P wave spotting in AF is not forbidden
Fibrillation is a continuous, chaotic muscular activity. In AF, atrial muscle is expected to lose all coordinated contractions with fibrillatory waves replacing P waves. Have you ever spotted a suspicious P wave in a strip of otherwise explicit AF? If not, this write-up is not for you.
An evolving rare theme in Atrial fibrillation
Have a look at this ECG
Here is an ECG, that was reported as AF, multiple APDs, or Possible AF, Pre AF. I suggested the term AF in transition. While few agreed, many said it is a straightforward SR with APDs, making it appear irregular RR.
But, the fact of ...
Source: Dr.S.Venkatesan MD - March 8, 2023 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized cardiology research topics for fellows causes of absent p wabes p vs f waves in af p waves in atrial fibrillation research topics in atrial fibrillation Source Type: blogs
What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.
If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation?This is a trick question, as you will see below. But you can make a diagnosis here, and Pendell and I do this all the time when reading ECGs from databases. I sent this to Pendell without any information at all, and he replied " Postero-lateral Reperfusion. "The T-waves in V2-V4appear hyperacute, suggesting LAD occlusion,BUT there is also T-wave inversion that is typical morphology forreperfusion in V5 and V6.Thus, one must think of reperfusion. When there is reperfusion and there are large T-waves in...
Source: Dr. Smith's ECG Blog - March 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Our OMI Toolbox Application is out now !
We are happy to announce that our " OMI Toolbox " application has just released and ready for your use. As myocardial infarction (MI) and many other diagnoses (for example left ventricular hypertrophy, prior MI etc.) can cause ST-segment elevation (STE) on electrocardiogram (ECG), the distinction between them may be hard and complicated. Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO). For this purpose, only one set of diagnostic or differentiating criteria (STEMI criteria) is not enough, therefore a bunch of different tools are needed to make a&nbs...
Source: Dr. Smith's ECG Blog - March 3, 2023 Category: Cardiology Authors: Emre Aslanger Source Type: blogs
A COVID-19 vaccine exemption letter
BY ANISH KOKA
I recently saw a young man who came to see me because his place of future employment, a large health system was requiring him to complete the 1º series of his COVID-19 vaccination. He was concerned because he had chest pain after his first mRNA vaccine and was uncomfortable with the risks of a second mRNA dose. He attempted to get a Johnson and Johnson vaccine and was told by pharmacists he was not allowed to mix and match this particular vaccine as he had already received an mRNA dose. With no other option, he came to ask me whether I thought a vaccine exemption was reasonable in his case. He already had...
Source: The Health Care Blog - February 24, 2023 Category: Consumer Health News Authors: Ryan Bose-Roy Tags: Medical Practice Anish Koka COVID-19 vaccine exemption vaccines Source Type: blogs
A man in his 40s with epigastric pain and ST Elevation
Case submitted by Magnus Nossen MD, written by Pendell MeyersA previously healthy man in his 40s presented to the ED with epigastric abdominal pain off and on for several days. Vitals were within normal limits.It is unclear whether he had active pain at the time of the first ECG:What do you think?Here is PM Cardio ' s Queen of Hearts interpretation (AI ECG interpretation trained by Meyers, Smith, and PM Cardio team using thousands of cases and their outcomes):The output number ranges from 0 to 1, with numbers closer to zero meaning likely NOT OMI, and numbers closer to 1 meaning OMI. This result of 0.0002 is obviousl...
Source: Dr. Smith's ECG Blog - February 23, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, among other symptoms. What do you see?
This patient had many complaints including chest pain.The computer called this ***Acute STEMI***What do you think?STEMI never has a very short QT. This QT interval is 320 ms, with a QTc of around 350, depending on which correction formula you use. (There is Bazett, Fridericia, Hodges, Framingham and Rautaharju -- see here at mdcalc: https://www.mdcalc.com/calc/48/corrected-qt-interval-qtcIf the ST Elevation here were due to STEMI, it would be an LAD Occlusion. You can use myLAD Occlusion/Normal Variant STE formula on this. I did, and the result was the lowest value I have ever obtained (1...
Source: Dr. Smith's ECG Blog - February 17, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm
Conclusion: Millimeter-based STEMI criteria are not met in ECG #1. That said, in this patient with severe new chest pain — the overall ECG picture with ST-T wave abnormalities in 9/12 leads has to be considered (as stated by Dr. McLaren) — as " All concerning for acute LAD occlusion ". (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - February 13, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
What is the ECG Diagnosis?
