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
Physical Examination as a Helpful Aid in Decision-Making in Challenging ECGs
Discussion continuedThe absence of pace spikes suggests this is not a pacemaker/ICD-related rhythm in this patient with an ICD.The presence of thinned myocardium and known large amount of scar tissue makes for a nidus for VT. Thus VT is very probable.A wide native QRS can be expected in a patient with a dilated heart and a history of heart failure, even if it is sinus rhythm. so the question of whether those are P-waves is critical.Additionally, the qR morphology, particularly in a patient with right bundle branch block (RBBB) type wide QRS complex tachycardia (WQCT), lends further support for VT.Furthermore, a pertinent p...
Source: Dr. Smith's ECG Blog - January 1, 2024 Category: Cardiology Authors: Emre Aslanger Source Type: blogs
50-year old with chest pain, “no ischemic changes”
Written by Jesse McLaren A previously healthy 50 year-old presented
with 24 hours of intermittent exertional chest pain, radiating to the arms and
associated with shortness of breath. It was ongoing on arrival in the emergency
department. Below is the old ECG (on top) and then new ECG (on bottom). What do
you think?There is normal sinus rhythm, normal
conduction, normal axis, and tall precordial voltages with J waves from early
repolarization. The old ECG has proportional ST elevation and T waves.But the
new ECG has new Q waves in aVL and V2 (the distribution of the first diagonal
artery) – and in the next context o...
Source: Dr. Smith's ECG Blog - December 30, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Acute OMI or " Benign " Early Repolarization?
Written by Willy FrickA man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. He described it as severe, sharp, and substernal with associated nausea, vomiting, chills, and diaphoresis. The following ECG was obtained. Note that the machine read is" normal sinus rhythm, normal ECG. " Cardiology over read the tracing and signed the interpretation without modification.ECG 1What do you think?The Queen of Hear...
Source: Dr. Smith's ECG Blog - December 27, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
An elderly patient with stuttering chest pain. Don't jump to conclusions.
I was reading ECGs on the system and saw this one, and instantly knew the probable ECG diagnosis:What do you think?I went to the patient ' s chart:Elderly woman with stuttering chest pain and SOB, and dizziness.What do you think now?This is a very typical ECG for Hypertrophic Cardiomyopathy. I sent it to our EKG Nerdz group and Jesse McLaren replied: " Apical HOCM "It reminded me of many other cases I have seen, such as this one: Left Bundle Branch Block with Less Than 1 mm of Concordant ST Elevation (in the Setting of Hypertrophic Cardiomyopathy)HOCM that mimicked LBBB with OMI (concordant STE in V5)Case continu...
Source: Dr. Smith's ECG Blog - December 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A young woman with palpitations. What med is she on? With what medication is she non-compliant? What management?
Written by Pendell MeyersA woman in her 20s with connective tissue disorder and history of aortic root and valve repair presented with palpitations. Here is her triage ECG: What do you think?Atrial flutter with 2:1 conduction. The atrial flutter rate is approximately 200 bpm, with 2:1 AV conduction resulting in ventricular rate almost exactly 100 bpm. The fact that the atrial flutter rate is 200 bpm (rather than more typical adult rate of ~300 bpm) suggests that the patient must have one or both of the following:1) enlarged atria ( " bigger race track " )2) sodium channel blockade ( " slower race car "...
Source: Dr. Smith's ECG Blog - December 24, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Is there OMI on this ECG?
This is a case I had quite a while back. The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. It does not look entirely normal, since there are some nonspecific STT abnormalities, such as flattening of the T waves in aVL. There is a normal amount of ST elevation in the precordial leads. There are no hyperacute T waves. There is no inappropriate ST depression. But it certainly shows no sign of OMI.Or does it?Here is the Queen ' s interpretat...
Source: Dr. Smith's ECG Blog - December 22, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Concerning EKG with a Non-obstructive angiogram. What happened?
