Chest pain and T wave inversion, NSTEMI?
Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLarenA 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. The nurse alerted the MD because the patient was still symptomatic, diaphoretic and “looking unwell”. What do you think? ECG interpretation: sinus rhythm, normal conduction (PR, QRS, and QTc), normal axis, delayed R-wave progression, and normal voltages. There ’s primary TWI inferiorly (aVF and III) and V6, with reciprocal tall T-wave in lead I/aVL, and a Q wave in III. The...
Source: Dr. Smith's ECG Blog - August 10, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Lecture by Smith: Selected Cases of Occlusion MI (OMI), or not, on the ECG
This may be my best lecture yet. I gave it virtually to the Kaiser group.You can access it also on the " Lectures and Podcasts " link on the Banner above.https://drive.google.com/file/d/1SSe2AmEyfkrQhRJt1FGmVxvnt3g3c4BN/view?usp=drive_link===================================MY Comment, by KEN GRAUER, MD (8/6/2023):===================================Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI ”. For skeptics (including cardiologists) — Any questions about “Who is Dr. Smith?” are compellingly answered by the several...
Source: Dr. Smith's ECG Blog - August 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
OMI Pocket Guide
📕OMI Pocket Guide TheOMI Pocket Guide (https://omiguide.org) is a user-friendly online resource designed to help healthcare professionals learn how to recognize subtle signs of acute coronary occlusion on the ECG which represent occlusion myocardial infarctions (OMI). Learning to recognize OMIs is an important clinical skill because it helps identify the subpopulation of " NSTEMIs " who are likely to be found with total thrombotic occlusion at the time of cardiac catherization.Although there are more criteria to consider when looking for OMIs compared to STEMIs, anyone can learn them, and this guid...
Source: Dr. Smith's ECG Blog - August 3, 2023 Category: Cardiology Authors: Mark Hellerman Source Type: blogs
A woman in her 50s with chest pain and lightheadedness and " anterior subendocardial ischemia "
Written by Pendell MeyersA woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. Here is her triage ECG during active symptoms:What do you think?The ED physician read this as " Normal sinus rhythm. LVH. Marked ST abnormality, possible anterior subendocardial injury. " Smith: I suspect this was a confirmation of the conventional computer interpretation. These are often wrong and lead the physician astray.This is wrong on many levels. The rhythm is some form of heart block (see Ken ' s comments at end of post) with junctional escape. The STD maximal in ...
Source: Dr. Smith's ECG Blog - July 30, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Profound ST depression in II, III, aVF
Conclusion:Type II MI probable due to hypoxia and tachycardia from resp arrest and amphetamine use. Whether the ST Depression on the ECG represents ischemia or not is uncertain, but it does not represent acute coronary syndrome.===================================MY Comment, by KEN GRAUER, MD (7/26/2023):===================================The most interesting aspects of today ’s case are: i) The tale told by the 6 ECGs; and, ii) The surprise finding of positive troponins! The Sum is More than Each of its Parts:If we look back at the initial ECG&nb...
Source: Dr. Smith's ECG Blog - July 27, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Patient with Vertigo
This patient presented with vertigo and had an ECG recordedWhat do you think?I saw this and was worried about inferior OMI due to some subtle STE in III with very worrisome reciprocal findings in aVL. But the well-formed Q-wave and the presence of a normal T-wave in inferior leads led me to believe this was Old Inferior MI with persistent ST Elevation, otherwise known as inferior LV aneurysm.Anterior LV aneurysm is much easier to recognize because the Q-wave is usually a QS-wave (no R-wave at all), in at least one lead. Or at least only a very tiny r-wave (1 mm or so).Thus, acute inferior OMI and inferior LV an...
Source: Dr. Smith's ECG Blog - July 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 70s with weakness and syncope
DiscussionBrugada Type 1 ECG changes are associated with sudden cardiac death (SCD) and the occurrence of ventricular dysrhythmias. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% per year. In patients that only have this pattern induced by a sodium channel blocking agent have a lower rate of SCD (0 - 0.35% per year)[1]. Drugs that have been associated with Brugada ECG patterns include tricyclic antidepressants, anesthetics, cocaine, methadone, antihistamines, electrolyte derangements, and even tramadol. [2]. Our patient had a Brugada Type ...
Source: Dr. Smith's ECG Blog - July 22, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A young man with tachycardia. Should We Try Adenosine?
A young man presented with weakness and fever. His pulse was 186. An ECG was recorded:What do you think?There is a regular narrow complex tachycardia. Thus, it is supraventricular tachycardia. It is important to remember thatSVT includes Sinus Tachycardia! That is why I like to call re-entrant SVT " Paroxysmal " SVT, or PSVT). The sinus node is " supraventricular " and in young people it can beat VERY fast. Especially when there is fever.You must look closely for P-waves, and if you do, the P-waves are obvious (if you look at the leads most likely to reveal P-waves: leads II and V1)...
