Posterior leads can give false reassurance
A 40-something woman with diabetes and peripheral vascular disease who frequently needs the ED for chronic pain called 911 for sudden severe chest pain. The patient was very agitated and could not hold still.I greeted medics at the door to view the prehospital ECG.Here it is:It is not normal, but there is no specific evidence of Occlusion MI (OMI)There are some Q-waves in inferior and lateral leads (of uncertain age) and there is some " terminal QRS distortion " in inferior leads and V4-V6, but this finding may be present normally in these leads (it is NOT normal in lead V2/V3 in the presence of normal variant ST ele...
Source: Dr. Smith's ECG Blog - September 21, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
This ECG is nearly pathognomonic. What is it? (hint: it's not Wellens')
I was texted this ECG:What did I say?My response: " takotusubo "Even without a history, this is the likely diagnosis. Later, I obtained the history: 60-something woman who presented with agitation and had taken a benzodiazepine overdose. There was no report of chest pain. She had a respiratory alkalosis, with venous pH of 7.56 (equivalent to an arterial pH of higher than 7.60 and possibly contributing to the long QT and ECG abnormalities). Electrolytes were normal. She was also on Duloxetine, which can prolong the QT, and on Lithium (but her level was very low).This is almost certainly ta...
Source: Dr. Smith's ECG Blog - September 19, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain, peak troponin 100,000 ng/L and this ECG on discharge: what ’s the diagnosis?
Written by Jesse McLaren, with edits by Smith Usually cases are presented in chronological order the way they appear in real life. But this case will be represented in reverse chronological order. At each step we ’ll ask the question, “what’s the diagnosis?” using the STEMI paradigm (was this STEMI or NSTEMI?) and OMI paradigm (was this Occlusion MI or Non-Occlusion MI?). Discharge A 60 year old without prior cardiac history was admitted with chest pain, had a peak troponin of 100,000 ng/L (normal<16 in female and<26 in males), and was discharged with the following ECG (#4). What ’s the...
Source: Dr. Smith's ECG Blog - September 13, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 60s with chest pain and LBBB
Sent by Ali Khan MD, written by Pendell MeyersA man in his 60s with HTN, HLD, known prior LBBB, presented with episodes of chest pain radiating to the left shoulder, with diaphoresis and dyspnea. Episodes started yesterday after starting to exercise, came and went throughout the day, and he decided to present to the ED the next morning after the one of these episodes failed to resolve like the others.Here is his ECG at triage with ongoing pain (prior unavailable):Same image optimized by PM Cardio appWhat do you think?I sent this to Drs. Smith, McLaren, and Grauer all of whom immediately diagnosed LAD occlusion based ...
Source: Dr. Smith's ECG Blog - September 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Two patients with chest pain. Do either of them need emergent reperfusion? Both? Neither?
Written by Pendell MeyersHere is a quick comparison / quiz post. It will be easy for long time blog readers. The two ECGs below are both from middle aged patients with acute chest pain. Do either, neither, or both patients have an ECG diagnostic of OMI, warranting emergent reperfusion therapy?Patient #1:Patient #2:Distinguishing subtle OMI from normal variant ST elevation can be a difficult but important skill that is achieved through supervised pattern memorization and recognition. As in the cases above, the distinction CANNOT BE MADE BY AMOUNT OF MILLIMETERS. Patient #1 has a totally normal, normal variant ECG...
Source: Dr. Smith's ECG Blog - September 9, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Neuroprotective CPR by Keith Lurie at Florida EMS Webinar
This is leading edge cardiac arrest resuscitation.Neuroprotective CPR by Keith Lurie at Florida EMS Webinar (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - September 8, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Take part in the EDUCATE Trial.
Dear colleague, In collaboration with the Mayo Clinic, Washington University in St. Louis, and The EKG Guy, we have designed an ECG education study -- The EDUCATE Trial. This work is investigator-sponsored by GE Healthcare. In just a couple of weeks, this has grown to over a dozen other institutions and into an international opportunity. We are very grateful for all the support and excitement!With that said, on behalf of the EDUCATE trial investigators, we would like to invite you to join. We only have limited funding so it will be on a first come basis.WHAT YOU NEED ...
Source: Dr. Smith's ECG Blog - September 7, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Unstable Angina still exists. It can be missed especially high sensitivity troponin is not used. Sometimes you can catch it on the ECG.
A 50-something woman with H/o HTN, ESRD, CAD S/p complex PCI to ostial LAD and ramus (10/2020) and CABG x3 (LIMA to LAD, SVG to OM, SVG to ramus)She complained of intermittent episodes of substernal chest pain, radiating to left shoulder, lasting 2-3 minutes.This had been worked up before at another ED on 3 occasions for the same chest discomfort.--The 1st time, she was " ruled out " with a point of care (POC) troponin ＜0.03 ng/mL.--The 2nd time, she was " ruled out " again with a POC troponin ＜0.03 ng/mL.--The 3rd time, she " ruled out " with a laboratory-based 4th generation troponin at 0.018 ng/m...
