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
Young Man with Very Fast Regular Wide Complex Tachycardia
EMS was dispatched for a 30-something male who feels his heart is racing. Sudden onset.The patient had no previous medical history.Vitals were normal except for a heart rate of 226.A prehospital 12-lead was recorded:There is a regular wide complex tachycardia. The computer diagnosed this as Ventricular Tachycardia.Is it definitely VT??The patient was given 6mg, then 12 mg, of adenosine, without a change in the rhythm.He arrived in the ED and had an immediate bedside cardiac ultrasound while this ECG was being recorded.The bedside ultrasound (video not available) reportedly showed only a slightly reduced LV func...
Source: Dr. Smith's ECG Blog - June 28, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
An Intriguing Rhythm: Who Belongs to Whom?
===================================MY Comment, by KEN GRAUER, MD (6/26/2023): ===================================The tracing in Figure-1 was sent to me — without the benefit of any history. How would YOU interpret this tracing?Figure-1: The initial ECG in today ' s case. (To improve visualization — I ' ve digitized the original ECG using PMcardio).MY Initial Thoughts:My attention was immediately drawn to the long lead rhythm strip in Figure-1. A lot is going on ...The rhythm is clearly irregular. All QRS complexes in this tracing are narrow...
Source: Dr. Smith's ECG Blog - June 26, 2023 Category: Cardiology Authors: ECG Interpretation Source Type: blogs
Wide complex tachycardia and hypotension in a 50-something with h/o cardiomyopathy -- what is it?
A 50-something male with unspecified history of cardiomyopathy presented in diabetic ketoacidosis (without significant hyperkalemia) with a wide complex tachycardia and hypotension.Bedside echo showed " mildly reduced " LV EF.Here is the ED ECG:What do you think?Analysis: there is a wide complex tachycardia. It is regular. There are no P-waves. The morphology is of RBBB and LAFB. The initial part of the QRS is very fast, suggesting that it starts in conducting fibers and not in myocardium. Thus, it is probably SVT with aberrancy (RBBB + LAFB) or it is posterior fascicular VT (which starts in the pos...
Source: Dr. Smith's ECG Blog - June 23, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 50s with acute chest pain who is lucky to still be alive.
Sent by Magnus Nossen MD, written by Pendell MeyersA man in his 50s, previously healthy, developed acute chest pain. EMS was called, and they recorded the following ECG on scene at 13:16:What do you think?Below is the version standardized by PM Cardio appMeyers interpretation:Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). There is a relatively normal QRS yet there is STD maximal in V2-V4, which resolves from V4 to V6. The inferior leads may have a slightly full T wave (possibly hyperacute if compared to baseline which...
Source: Dr. Smith's ECG Blog - June 21, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A man with chest pain off and on for two days, and " No STEMI " at triage.
Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen SmithA 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.What do you think?This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 mm STE in III, and possibly 0.5 mm in aVF), but there is clear evidence of OMI findings on this ECG. Leads II, III, and aVF hav...
Source: Dr. Smith's ECG Blog - June 19, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Active chest pain. Fake? or Inferior OMI? Hyperacute T waves?
Written by Pendell MeyersA middle aged man called EMS for acute chest pain.EMS recorded this ECG during active symptoms and transmitted it to the ED:I had no information when I was shown the ECG. I said " Not OMI. Some probably thought the inferior leads showed findings of OMI, but that ' s a fake. " Others probably thought lead V4 has a hyperacute T wave. But these T waves are asymmetric and not " fat " enough. I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 mm of STE in II and III, or III and aVF, or V4 and V5, so some might say it fulfills STEMI criteria (remember, the ...
Source: Dr. Smith's ECG Blog - June 17, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Two ECGs texted to me in the same hour. What would you recommend?
Written by Pendell MeyersBoth of these cases were sent to me with no information other than adults with acute chest pain. What would be your response?Case 1:Case 2:What if I told you that Case 1 has an abnormal initial troponin, and Case 2 has a normal initial troponin? Case 1An elderly male presented with chest pain. His vitals were within normal limits except some mild hypertension. Here was his triage ECG:What do you think?I texted back: " I just see LVH with no signs of OMI " .I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict:You can subscribe for news and early access (via partic...
