A 30-something with Chest pain, elevated troponin, with Subtle ST Elevation and hyperacute T-waves.
A 30-something male presented in the middle of the night with several hours of sharp, non-radiating, left sided chest pain.  It was there earlier, went away, and then returned approximately 1 hour prior to arrival. He is a smoker and has some family history of early MI.  Exam and vital signs were normal.Here was the triage ECG:There appears to be diffuse ST Elevation (II, III, aVF with reciprocal STD in aVL, V3-V6, and lead I, with T-waves that appear to be hyperacute (broad and fat, but on the other hand they have no straightening of the ST segment).  ST depression and T-wave inversion in V2 sugge...
Source: Dr. Smith's ECG Blog - May 24, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?
Written by Jesse McLaren, with comments by Smith and Grauer Four patients presented with cardiorespiratory symptoms, with inferior ST elevation and reciprocal change on their ECG. Which patient had occlusion MI?  Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. First let ’s start with each ECG without clinical context. What do you think of each ECG? ECG 1: ECG 2:ECG 3:ECG 4:Now let ’s introduce some clinical context. How would this change management? Patient 1: 30 year old previously healthy, presenting with syncope, now asymptomatic with n...
Source: Dr. Smith's ECG Blog - May 23, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

Chest pain, shortness of breath, T wave inversion, and rising troponin in a young healthy runner.
In this study, 40 presumably healthy male marathon runners had their cardiac troponin and other findings measured before and after running a marathon. 39 pts (97.5%) had baseline cTnT values below the reference limit (less than 14 ng/L). 38 pts (95%) of participants had post-marathon cTnT concentration rise above this reference limit. The median post-marathon cTnT was 41 ng/L, and the 95th percentile concentration was 90 ng/L. None reported " cardiac symptoms " after the race.See this single post for many examples of BTWI:Understanding this pathognomonic ECG would have greatly benefitted the patient.More cases involving BT...
Source: Dr. Smith's ECG Blog - May 19, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

A 30-something with palpitations and lightheadedness
A 30-something male without any significant past medical history presented with palpitations and presyncope.Here is his ED ECG:Regular Wide Complex Tachycardia at a rate of 229First: What do you want to do?Next: What do you think is the ECG diagnosis?First. Before getting into analysis, a regular wide complex tachycardia could be 1. ventricular tachycardia (VT) or 2. AV reciprocating tachycardia (AVRT, antidromic WPW) or 3.SVT with aberrancy.  (SVT would usually be AVNRT or orthodromic WPW)Sinceadenosineis safe in VT, and it works for AVRT and AVNRT, it is worthwhile trying adenosine.  Or, of cours...
Source: Dr. Smith's ECG Blog - May 14, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

Quiz post - which of these, if any, are OMI? What is the South African Flag Sign? Will you activate the cath lab? Can you tell the difference on ECG?
 Written by Pendell Meyers, additions and edits by Grauer, Smith, McLarenBelow we have 5 cases of adults (ranging from 40-70 years old) who all presented to the ED with acute nontraumatic chest pain that sounded at least somewhat like potential ACS to the provider. You should look at each ECG and decide if it is OMI, not OMI, or something else.Our goal in this post is to compare and contrast OMIs with false positives that mimic them. In this post we will examine the anterolateral distribution that has been described as the " South African Flag Sign. " (SAFS)It is very hard to describe why an ECG expert can easily...
Source: Dr. Smith's ECG Blog - May 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Unstable Angina Still Exists in Era of high sensitivity troponin, with a short lesson on troponin interpretation
42 y.o. male with no past medical history presented for chest pain of onset 2 weeks prior.  It is not constant, but lasts only a couple minutes.  It is substernal without radiation, and is associated with SOB.  Onset of chest pain was 2 weeks.  States it is not constant. He has PMH of HTN, hyperlidemia, DM2, 1/3 ppd smoking (4 risk factors).A few days prior, his chest pain was intense and lasted about 10 minutes and it made him sweat. On the day of presentation, he was walking to the ED from the parking lot and the chest pain recurred and lasted about 2 minutes.  Here is his ED ECG:T...
Source: Dr. Smith's ECG Blog - May 8, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?
Submitted and written byDestiny Folk MD, peer reviewed by Meyers, Smith, Grauer, McLarenA man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. EMS arrived and found him awake and alert. He complained of generalized weakness and left lower extremity numbness. He reported that 12 hours prior to arrival he used fentanyl and cocaine. He reported difficulty walking and felt as if his left leg was “asleep.” He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. On arrival in the ED, he wa...
Source: Dr. Smith's ECG Blog - May 5, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Why is there inferior ST elevation, and would you get posterior leads?
Written by Jesse McLaren, with comments by Smith and Grauer A 75 year-old presented with 8 hours of epigastric pain and one episode of vomiting. They had a history of gallstones but no cardiac history. Vitals were normal except a heart rate of 55, and below is the triage ECG.What do you think?There ’s bradycardia but it is not sinus: while the P wave is upright in I it is inverted in II so it is a low atrial rhythm. Conduction is otherwise normal, axis is indeterminate, and voltages are normal. There is early R wave progression with R>S in V1-2, primary ST depression in V2-3, and a Q wave with hyperacute T wave i...
Source: Dr. Smith's ECG Blog - May 3, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