Source: Dr. Smith's ECG Blog - September 5, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Acute chest pain and a bizarre ECG
Written by Pendell MeyersA middle aged adult presented with acute undifferentiated chest pain.Here is his ECG at triage:What do you think?I sent this ECG with no clinical information to Dr. McLaren, who replied simply " Artifact " . He is referring to an artifactual ECG pattern that corresponds with the cardiac cycle which is known as " arterial pulse tapping artifact. " See the discussion and links at the end of the post for more information, but this phenotype of ECG artifact is not yet well understood (to my knowledge). In some cases, it has been attributed to placement of an electrode near a pulsing anatomic...
Source: Dr. Smith's ECG Blog - August 26, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Very fast narrow complex tachycardia
A 50-something with h/o palpitations, chest pain, and EF of 40% (of unknown etiology) presented with chest pain.Blood pressure, perfusion, and mental status were normal. Patient was comfortable appearing. Here is his initial ED ECG:Narrow Complex Tachycardia at a rate of 217AModified Valsalva was attempted without success.Then 6 mg of adenosinewas given. There was a 2 second interruption, and then this rhythm strip was recorded: There is now a wide complex, with RBBB pattern. For unknown reason, the right bundle no longer repolarizes in time for the next beat. It is r...
Source: Dr. Smith's ECG Blog - August 23, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
60 year old with vomiting, diarrhea, and syncope: is this Wellens? Is this type 2 MI?
Written by Jesse McLaren, with edits/comments by Smith and Grauer A 60 year-old patient with diabetes and ESRD presented with 24 hours of vomiting, diarrhea, weakness and then a syncopal episode. Vitals: RR 18, sat 98%, HR 103, BP 124/71 and temp 38.0. Here ’s their ECG: is this Wellens? There ’s borderline sinus tach, normal conduction, normal axis, and low voltages in the limb leads. The anterior leads have loss of R waves, mild convex ST segments and primary T wave inversion. In the context of QS waves, T wave inversion indicates old or subacute infarct, or reperfusion after signif icant infarc...
Source: Dr. Smith's ECG Blog - August 19, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Does this ST Depression Maximal in V3 Represent Posterior OMI?
I saw this EKG when reading through the system:What do you think?This is what I wrote:ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSERIGHT AXIS DEVIATION [QRS AXIS> 100]RIGHT BUNDLE BRANCH BLOCK MARKED ST DEPRESSION, CONSIDER SUBENDOCARDIAL INJURY " Severe ischemia (STE in I and aVL with reciprocal STD in inferior leads; precordial STD precordial maximal in V3): subendocardial ischemia vs. acute coronary occlusion. Atrial fib may cause Occlusion mimic. "***ACUTE MI***(I allowed Acute MI to be in the report because I knew there would be an elevated troponin from ischemia, wh...
Source: Dr. Smith's ECG Blog - August 17, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 30s with several days of chest pain and an episode of altered mental status.
Written by Pendell Meyers, reviewed by Smith, Grauer, McLarenA woman in her early 30s with history of diabetes had 2-3 days of gradual onset nonradiating chest pain with associated nausea, malaise, and shortness of breath. Then she had an " abrupt change in her mental status and became more somnolent and less responsive " at home in front of her family. Her family called EMS, who found the patient awake and alert complaining of worsening chest pain compared to the prior few days.En route to the ED, they recorded this ECG and transmitted it, asking whether the cath lab should be activated:What do you think?There is sinus rh...
Source: Dr. Smith's ECG Blog - August 15, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Inferior ST Elevation and Hyperacute T-waves, but Patient is Pain Free. What is going on?
Conclusion — the 145 pts studied by de Zwaan, B är& Wellens in 1982 continue to provide clinical insight into the nature of Wellens ' Syndrome some 40 years after this manuscript was written. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - August 12, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 40s with multitrauma from motor vehicle collision
DiscussionThis is a case where clinical context is of vital importance, because the EKG manifestations of cardiac contusion are fairly unpredictable. Intramyocardial hemorrhage, edema, and necrosis of myocardial muscle cells are characteristics of cardiac contusion. All of these cause troponin elevation, making troponin a very specific marker for cardiac injury. It is suggested that a troponin that is within normal reference range at about 4-6 hours from the inciting event suggests strongly the absence of cardiac injury in blunt chest trauma (Sybrandy).The EKG is not generally sensitive for cardiac contusion. The right ven...
Source: Dr. Smith's ECG Blog - August 6, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
