Unconscious + STEMI criteria: activate the cath lab?
Case submitted and written by Dr. Mazen El-Baba and Dr. Evelyn Dell, with edits from Jesse McLarenEMS brought a John Doe, in his 30s, who was found in an urban forest near a homeless encampment on a cool fall day. There were no signs of trauma on scene or on the patient. EMS reported an initial GCS of 8 with pupils equal and reactive. The patient had a witnessed generalized tonic-clonic seizure leading to GCS 4.Vitals: HR 45; systolic BP was 110-120; irregular respiratory rate; oxygen saturation was normal; tympanic temperature 30; glucose was 6. In the resuscitation room, the patient had another seizure that stopped after...
Source: Dr. Smith's ECG Blog - January 21, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Epsilon Wave
Epsilon wave, the classical ECG finding in arrhythmogenic right ventricular dysplasia is seen at the end of the QRS complex. Epsilon wave is typically seen in right precordial leads though it has been noted in left precordial leads in those with left ventricular involvement. ARVD is better termed arrhythmogenic cardiomyopathy because of the possibility of left ventricular involvement. Epsilon wave represents the delayed activation of surviving islands of myocardium within the fibrofatty tissue in ARVD [1]. Some have called it as a ‘post excitation’ wave, as a corollary to the delta wave in pre excitation.
It ...
Source: Cardiophile MD - January 20, 2023 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
OMI can be very subtle and easy to miss, but be a very large infarction.
I was reading ECGs on the system and came across this one. There is minimal STE in II, III, with an inverted T-wave in aVL.There is a very flat ST segment in V2, with 0.5 mm of STD, highly suspicious for posterior OMI.We showedin this paper that ANY amount of STD maximal in V1-V4 (especially in V2) in a patient with chest symptoms is posterior OMI until proven otherwiseI knew that if this is a patient with chest discomfort, that it is an infero-posterior OMI.So I went to the chart and found that it was from a 50-something woman with CP of a couple hours duration.Unfortunately, the OMI was not seen.When the ...
Source: Dr. Smith's ECG Blog - January 15, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Which is the Ideal site to ablate VT circuit ?
Management of recurrent ventricular tachycardia has developed a lot in recent times. Anti-arrhythmic drugs(AADs) were a cornerstone for recurrent and refractory VTs .Surgeries including CABG, repair of the aneurysm, and subendocardial resection has helped to control many post-MI ischemic VTs. Soon they became obsolete. Realistically, PCIs had little impact on post-MI VT for some unknown reasons. However, with the advent of ICDs and RF, ablation, a new dimension is added to this field.
ICDs, though an attractive device, don’t prevent a VT but vow to nullify the consequence of VT. This is problematic. ICDs in spit...
Source: Dr.S.Venkatesan MD - January 12, 2023 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs
Quiz post: do either or both of these patients have high lateral OMI / South African flag sign?
Written by Pendell Meyers, edits by SmithTwo patients presented with acute chest pain/pressure. Here are their ECGs:Patient 1:Patient 2:See below for " answers " , and below that for both cases." Answers " : Patient 1 shows very subtle high lateral OMI, South African flag sign. She had an acute LAD OMI in the process of reperfusion, see case below.Patient 2 has a normal variant ECG which mimics high lateral OMI, and ruled out for MI, see case below.Here is theSouth African Flag sign (Figure by Ken Grauer — with the original 12-lead from Patient 1 attached below — See his Comment from theApril 8, 2022 post in...
Source: Dr. Smith's ECG Blog - January 12, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A woman in her 50s with acute chest pain
Submitted and written by Anonymous, edits by Meyers and SmithA 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache.Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 FTriage ECG:ECG Interpretation:Sinus rhythm with normal QRS. There is slight STE in V1, V2, and aVR, with STD in V3-V6, I, aVL, and II. There are T waves in lead III which are suspicious for hyperacute T waves, with reciprocal negative large T wave inversions in aVL. I do not think this ECG is by itself diagnostico...
Source: Dr. Smith's ECG Blog - January 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
An ECG which is obviously diagnostic of OMI can appear wholly non-specific to most interpreters. A comment on AI.
This was texted to me by a former resident, with no information:What do you think?Here Ken Grauer has used the PM Cardio app to improve the image:This was my immediate response:" Acute proximal LAD OMI " To me it is obvious and diagnostic.There are hyperacute T-waves in I, aVL, V2-V6. These are wide, bulky, with large area under the curve relative to the QRS size.Furthermore, there is a QS-wave in V3 and qrS in V4, both diagnostic of MI at some time (past or present). We have shownhere and validatedhere that old MI has relatively small T-wave (by amplitude). In this situation (QS-waves), ...