CONCLUSION: Given resolution of severe CP in association with the above marked improvement of ST-T wave abnormalities in virtually all leads during the less than 1 hour between the recording of ECGs #1 and #2 — this strongly suggests reopening of a " culprit " vessel (whichever vessel this was) — regardless of the fact that " no obstructive lesion was seen " at the time the cardiac catheterization happened to be done.The more than doubling of Troponin (even though " normal limits " for Troponin were not surpassed) — is consistent with a brief OMI, with only...
Source: Dr. Smith's ECG Blog - December 19, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
An ECG with only «marginal» change
DISCUSSION: This case nicely illustrates how subtle OMI changes really can be. The Queen of Hearts AI model did not identify OMI in the initial ECG.Below is the QoH explainability for the limb leads of the ECG #2 (left part of the image) and limb leads of ECG #3 (right side of the image). The sets of six limb leads are put next to each other for comparison. I ' ve excluded the precordial leads as they didn ' t add much information in this case. You can look at each leads and compare the two ECGs. You then can appreciate the dynamic change and see what parts of the waveform the QoH identifies as ischemic findings....
Source: Dr. Smith's ECG Blog - December 15, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Proportionality is a major element in the ECG Diagnosis of OMI.
This middle aged patient presented with chest pain:What do you think?There is VERY low voltage. There is some ST Elevation, but it is MINIMAL. But look how small the QRS is!!Let ' s stretch out the QRS vertically so it is not so tiny:On upper left is the original. On the right are the precordial leads stretched vertically, so that the QRS is not tiny. Now you can see the STE and Hyperacute T-wave better.I published, and Emre Aslanger externally validated,the4-Variable formula for differentiating the ST Elevation of LAD OMI from Normal ST Elevation. It is derived/validated/...
Source: Dr. Smith's ECG Blog - December 13, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Occlusion myocardial infarction is a clinical diagnosis
Written by Willy Frick (@Willyhfrick). Willy is a cardiology fellow with a keen interest in the ECG in OMI.A woman in her late 70s presented with left arm pain. The arm pain started the day prior when she was at the dentist ' s office for a root canal. Her systolic blood pressure at the dentist was over 200 mm Hg. She was given nitroglycerin which improved her blood pressure, and she completed the procedure. Her arm pain abated. The pain returned that evening and woke her from sleep. She eventually fell back asleep, and woke up feeling normal the next day (the day of presentation). After dinner the day of presentatio...
Source: Dr. Smith's ECG Blog - December 11, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
Syncope While Driving. Activate the Cath Lab?
A 50-something had syncope while driving. He was belted and it was low speed. He had a prehospital ECG. He was ambulatory at the scene. He has a history of STEMI and heart failure. The medics stated he had been nauseated and diaphoretic, but he did not have any chest pain or SOB. They recorded a prehospital ECG:What do you think?I read this blinded, with no clinical information, and read it as inferior OMI. There is STE in inferior leads with a large T-wave and reciprocal ST depression in aVL with a reciprocally inverted T-wave. It is all but diagnostic of OMI. The on...
Source: Dr. Smith's ECG Blog - December 9, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
" A patient just arrived as a transfer for NSTEMI. "
Conclusion: Our THANKS to Dr. Frick for his detailed and highly insightful presentation. CREDIT to him for masterful correlation of clinical events to each ECG — that thoroughly supports his explanation of the successful treatment received by this patient with evolving LAD OMI.QUESTION: Isn ' t it so much EASIER with the lead-to-lead comparison facilitated by Figure-1 — to see the subtle-but-important evolution of ST-T wave changes that so closely correspond to clinical events? (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - December 7, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.
Acute coronary syndrome in a pediatric patient?Written by Kirsten Morrissey, MD with edits by Bracey,
Grauer, Meyers, and Smith An older teen was transferred from an outside hospital
with elevated serum troponin and and ECG demonstrating ST elevations. The patient was obese and had a medical history of only recurrent tonsillitis status post tonsillectomy and adenoidectomy but was otherwise healthy and fully vaccinated. He reported 1.5 days of chest pain that started as substernal and crushing in nature awakening him from sleep and occasionally traveling to right side of neck. The pain ...
Source: Dr. Smith's ECG Blog - December 5, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