I came across this ECG while reading ECGs for Cardiologs in order to train the Cardiologs Deep Convolutional Neural Network. I don ' t have any clinical information or any other associated ECGs on this case, but wanted to post it here because it is interesting and it ispathognomonic.What is it?This is a proximal LAD Occlusion. First, there are hyperacute T-waves in V2-V4. These are preceded by ST depression and are de Winter ' s T-waves, though somewhat atypical. There is also a hyperacute T-wave in aVL with subtle STE. There is reciprocal ST depression in II, III, and aVF: it is more vis...
Source: Dr. Smith's ECG Blog - February 10, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 60s with acute chest pain
Sent by anonymous, written by Pendell MeyersA man in his 60s presented with acute chest pain with diaphoresis. He had received aspirin and nitroglycerin by EMS, with some improvement. His vitals were within normal limits. Here is his triage ECG:2045:What do you think?The ECG is subtle, but diagnostic of infero-posterior OMI. The QRS is normal, yet in aVL the normal upright small QRS complex is followed by in appropriately large-volume T wave inversion, which is reciprocal to the T waves in lead III, which are probably hyperacute if compared to available baseline. Corroborating this is the subtle ST depression in V2-V3 whic...
Source: Dr. Smith's ECG Blog - February 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
This patient did not present with chest pain
This was posted a few years ago. I ' m highlighting it again, with comments from Ken Grauer below.This was sent to me by Jason Winter. @JasonWinterECGThis is a 36 yo m with h/o TBI and epilepsy. He had a seizure this morning and rolled out of bed unable to get up. There were no injuries and no chest pain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. The medics recorded a prehospital ECG: The computerized QTc is 397 msJason writes: "What ' s your thoughts Steve? "Jason was very skeptical of STEMI.What do you think?Jason,I agree.V4 especially looks li...
Source: Dr. Smith's ECG Blog - February 4, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Dueling OMI: does this 30 year old with chest pain have any signs of occlusion or reperfusion?
Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. Below is ECG #1 at triage. Are there any signs of occlusion or reperfusion?There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages. There’s mild inferior ST elevation in III that doesn’t meet STEMI criteria, but it’s associated with ST depression in aVL and V2 that makes itdiagnostic of infero-posterior Occlusion MI (from either RCA or circumflex) – accomp...
Source: Dr. Smith's ECG Blog - January 29, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)
Submitted by anonymous, written by Pendell Meyers. Additional case by Smith.Case 1A middle aged woman presented with acute chest pain and shortness of breath, unclear time since onset, and likely with episodic symptoms off and on throughout the day. Her vitals were within normal limits.ED1 @1512What do you think?Meyers: Very clear and specific for acute LAD OMI, with hyperacute T waves in the LAD distribution including leads V2-V6, II, III and aVF. Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of suf...
Source: Dr. Smith's ECG Blog - January 28, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Cardiology update: Should mRNA vaccine myocarditis be a contraindication to future COVID-19 vaccinations ?
BY ANISH KOKA
Myopericarditis is a now a well reported complication associated with Sars-Cov-2 (COVID-19) vaccinations. This has been particularly common with the messenger RNA (mRNA) vaccines (BNT162b2 and mrna-1273), with a particular predilection for young males.
Current guidance by the Australian government “technical advisory groups” as well as the Australian Cardiology Society suggest patients who have experienced myocarditis after an mRNA vaccine may consider a non-mRNA vaccine once “symptom free for at least 6 weeks”.
A just published report of 2 cases from Australia that document myopericarditi...
Source: The Health Care Blog - January 26, 2023 Category: Consumer Health News Authors: Ryan Bose-Roy Tags: Health Policy Anish Koka mRNA vaccine myocarditis Source Type: blogs
What is this Rhythm?
==================================My Comment by KEN GRAUER, MD (1/26/2023):==================================While reading ECGs — Dr. Smith came across the intriguing tracing shown in Figure-1. No history was available. However, the rhythm is indeed challenging — and illustrates a number of important principles in rhythm interpretation of interest to all emergency care providers.How would YOU interpret the ECG in Figure-1? Can you come up with a definitive rhythm diagnosis?Figure-1: 12-lead ECG and simultaneously-recorded 3-lead rhyth...
Source: Dr. Smith's ECG Blog - January 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain, and Cardiology didn't take the hint from the ICD
Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and GrauerA 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG:What do you think?Triage physician interpretation: -sinus bradycardia-lateral ST depressionsWhile there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. Additionally, lead V3 has ST depressions, which are always abnormal (recall that lead V3 will haveST elevation under nor...
Source: Dr. Smith's ECG Blog - January 23, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