A man in his 40s who really needs you to understand his ECG
 Written by Pendell MeyersA man in his 40s presented for " left sided chest pain sudden onset yesterday when sneezing and coughing that is worsened with inspiration. " He also complained of associated SOB, dizziness, jaw pain, and back pain, which he described as " muscle spasms. " He has also had rhinorrhea and cough for 1 week. Also, left hand numbness today. He went to urgent care for evaluation. An ECG was performed there (unavailable) which reportedly was abnormal, so EMS was called to urgent care to take him to the ED.On EMS arrival, they noted the patient vomited then became unresponsive. He was reportedly...
Source: Dr. Smith's ECG Blog - May 1, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

A man in his 40s with RUQ abdominal pain
Conclusion:In hemodynamically stable patients with chest pain, sinus tachycardia aids in the identification of patients unlikely to have type I MI, especially in those with HR greater than 120 bpm.===================================MY Comment by KEN GRAUER, MD (4/28/2020):===================================Insightful case presented by Drs. Goss and Meyers highlighting the importance of recognizing the ECG signs of acute PE. I focus my comments on further dissecting some of these " tell-tale " ECG features.The " theme " of today ' s case was "pattern recognition". Like the ECG diagnos...
Source: Dr. Smith's ECG Blog - April 28, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

RBBB and LAFB: Is there a " concordance " of the ST segment in inferior leads? Is the ST depression in V3 due to RBBB only?
Conclusion:There was indeed OMI of a very small vessel.  It may have been due to an embolism.  No matter the etiology, it did manifest on the ECG and was easily, but mistakenly, attributed to RBBB and high voltage.Learning Points:1.  ST depression is only normal following an R ' -wave in V1-V3.  If there is no R ' -wave, then ST depression should be considered ischemic.2.  Make sure you identify the end of the QRS in any BBB before attributing deviations to the ST segment.3.  Always compare with a previous ECG if one is available.===================================Comment by KEN GRAU...
Source: Dr. Smith's ECG Blog - April 26, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

A woman in her 60s with palpitations
Conclusion:The final tracing in Today ' s Case was obtained the day after the run of ATach that was caught on Telemetry. I found it interesting to compare this last ECG #4  — with the post-cardioversion ECG #2  — and then with QRS morphology in selected leads during full preexcitation that was seen in ECG #1 (these 3 tracings put together in Figure-4):Sinus rhythm is again present in ECG #4 (RED arrows in lead II). However, the PR interval is short — and delta waves are seen.Compared to ECG #2  — there is more preexcitation in...
Source: Dr. Smith's ECG Blog - April 24, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain, a ‘normal’ ECG, a'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.
Written by Jesse McLaren, with comments from Smith and GrauerA 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. ECG was labeled ‘normal’ by the computer (confirmed by the overreading cardiologist) and the high-sensitivity Troponin I was normal at a value of 11 ng/L (Abbott Alinity assay, where normal is<26 in males,<16 in females; this assay is nearly identical to the Abbott Architect high sensitivity assay). So the patient was low risk according to HEART and EDACS scores. Should this patient be discharged home? How about a stress test?   ...
Source: Dr. Smith's ECG Blog - April 22, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

What do you think when you see ST elevation or ST depression on the monitor? (A lesson on High Pass filtering from Christopher Watford)
This has an explanation fromChristopher Watford, who is not only a paramedic with amazing EKG skills, but a math and computer wizard. @ECGWatford  https://twitter.com/ecgwatford This patient was on a monitor, which showed this:The upper tracing is analogous to V5The lower is analogous to V1What do you think?The ST depression here is about 30% of the height of the R-wave.  The ST Elevation is about 30% of the depth of the S-waveI wanted to show the residents how poorly this correlates with a 12-lead ECG, so we recorded one at the same time:The STE in V1 is less than 10% of the S-waveThe STD in V5 is...
Source: Dr. Smith's ECG Blog - April 20, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

What is this ST Elevation?
This patient was sent to the ED because of a potassium of 6.1 mEq/L and some acute renal insufficiency.He had an ECG recorded:This was brought to me for analysis.  The computer read " Septal Myocardial Infarction "What do you think?There is saddleback ST Elevation and Q-waves in leads V1 and V2.  Whenever I see a saddleback, or Q-waves in V1, V2, I look to see if the leads were placed too high.  How would I know?  By looking at the P-wave in lead V2, which should always be upright. Furthermore, the P-wave in lead V1 should almost always be biphasic up-down.  In this ECG, the P-wave i...
Source: Dr. Smith's ECG Blog - April 17, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs