Chest pain and new regional/reciprocal ECG changes compared to previous ECGs: code STEMI?
Written by Jesse McLaren A 45 year old presented with two weeks of recurring
non-exertional chest pain, now constant for an hour. Below is old and then new
ECG (old on top; new below). What do you think?Both ECGs have normal sinus rhythm, normal conduction and
normal voltages. There ’s a change in axis that may interfere with direct
lead-to-lead comparison, but there appear to be larger T waves in I/aVL and new
TWI in III/aVF. But do they represent acute coronary occlusion? Because of the ECG changes in a patient with chest pain, and
with inferolateral hypokinesis on POCUS, the cath lab was activated. But...
Source: Dr. Smith's ECG Blog - November 27, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?
A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest. She said this was midsternal and felt like a tightness. This originally radiated into her left arm. Over some time and the pain moved into her other arm as well as her jaw. She also had some shortness of breath. She was brought in by ambulance and re...
Source: Dr. Smith's ECG Blog - November 15, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
How important are old ECGs in Non-obvious cases of potential OMI?
Conclusion: As per Dr. Smith — the cath lab was initially activated on the basis of the history of changing symptoms occurring in association with dynamic ST-T wave changes on these 3 serial ECGs shown in Figure-1.BUT — Review of this patient ' s medical chart revealed previous ECGs showing a similar pattern of labile ECG changes. Some patients do this ... that is, show a pattern of labile ST-T wave changes not due to an acute coronary event.Despite the seemingly worrisome ST-T wave changes on serial tracings shown in Figure-1 — an acute event was definitively ruled out b...
Source: Dr. Smith's ECG Blog - November 14, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
See this " NSTEMI " go unrecognized for what it really is, how it progresses, and what happens
Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc.A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest.Triage ECG at Time = 0: Smith: I am suspicious for posterior OMI due to ST depression in V2 and V3Baseline EKG (several months prior):Smith: Now I am even more suspicious of posterior OMI, as the baseline ECG has normal ST elevation in V2 and V3ECG Interpretation:The tri...
Source: Dr. Smith's ECG Blog - November 3, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
What do you think of this ECG that was texted to me?
This ECG was texted to me by a colleague. I assumed it was from a patient with symptoms compatible with ACS/OMI.What do you think?There is sinus rhythm with RBBB and ST Elevation in V2 which is concordant with the QRS. The ST segment in RBBB should be ST depression, discordant to the positive R ' -wave (i.e., opposite direction of the upright R ' -wave). But we sometimes see this concordant STE even in non-ischemic ECGs:PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don ' t miss case 4 at the bottom.This STE suggests OMI, but we have seen many cases like this th...
Source: Dr. Smith's ECG Blog - November 1, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 20-something woman with cardiac arrest.
The patient is a 20 something female. She is healthy with no known cardiac disease. She was admitted to the neurology department due to headache and vomiting. She was found to have a viral CNS infection. A few days into her hospital stay she developedchest discomfort and the following ECG was recorded. What do you think? Why such large T-waves? Are these hyperacute T-waves? Are these ECG changes related to the CNS infection perhaps? What disease processes would you put on your list of differential diagnoses?When I saw the ECG of this patient I saw that there was definitely something " off " . I didn ' t get...
Source: Dr. Smith's ECG Blog - October 18, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
A 60-year-old diabetic with chest pain, cath lab activated
Conclusion: It literally took me no more thanseconds to recognize APTA in today ' s tracing because:i) I saw anormal-lookinglead I —despite bizarre deflections elsewhere; —ii) Withmaximal artifact inleads II,III,aVF— and abouthalf that artifact amount inaVR,aVL; —and,iii) Alesser amount of artifact in each of the chest leads. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - September 15, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Judge for yourself the management of this patient with " NSTEMI, multivessel disease "
DISCUSSION:The administration of
opioid analgesia prior to cath in patients with concern for ACS is associated
with longer door-to-balloon times, and greater peak troponin levels. The rate
of Occlusion MI in those who received pre-cath opioids was double the rate of
those without pre-cath opioids, and STEMI(-) OMI patients who received pre-cath
opioids waited 10 hours on average longer to get cath than those who did not
received opioids. These results add support to our hypothesis that a major
mechanism of harm caused by opioid medications in ACS patients involves delays
to the cath lab for patients with STEMI(-) OMI.=====...
