Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?
This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG. The fact that not a single one of these patients had ACS shows that the population studied could not possibly support their conclusion. It should never have been published.According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion.This is obviously unreliable
data, as Dr. Smith ’s Blog has published51
cases of OMI with ECGs labeled ‘normal’, 35 of which were identified by the
Queen ...
Source: Dr. Smith's ECG Blog - March 14, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 40s with 3 days of stuttering chest pain
Written byWilly FrickA man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:What do you...
Source: Dr. Smith's ECG Blog - March 13, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Acute chest pain and ST Elevation. CT done to look for aortic dissection.....
Written byWilly FrickA 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. He had associated nausea, vomiting, and dyspnea.What do you think?This ECG together with these symptoms is certainly concerning for OMI, but the ECG is not fully diagnostic, and another consideration could be acute pericarditis. Mistaking OMI for pericarditis is a much more harmful error than the converse. Still, in the interest of studying the ECG, here are some findings that could support pericarditis:Absence of large T-waves (flat ST segments)Absence of any STD in aVL (which is s...
Source: Dr. Smith's ECG Blog - March 9, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart. A case of irregular accelerated idioventricular rhythm (AIVR)
A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this? There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex. It is irregular. It is not fast (cannot be VT). There is no atrial activity to suggest atrial fibrillation. There are whatcould be interpreted as delta wavesif, and only if, th...
Source: Dr. Smith's ECG Blog - March 7, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart
A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this? There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex. It is irregular. It is not fast (cannot be VT). There is no atrial activity to suggest atrial fibrillation. There are whatcould be interpreted as delta wavesif, and only if, th...
Source: Dr. Smith's ECG Blog - March 7, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
When the conventional algorithm diagnoses the ECG as COMPLETELY NORMAL, but there is in fact OMI, what does the Queen of Hearts PM Cardio AI app say? (with 10 case examples)
Conclusions Need Scrutiny.Proximal LAD Occlusion with STE in I and aVL, and hyperacute T-waves in V2-V6.Algorithm: Marquette 12 SL (GE)The Queen gets it rightCase 9 (prehospital and ED ECGs). Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story. 30 yo woman with trapezius pain. HEART Pathway = 0. Computer " Normal " ECG. Reality: ECG is Diagnostic of LAD Occlusion.Prehospital ECG:There are hyperacute T-waves in V3-V5.The Queen gets it rightFirst ED ECG:Hyperacute T-waves persist. Called normal again! Algorithm: Veritas (on Mortara...
Source: Dr. Smith's ECG Blog - March 4, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
" Seizure " in a 60 year old male
This 60 yo male had an apparent tonic clonic seizure. He had no history of seizures. He was unconscious for 8 minutes and slowly awoke in the ambulance, complaining of nausea only. First responders found him to bevery tachycardic, confused, perserverating and with no memory of the event. There was tongue biting. Lightheadedness continued.The tachycardia was gone by the time paramedics arrived.He had a prehospital ECG:What do you think?Interpretation. There is terminal T-wave inversion in V2, highly suggestive of Wellens ' pattern. But syncope or seizure alone, without chest pain, i...
Source: Dr. Smith's ECG Blog - March 1, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
How will you save this critically ill patient? A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.
Written by Pendell MeyersA woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. An ECG was performed:What do you think?Extremely wide complex monomorphic rhythm just over 100 bpm. The QRS is so wide andsinusoidal that the only real possibilities left are hyperkalemia or Na channel blockade. Hyperkalemia is by far more common.Indeed, further history revealed two missed dialysis sessions. And of course on exam she has a dialysis fistula.EMS reportedly gave 4 grams of calcium (unknown w...
Source: Dr. Smith's ECG Blog - February 22, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
Tachycardia and hyperkalemia. What will happen after therapy with 1 gram of Ca gluconate and some bicarbonate?