Source: Dr. Smith's ECG Blog - June 15, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A young man with another episode of tachycardia. What is it? And why give adenosine in sinus rhythm?
Written by Bobby Nicholson MD and Pendell MeyersA man in his 30s presented to the ED for evaluation of chest pain and palpitations. He described it as a " jackhammering " sensation, associated with palpitations, diaphoresis, and shortness of breath, and he stated it started soon after consuming an " energy drink " (product/contents unknown).He stated these symptoms were the same as a prior episode which required cardioversion. He states that he has
a heart condition which he does not know the name of and that he has felt his
heart race like this once before and needed to be shocked. He was seen by a
cardiologist in fo...
Source: Dr. Smith's ECG Blog - June 11, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
75 year old with 24 hours of chest pain, STEMI negative
Written by Jesse McLaren A 75 year old
with a history of CABG called EMS after 24 hours of chest pain. HR 40, BP
135/70, RR16, O2 100%. Here ’s the paramedic ECG (digitized by PMcardio). What
do you think? There ’s sinus
bradycardia, normal conduction, normal axis, delayed R wave progression, and
normal voltages. There are inferior Q waves and lead III has mild concave ST
elevation, with subtle reciprocal ST depression in I/aVL. This is diagnostic of
inferior OMI, likely from the RCA. The patient has a hi story of CABG so some of
these changes could be old, but with ongoing chest pain and bradycardia in a
hig...
Source: Dr. Smith's ECG Blog - June 8, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A 50-something with acute chest pain
A 50-something presented with acute chest pain.Here is her ED ECG. It was texted to me while I was out and about. He wrote:" Steve, what do you think about hyperacute T waves in this? 54-year-old female with CP. I initially interpreted as normal, but I am second-guessing myself, since she is hanging out in triage with me. "What do you think, Dear Reader?Analysis: There is ST elevation in multiple leads. There are tall T-waves in multiple leads. So one might think this is an acute OMI with STE and hyperacute T-waves. I immediately responded: Good question, but I think they are normal....
Source: Dr. Smith's ECG Blog - June 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 40-something male with resolving chest pain and a " Normal ECG " by computer and cardiology overread
A 40-something male presented by ambulance with one hour of chest pain that was improving after sublingual nitroglycerine and 325 mg of aspirin, chewed. Here is his initial ED ECG:What do you think?I read this ECG without any history as reperfusing inferior and posterior OMI due to the Q-wave in lead III with minimal STE and reciprocal ST depression in V2-V4 (which should never be there). The large upright T-wave in V2 is consistent with reperfusion.Any ST Depression Maximal in V1-V4 is OMI until proven otherwiseI sent this ECG with no information to Pendell. We send each other EKG by the dozens...
Source: Dr. Smith's ECG Blog - June 5, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A young lady with wide complex tachycardia. My first time actually making this diagnosis de novo in real life in the ED!
Written by Pendell MeyersA woman in her 30s with minimal past medical history presented simply stating she was " feeling unwell. " Her symptoms started suddenly about 48 hours ago, but had continued to worsen, including epigastric discomfort, nausea, cough, and dyspnea and lightheadedness on exertion. She denied chest pain and denied feeling any palpitations, even during her triage ECG:What do you think?Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED.She was awake, alert, well perfused, with normal mental status and overall unremarkable physical exam except for ...
Source: Dr. Smith's ECG Blog - June 3, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).
I received the following text message with these 3 EKGs (providers text me ECGs all day every day; most are false positives; many are subtle true positives):" Hi Steve, here are 3 EKGs for you (my colleague ' s case). A 67 yo f developed chest pain this morning. "EKG #1Followed 15 minutes by this #2 EKG:Then the patient received aspirin andDilaudid (hydromorphone, same effect as morphine) and the pain went away and there was this 3rd ECG:Smith comment: hydromorphone will make any pain go away (or improve) without any improvement in the underlying pathology. Do NOT give it unless you are committed to t...
Source: Dr. Smith's ECG Blog - May 31, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
