What is this ECG finding? Do you understand it before you hear the clinical context?
Written by Pendell MeyersFirst try to interpret this ECG with no clinical context:The ECG shows an irregularly irregular rhythm, therefore almost certainly atrial fibrillation. After an initially narrow QRS, there is a very large abnormal extra wave at the end of the QRS complex. These are Osborn waves usually associated with hypothermia. There is also large T wave inversion and long QT.Clinical context:A man in his 50s was found down outside in the cold, unresponsive but with intact vital signs. He was intubated on arrival at the ED for mental status and airway protection due to vomiting. Initial vitals included...
Source: Dr. Smith's ECG Blog - February 2, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, ST Elevation, well-formed Q-waves, and infarction with peak hs troponin I over 1000 ng/L. Is it OMI?
A 60-something male presented stating that he had had chest pain that morning which awoke him from sleep but then resolved after several minutes. He has had similar pain in the past which he attributed to acid reflux. He has a history of untreated hypertension.He is pain free now.His systolic BP was 200.The patient is pain free at the time of this ECG:What do you think?The conventional algorithm said:SINUS RHYTHMANTERIOR MYOCARDIAL INFARCTION , PROBABLY RECENT [40+ ms Q WAVE AND/OR ST/T ABNORMALITY IN V3/V4]***ACUTE MI*** There are well-formed Q-waves in precordial leads. The T-waves are inverted.&nb...
Source: Dr. Smith's ECG Blog - January 31, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 40-something with chest pain
This was sent by Sam Ghali @EM_RESUSA 44 year old man presented with chest painThe tech came running with the ECG as the computer called " STEMI! "The conventional computer algorithm read: ***STEMI***The cardiologist overread was: " ST Elevation. Consider Anterolateral Injury or Acute Infarct "What do you think?Sam sent this to me and asked: " What do you think, Steve? "My answer:--Tough one!--But I ' m going to stick my neck out and say " Not OMI "--STE in V2 has a near " saddleback " configuration, and that is a sign of false positive STE.--Tell me the outcome!He responded:--You nailed it!--The Saddleback in V2 isexactly...
Source: Dr. Smith's ECG Blog - January 29, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.
This article,published this month (!), tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal:Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage PatientsI reviewed this article for a different journal and recommended rejection and it was rejected. There were zero patients in this study with a " normal " ECG who had any kind of ACS! This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value.&nb...
Source: Dr. Smith's ECG Blog - January 27, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Acute chest pain in a patient with LVH and known coronary disease. What does the ECG show?
A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain.Here is his ED ECG:What do you think?There is a flat and downsloping ST segment in V2 and V3. This could be due to posterior OMI. Is there an old ECG for comparison?Here is the most recent previous ECG:Indeed, there was some normal ST elevation in V2 and V3, discordant to a relatively deep S-wave which could be due to some LVH.Here is another previous ECG:So it looks like a posterior OMI.2 years prior he had an angiogram which showed 90% proximal stenosis of the circumflex. It...
Source: Dr. Smith's ECG Blog - January 25, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
What kind of AV block is this? And why does she develop Ventricular Tachycardia?
Discussion: The initial ECG in today ' s case is pathological for any patient, especially for a 50-year old previously heathy female. Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc). Usually the medical history will provide clues to the cause. Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. When assessing patients with early onset high grade conduction disorders and ventricular tachydysrhythmi...
Source: Dr. Smith's ECG Blog - January 23, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
A man in his 30s with chest pain. How was he managed? What if they had used the Queen of Hearts?
Written by Pendell MeyersA man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity. He stated it did not feel like his prior episodes of reflux. Vitals were within normal limits except some hypertension. Triage ECG:And here she explains her assessment:The ECG was read as simply " No ST elevation. " Which is true.The initial high sensitivity troponin I returned at around 3300 ng/L. No repeat E...
Source: Dr. Smith's ECG Blog - January 20, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?
Written by Jesse McLaren Two patients
presented with acute chest pain, and below are the precordial leads V1-6 for
each. Patient 1 (ECG on the left) was a 45 year-old male, and patient 2 (ECG is
on the right) was a 70 year-old male. The limb leads have been removed because
there was no ST elevation in those leads, the QRS complexes have been
obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation. Using the
current paradigm, can you tell which patient had an acute coronary occlusion? Using
T wave amplitude, can you tell which ECG has hyperacute T waves?...