Source: Dr. Smith's ECG Blog - July 19, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 40-something presented after attempted prehospital resuscitation with persistent Ventricular Fibrillation
A 40-something with persistent Ventricular Fibrillation presented after attempted prehospital resuscitationA 40-something with no previous cardiac history presented to the ED in persistent Ventricular Fibrillation after attempted prehospital resuscitation. He underwent further standard resuscitation EXCEPT that we applied the Inspiratory Threshold Device (ResQPod) AND applied Dual Sequential Defibrillation (this simply means we applied 2 sets of pads, had 2 defib machines, and defibrillated with both with only a fraction of one second separating each defibrillation.Two recent interventions have proven in randomized t...
Source: Dr. Smith's ECG Blog - July 14, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
I was reading ECGs on the system when I came across this one, called " normal " by the conventional computer algorithm
I come in early for every shift to read the ECGs on the system that have not yet been " confirmed " . I came across this one:The computer calls is: " SINUS RHYTHM. NORMAL ECG "What do you think? Be VERY careful when the computer calls the ECG " Normal " . I saw the inferior ST depression (which is reciprocal to subtle STE in aVL) and the subtle ST depression in precordial leads and thought:" If this patient came in with chest pain, then it is an acute OMI. "So I looked on the computer. Turns out that it was a 50-something patient with no previous cardiac history who had called 911 for chest pain...
Source: Dr. Smith's ECG Blog - July 12, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 60 year old with chest pain
:what do you think?The medics came to me worried about hyperacute T-waves. But these are not HATW and I immediately said so. Why?The ST segment is too flat, resulting in a narrow base for the T-wave even though the QT interval is quite long (QTc Hodges = 464 and a lot longer by Bazett). T-wave hyperacuteness is due to area under the curve, which is height + width + straightness of the ST segment. The width of the T-wave is not determined only by the QT interval! It is also determined by the ST segment itself. A patient with hypocalcemia has a long ST segment and thus long QT, but no...
Source: Dr. Smith's ECG Blog - July 10, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
This was texted to me by a former resident. An 80-something woman who presented with chest pain and dyspnea.
This was texted to me. An 80-something woman who presented with chest pain and dyspnea.What do you think?The rhythm appears to be atrial fibrillation. In any case, it is clearly a supraventricular rhythm. There is significant ST depression in V2-V4. Is this posterior OMI?Before jumping to any conclusions about the significance of ST-T abnormalities, you must first be certain that they are not a result of (secondary to) any QRS abnormalities. Do you see any such abnormalities?There is a large R-wave in V1. Is this RBBB? No, it is not RBBB. The QRS is not wide enough, there are no wi...
Source: Dr. Smith's ECG Blog - July 7, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
This was texted to me in real time. The patient has acute chest pain.
This was texted to me in real time. The patient has acute chest pain.What do you think?Here was my answer:" Not ischemia. Chronic. Maybe HOCM or another form of LVH. I would not activate cath lab. Get serial troponins "It is a scary ECG, with a lot of ST Elevation and what appear to be hyperacute T-waves in inferior leads, and profound reciprocal ST Depression in aVL. There are Q-waves in V4-V6, with what appear to be hyperacute T-waves. Any objective, rule-based analysis of this ECG would scream " STEMI " or " OMI " . But, alas, ECGs are like faces. No measurements can t...
Source: Dr. Smith's ECG Blog - July 5, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
63 year old with " good story for ACS " but negative troponins.....
This was texted to me from a former resident, while working at a small rural hospital, with the statement:" I can ’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS. " (Chest pain or discomfort)What do you think?Here was my response:" Suspicious for inferior posterior OMI. Get serial ECGs "He then sent a previous from 4 years prior:" This is totally normal, which confirms that the first EKG does indeed represent OMI "Then the patient ' s chest pain resolved and he recorded another:The ST depression in aVL is gone and the T-waves are less hyperacu...
Source: Dr. Smith's ECG Blog - July 2, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain with 2 serial ECGs, with dynamic change, texted to me
These were texted to me only with " chest pain. "First:2nd:What was my response?Smith: Young thin black male. No OMI.Texter: Can ' t fool you. It was indeed. Queen: #1: NOT OMI, HIGH CONFIDENCEQueen: #2: NOT OMI, HIGH CONFIDENCEECG 1 Interpretation: there is terminal T-wave in V3-V6. Is this Wellens ' pattern A? No. this is classic Benign T-wave Inversion. It helps to know that the patient has active chest pain, as Wellen ' s is a post occlusion (reperfusion) state, with open artery and pain-free.See 2 dozen examples here: Understanding this pathognomonic ECG would have greatly...
Source: Dr. Smith's ECG Blog - June 30, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