Source: Dr. Smith's ECG Blog - September 10, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
50 year-old in remote rural community with chest pain and ‘normal’ ECG
Submitted by anonymous, edited by Jesse McLarenThe first person " I " and " me " is this anonymous sender. A 50 year old presented to the emergency department of a
remote rural community (where the nearest cath lab is a plane ride away) with
one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you
manage the patient?There ’s normal sinus rhythm, normal conduction, normal axis,
normal R wave progression and normal voltages. There’s clear T wave inversion
in III/aVF, which is reciprocal to subtle ST elevation and h...
Source: Dr. Smith's ECG Blog - September 8, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A woman in her 70s with chest pain
Case sent by Logan Stark MD, written by Pendell Meyers A woman in her 70s presented with acute chest pain. It started 10 hours prior to arrival, then had improved, then recently returned. No prior ECG was available. Here is her triage ECG:What do you think?The ECG was sent to me with no information, and I replied " OMI " .I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict:V1 and V2 have abnormal STE, and V2 has a hyperacute T wave. There is reciprocal STD in II, III, and aVF. One more thing that should be mentioned: since there are only Q waves from V1 to V3, it is possible that t...
Source: Dr. Smith's ECG Blog - August 30, 2023 Category: Cardiology Authors: Pendell 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
Reviewing the all-in-pod heart health segment
BY ANISH KOKA
The All-in podcast is a fairly popular show that features successful silicon valley investors commenting about everything worth commenting on from politics to health. The group has good chemistry and interesting insights that breaks the mold of the usual tribal politics that controls legacy media analysis of current events.
Last week, the podcast touched on a topic I spend a fair amount of time on: Cardiology.
Brad Gerstner, who is actually a guest host for this particular episode starts off by referencing something called Heartflow to evaluate the heart that has been recommended by one of the o...
Source: The Health Care Blog - July 20, 2023 Category: Consumer Health News Authors: Ryan Bose-Roy Tags: Medical Practice All-in Podcast Anish Koka Brad Gerstner cardiology Source Type: blogs
Pulmonary Arterial Hypertension: Unraveling Its Impact On Heart And Lungs
Conclusion
Navigating the complexities of Pulmonary Arterial Hypertension (PAH) might seem daunting. However, with the right knowledge and proactive approach, it’s possible to manage the condition and maintain a good quality of life.
PAH, a unique type of high blood pressure affecting the arteries in the lungs, can put extra strain on the heart. Over time, this can lead to heart failure. The condition’s root cause may vary, from genetic factors to other health issues like heart defects, liver disease, or autoimmune diseases. Remember, sometimes the cause remains unknown, resulting in idiopathic pulmonary ...
Source: The EMT Spot - July 19, 2023 Category: Emergency Medicine Authors: Michael Rotman, MD, FRCPC, PhD Tags: Blood Pressure 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
7 Diagnosis And Tests For Low Blood Pressure: A Comprehensive Guide
Conclusion
Accurate assessment and recognition of low blood pressure are crucial for effective management.
Diagnostic techniques, including medical history assessment, physical examination, ECG, blood tests, Holter monitor, tilt table test, stress test, and imaging tests, help identify underlying causes, assess severity, and rule out complications.
Smart blood pressure monitors connected to mobile devices have revolutionized diagnosis and monitoring. These devices provide instant, accurate readings for real-time tracking and analysis.
This involves increasing salt intake, staying hydrated, exercising regularly,...
Source: The EMT Spot - June 13, 2023 Category: Emergency Medicine Authors: Michael Rotman, MD, FRCPC, PhD Tags: Blood Pressure Source Type: blogs