Source: Dr. Smith's ECG Blog - January 17, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Noisy, low amplitude ECG in a patient with chest pain
Written by Colin Jenkins. Colin is an emergency medicine resident beginning his critical care fellowship in the summer with a strong interest in the role of ECG in critical care and OMI. Edits by Willy Frick.A patient in their 40s with type 1 diabetes mellitus and hyperlipidemia presented to the emergency department with 5 days of “flu-like” illness. They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They denied fever, cough, dyspnea, and sick contacts. They described the chest pain as severe, crushing, and non-radiating. It was not wo...
Source: Dr. Smith's ECG Blog - January 15, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Orthostatic hypotension onset after invasive procedure?
Written by Willy FrickA man in his 70s with a history of HFrEF and sick sinus syndrome s/p dual chamber pacemaker placement was admitted for overnight observation following outpatient placement of a mitral valve clip. The procedure note indicates uncomplicated clip placement. The next morning, the following ECG was obtained.What do you think?The tracing shows sinus rhythm with PVCs and non-specific ST&T wave abnormality. But there is something more important to notice, which is the pacer spikes. They do not make sense. Some of them are in the middle of or after P waves, and there ' s even one that falls at the end...
Source: Dr. Smith's ECG Blog - January 13, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?
The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. She also has a hx of paroxysmal atrial fibrillation and is on oral anticoagulant treatment. She had a single chamber ICD/Pacemaker implanted several years prior due to ventricular tachycardia. The last echocardiography 12 months ago showed HFmrEF.She presented to the emergency department after a couple of days of chest discomfort. The ECG below was recorded. What is your assessment? How would you manage this patient?The ECG was interpreted as showing atrial flutter with 2:1 conduction. The patient was deemed stable and...
Source: Dr. Smith's ECG Blog - January 10, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
What do you suspect from this ECG in this 40-something with SOB and Chest pain?
I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information:What do you think?The Queen diagnosed " OMI with high confidence " due to the ST Elevation in V1-V3.Smith interpretation: This is highly likely to be due to extreme right heart strain and is nearly diagnostic of pulmonary embolism. Let me tell you about her hospitalization, discharged 1 day prior, but it was at another hospital (I wish I had the ECG from that hospitalization):The patient is 40 years old and presented to another hospital with chest pain and SOB. She had been sitting doing work when sh...
Source: Dr. Smith's ECG Blog - January 8, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Can you spot the problem with the recording of this 12-lead ECG?
Written by Willy FrickI was reading ECGs in the queue, and the following tracing appeared. I frequently check the chart if I want to know more clinical context (which is crucial for accurate interpretation). But in the reading software, all I am told is that it is a 77 year old man, and that the indication is " NSTEMI. "What do you think? Although not necessarily intentional, the first processing that I do when I see an ECG is to categorize as OMI or not. Here, I do not see OMI (although the ECG is falsely STEMI positive with just over 1 mm STE in V1 and about 2.5 mm STE in V2).The Queen of Hearts also sees&...
Source: Dr. Smith's ECG Blog - January 6, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Three normal high sensitivity troponins over 4 hours with a " normal ECG "
Written byWilly FrickA 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of " chest burning. " The documentation does not describe any additional details of the history. The following ECG was obtained.ECG 1What do you think?The ECG shows sinus bradycardia but is otherwise normal. There is TWI in lead III, but this can be seen in normal ECGs. No labs were obtained. The patient was given a prescription for albuterol and a referral to cardiology.Smith comment:No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matt...
Source: Dr. Smith's ECG Blog - January 5, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
EMS told " Not a STEMI " . What do you think?
Written by Pendell MeyersA woman in her 70s had acute chest pain and called EMS. On arrival, EMS recorded relatively normal vital signs and this EMS ECG:What do you think?Interpretation: diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Because the reciprocal area from V2-V4 is the posterior wall, many anterior OMIs do not have clear reciprocal findings on the standard 12 leads.Smith: there appears to be a" saddleback " in V2. Saddleback is strongly associ...
Source: Dr. Smith's ECG Blog - January 3, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