A 20-something type, 1 diabetic presented by EMS with altered mental status. Blood pressure was 117/80, pulse 161, Resp 45, SpO2 100 on oxygen.Here is the 12-lead ECG:Wide complex tachycardiaWhat do you think?The providers thought that this wide QRS was purely due to (severe) hyperkalemia. They treated with 4 ampules (200 mL) of bicarb and 1 gram of calcium gluconate. Note: 1 g of calcium gluconate is insufficient. 1 g of calcium chloride has 3x as much calcium and is indeed a good start.His pulse on the monitor suddenly went down to 140 and another 12-lead ECG was recorded:Sinus tachycardia at a rate...
Source: Dr. Smith's ECG Blog - February 20, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Acute dyspnea in an older woman, is it OMI?
Written by Willy FrickA woman in her 90s with a history of end stage renal disease and complete heart block status post dual chamber pacemaker presented from home with acute onset dyspnea. ECG is shown below.What do you think?The ST and T wave abnormalities jump off the page, but let ' s set that aside just for a moment to review the tracing systematically. The rate is 60 (and remember, slower heart rates are often seen in OMI). Close inspection revealsventricular pacing spikes, best seen in aVL. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it...
Source: Dr. Smith's ECG Blog - February 18, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
A young man with persistent palpitations
Written by Pendell MeyersA teenager was playing basketball when he suddenly developed palpitations and lightheadedness. He presented soon afterward at the Emergency Department with ongoing symptoms. Mentation and blood pressure were normal. He had no chest pain or shortness of breath. Heart rates on the monitor fluctuated from 180-250 bpm.Here is his triage ECG:What do you think?The ECG shows an irregularly irregular polymorphic wide complex rhythm, with some R-R intervals as short as approximately 220 msec or even less. But it is not disorganized enough to be polymorphic ventricular tachycardia. The rhythm is therefo...
Source: Dr. Smith's ECG Blog - February 16, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
A 40-something with 2 hours of new active chest pain and new T-wave inversion
A 41-year-old male who presents to the emergency department with chest pain. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling. No shortness of breath. No recent travel. No cough. No cardiac history. Here is his ECG:He had a previous ECG on file, from many years prior:What do you think?There is new T-wave inversion in inferior leads and V3-V6. This is recorded during pain. The faculty physician thought this is highlylikely to be ACS. ...
Source: Dr. Smith's ECG Blog - February 14, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Vomiting, Diarrhea, and " Bubbles in my Chest "
A 60-something complained of vomiting, diarrhea overnight, and " bubbles in my chest " that started just prior to calling 911.He had this ECG recorded prehospital:Smith interpretation:There are hyperacute T-waves in III and aVF, and reciprocal STD in aVL with a reciprocally inverted T-wave in aVL. There are also hyperacute T-waves in V3 and V4. There is STD in V1 and V2. So it appears to be diagnostic of OMI, but it is hard to figure out what exact territory and artery. It could be a proximal RCA with both inferior OMI, posterior OMI (pulling ST down in V1/V2), and RV OMI causing large ischemic...
Source: Dr. Smith's ECG Blog - February 12, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
See What PM Cardio Digitization can do with this ECG
This was a patient with chest pain. The ECG was faxed to a cardiologist. But it was very difficult for him to see.He showed this to me the next day.I told him that he could make it legible AND get an OMI diagnosis from the Queen of Hearts and sent this ECG to the Queen right before his eyes:She correctly rules out OMI:And the outcome was Not OMI (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - February 11, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain with anterior ST depression: look what happens if you use posterior leads.
Don ' t forget to watch theWebinar: Smith and Pendell Meyers interpret ECGs for OMI or not OMI on Monday Feb 12 at 11 AM U.S. Central time. Register here:https://zoom.us/webinar/register/7617067094184/WN_LMN0vPb1Rz-HZu12K-QuYQWritten by Jesse McLarenA 65 year old
with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented
with 3 days of fluctuating chest pain, which was ongoing at triage. What do you
think? Do you need posterior leads?There ’s atrial
flutter with controlled ventricular response, a non-specific intra-ventricular
conduction delay, borderline right axis, normal R wave...
Source: Dr. Smith's ECG Blog - February 9, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