Source: Dr. Smith's ECG Blog - January 1, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
30-something woman with a HEART score of zero, EDACS of 2, computer " Normal " ECG, and initial troponin < Limit of Detection
I was working in triage very late when a 30 yo previously completely healthy woman walked in with 30 minutes of central chest pressure.This ECG was recorded:The computer called it " Normal " except for " Possible right ventricular conduction delay "What do you think?I immediately recognized an inferior-posterior-lateral OMI. There are hyperacute T-waves in II, III, and aVF. They are too large, wide, fat, and bulky in comparison to the size of the QRS to be normal. The degree of upward concavity is less than normal. There is a downsloping ST segment in V2. There are relatively large T-waves in ...
Source: Dr. Smith's ECG Blog - December 23, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
See OMI vs. STEMI philosophy in action
by Emre AslangerDr. Aslanger is our newest editorial member. He is an interventional cardiologist in Turkey. Dr. Aslanger is also the author of the DIFFOCULT study:Emre K. Aslanger,a,⁎ Özlem Yıldırımtürk,b Bar ış Şimşek,c Emrah Bozbeyo ğlu,c Mustafa Aytek Şimşek,a Can Y ücel Karabay,b Stephen W. Smith,d and Muzaffer De ğertekina DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. International Journal of Cardiology Heart& VasculatureCaseA 40-year-old man presents with...
Source: Dr. Smith's ECG Blog - December 22, 2022 Category: Cardiology Authors: Emre Aslanger Source Type: blogs
Belt Monitors Heart Failure Patients
Researchers at Florida Atlantic University have developed a belt that can monitor heart failure patients for signs of disease progression. The wearable device measures heart rate, thoracic impedance, electrocardiogram, and motion, all of which can provide information on a heart failure patient’s status and potentially enable early detection of disease exacerbation. So far, the researchers have tested the device in a variety of everyday contexts, including routine activities, such as sitting, lying, standing, and walking, and found that it performs quite well. The researchers hope that the technology could help to reduce ...
Source: Medgadget - December 21, 2022 Category: Medical Devices Authors: Conn Hastings Tags: Cardiology Diagnostics Telemedicine FloridaAtlantic heart failure Source Type: blogs
A man in his 50s with acute chest pain and LVH
Sent by Drew Williams, written by Pendell MeyersA man in his 50s with history of hypertension was standing at the bus stop when he developed sudden onset severe pressure-like chest pain radiating to his neck and right arm, associated with dyspnea, diaphoresis, and presyncope. EMS arrived and administered aspirin and nitroglycerin. He reported several weeks of intermittent chest pain similar to the active pain, worsening over the past 2-3 days, some of them as long as an hour, but all spontaneously resolved and were of less intensity than the current symptoms.There are 2 very instructive posts which we link to at the bottom...
Source: Dr. Smith's ECG Blog - December 14, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal
Written by Pendell MeyersI was reading ECGs in a database (without any clinical information) when I came to this one:What do you think?Seeing only this ECG with no context, I thought this ECG was within normal limits. The upright and large T wave in V1 is unusual, but if it were hyperacute, I did not see reciprocal findings in V6 which would be concerning for LAD OMI pattern (we call that " precordial swirl " ).So, if I had to interpret this ECG with no other context, I would say I see no clear evidence of OMI.But I was able to see ECGs just before and after the ECG above.So I went back to the first ECG in this sequence, a...
Source: Dr. Smith's ECG Blog - December 12, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
65 year old with syncope and a'normal' ECG: discharge home?
A 65 year old with diabetes presented with a syncopal episode while sitting, associated with weakness but no chest pain or shortness of breath. Vital signs were normal and first ECG was labeled as normal by the computer and confirmed by the treating emergency physician and cardiology over-read. What do you think? There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages with J waves from early repolarization. There ' s inferior down-up ST segments and hyperacute T waves, with reciprocal up-down T wave in aVL. I sent this " normal " ECG without any informa...
Source: Dr. Smith's ECG Blog - December 6, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Syncope, hypotension, vomiting and diaphoresis in a 60-something male with Diabetes and Hypertension
I was texted this ECG by one of my partners, with the following history: A 60-something male with diabetes and HTN presented with syncope. Per EMS report, the patient had a syncopal episode at work. On medics arrival, patient noted to be pale and diaphoretic, SBPs 60-80s, complaining of nausea and had one episode of emesis en route, possible hematemesis. There was no chest discomfort, though the patient was non-English speaking and reportedly " stoic " .What do you think?This was my response, in quotes: " I have a sneaking suspicion that this is a mimic. Tough one! &n...
Source: Dr. Smith's ECG Blog - December 6, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Are these Hyperacute T-waves?
I received this ECG in a text message, with the message:" Hey, these look like hyperacute T waves to me, what do you think? It ’s an intubated septic nursing home patient. " " Here is her old ECG: "What do you think?Here is my response:" There is something wrong with this ECG. It might be another case of pulse tapping artifact. Change the location of the limb Electrodes and repeat the EKG. All leads except lead I look bizarre. "So he repeated the ECG after moving the limb lead electrodes:Much less bizarre appearing, and without the suggestion of hyperacute T-wavesPulse Tapping ArtifactEver sin...
Source: Dr. Smith's ECG Blog - December 5, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
