:What do you think?This is diagnostic of hyperkalemia. HyperK can result in all sorts of pseudoSTEMI or pseudoOMI patterns, including ST elevation, ST depression, and large T-waves.These T-waves are tall but have a narrow base and a corresponding flat ST segment (see lead V4). Also, there are no definite P-waves and this is another result of hyperkalemia. In fact, sometimes the sinus node is working and acting as a pacemaker but no P waves are visible!! This is called sino-ventricular rhythm. See these 3 other posts of sinoventricu...
Source: Dr. Smith's ECG Blog - February 27, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 40s with epigastric pain and ST Elevation
Case submitted by Magnus Nossen MD, written by Pendell MeyersA previously healthy man in his 40s presented to the ED with epigastric abdominal pain off and on for several days. Vitals were within normal limits.It is unclear whether he had active pain at the time of the first ECG:What do you think?Here is PM Cardio ' s Queen of Hearts interpretation (AI ECG interpretation trained by Meyers, Smith, and PM Cardio team using thousands of cases and their outcomes):The output number ranges from 0 to 1, with numbers closer to zero meaning likely NOT OMI, and numbers closer to 1 meaning OMI. This result of 0.0002 is obviousl...
Source: Dr. Smith's ECG Blog - February 23, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, among other symptoms. What do you see?
This patient had many complaints including chest pain.The computer called this ***Acute STEMI***What do you think?STEMI never has a very short QT. This QT interval is 320 ms, with a QTc of around 350, depending on which correction formula you use. (There is Bazett, Fridericia, Hodges, Framingham and Rautaharju -- see here at mdcalc: https://www.mdcalc.com/calc/48/corrected-qt-interval-qtcIf the ST Elevation here were due to STEMI, it would be an LAD Occlusion. You can use myLAD Occlusion/Normal Variant STE formula on this. I did, and the result was the lowest value I have ever obtained (1...
Source: Dr. Smith's ECG Blog - February 17, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm
Conclusion: Millimeter-based STEMI criteria are not met in ECG #1. That said, in this patient with severe new chest pain — the overall ECG picture with ST-T wave abnormalities in 9/12 leads has to be considered (as stated by Dr. McLaren) — as " All concerning for acute LAD occlusion ". (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - February 13, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
What is going on in V2 and V3, with a troponin I rising to 1826 ng/L at 4 hours?
I was reading EKGs on the system before a shift, and saw this one:What do you think?I was worried that the ST depression and T-wave inversion in V2 and V3 might be posterior OMI. I went to the chart and found that the patient was a sepsis patient with hypotension and a K of 3.0. There was no chest pain. So I thought it probably is not posterior OMI and I just moved on and kept reading EKGs.Later, I was working in the ED and a patient was moved from a regular room to the critical care area due to recurrent hypotension. The patient was now under my care. In reviewing the case, I saw the ECG and ...
Source: Dr. Smith's ECG Blog - February 12, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
What is the ECG Diagnosis?
I came across this ECG while reading ECGs for Cardiologs in order to train the Cardiologs Deep Convolutional Neural Network. I don ' t have any clinical information or any other associated ECGs on this case, but wanted to post it here because it is interesting and it ispathognomonic.What is it?This is a proximal LAD Occlusion. First, there are hyperacute T-waves in V2-V4. These are preceded by ST depression and are de Winter ' s T-waves, though somewhat atypical. There is also a hyperacute T-wave in aVL with subtle STE. There is reciprocal ST depression in II, III, and aVF: it is more vis...
Source: Dr. Smith's ECG Blog - February 10, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 60s with acute chest pain
Sent by anonymous, written by Pendell MeyersA man in his 60s presented with acute chest pain with diaphoresis. He had received aspirin and nitroglycerin by EMS, with some improvement. His vitals were within normal limits. Here is his triage ECG:2045:What do you think?The ECG is subtle, but diagnostic of infero-posterior OMI. The QRS is normal, yet in aVL the normal upright small QRS complex is followed by in appropriately large-volume T wave inversion, which is reciprocal to the T waves in lead III, which are probably hyperacute if compared to available baseline. Corroborating this is the subtle ST depression in V2-V3 whic...
Source: Dr. Smith's ECG Blog - February 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
This patient did not present with chest pain
This was posted a few years ago. I ' m highlighting it again, with comments from Ken Grauer below.This was sent to me by Jason Winter. @JasonWinterECGThis is a 36 yo m with h/o TBI and epilepsy. He had a seizure this morning and rolled out of bed unable to get up. There were no injuries and no chest pain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. The medics recorded a prehospital ECG: The computerized QTc is 397 msJason writes: "What ' s your thoughts Steve? "Jason was very skeptical of STEMI.What do you think?Jason,I agree.V4 especially looks li...
Source: Dr. Smith's ECG Blog - February 4, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Dueling OMI: does this 30 year old with chest pain have any signs of occlusion or reperfusion?
Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. Below is ECG #1 at triage. Are there any signs of occlusion or reperfusion?There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages. There’s mild inferior ST elevation in III that doesn’t meet STEMI criteria, but it’s associated with ST depression in aVL and V2 that makes itdiagnostic of infero-posterior Occlusion MI (from either RCA or circumflex) – accomp...
Source: Dr. Smith's ECG Blog - January 29, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
