Back to basics: what is this rhythm? What are your options for treating this patient?
Written by Bobby Nicholson MD, with edits by Meyers, Smith, GrauerA woman in her early 40s presented to the emergency department for evaluation of palpitations. She reported that she has been experiencing this since she was diagnosed with COVID a little over 1 week ago. She reported a prior history of SVT and has previously performed vagal maneuvers at home with symptom resolution. She reports that she is now unable to vagal out of her palpitations and is having shortness of breath and dull chest pain. Her initial EKG is below.We see a regular tachycardia with a narrow QRS complex and no evidence of OMI or subend...
Source: Dr. Smith's ECG Blog - October 25, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
30 yo woman with trapezius pain. HEART Pathway = 0. Computer " Normal " ECG. Reality: ECG is Diagnostic of LAD Occlusion.
This is a repost of this amazing case: Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.A completely healthy 30-something year old woman with no cardiac risk factors had sudden onset of bilateral trapezius pain that radiated around to her throat. It resolved after about 5 minutes, but then recurred and was sustained for over an hour. She called 911.EMS recorded these prehospital ECGs:Time 0:In V2-V4, there is ST elevation that does not meet STEMI " criteria, " of 1.5 mm at the J-point, relative to the PQ junction. But there are also u...
Source: Dr. Smith's ECG Blog - October 23, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Is there Terminal QRS Distortion?
This ECG has ST Elevation in multiple leads. Is it normal STE? Or is it ischemic STE?What do you think?This ECG is interesting because itmimics TQRSD. There are no S-waves in V2 and V3. BUT look at the very prominent J-waves (J point notching)!! It is several mm high!This is a normal ECG.This patient had CO poisoning but did not have myocardial injury or OMI. In fact, there was no chest pain either.This is a great demonstration that a normal ECG, if there is no S-wave in V2 and/or V3, the lead without an S-wave MUST have a J-wave in order to be truly normal.Anterior OMI? ...
Source: Dr. Smith's ECG Blog - October 17, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Precordial Swirl -- 20 cases of Swirl or Look-Alikes
Pendell (Pendell Meyers, of course), with a little help from Smith, coined a new LAD Occlusion pattern " Precordial Swirl, " in which there is rightward STE vector, withSTE in V1 and aVR, with reciprocal STD in V5 and V6. It is due to transmural ischemia not only of the anterior wall and apex, but due to transmural ischemia of the septum, usually due to occlusion proximal to the first septal perforator. It is easy to mistake if for LVH (or vice versa) because LVH often shows STE in V1-V3 and STD in V5, 6. LBBB also has discordant STE in V1-V3 and STD in V5, 6 -- I will not be giving examples of ...
Source: Dr. Smith's ECG Blog - October 15, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain and anterior ST depression. What ’s the cause(s)?
Written by Jesse McLaren, with edits from Smith and GrauerA 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. What do you think? I sent this to Dr. Meyers without any other information, and he responded, “do you have a prior to make sure that it is all just because of the delta wave? Would be careful to make sure it’s not inferoposterior OMI superimposed on baseline WPW.” In other words, when there are ST/T wave changes thefirst question is whether there ’s abnormal depolarization, because this will be followed by abnormal ...
Source: Dr. Smith's ECG Blog - October 13, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 30s with cardiac arrest and STE on the post-ROSC ECG
Conclusions: outpatients with witnessed cardiac arrest and primary PEA carry a high probability of Massive Pulmonary Embolism________________Case Continued:" Initial ROSC EKG showed what appeared to be in atrial fibrillation with inferior ST elevations, depressions in aVL, concerning for STEMI. "He had multiple cardiac arrests with ROSC regained each time. " Endotracheal tube re-intubation was confirmed multiple times, bilateral breath sounds, yet O2 saturation remained in the 50s and 60s. I was able to visualize the ETT on initial intubation pass through the cords however given his continued hypoxemia, I felt it...
Source: Dr. Smith's ECG Blog - October 10, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Acute chest pain: " Activate the Cath Lab!!!!! " Or not?
I was called to the resuscitation room to manage a STEMI patient.I walked into the resuscitation area and was handed this ECG:What did I say?Within 3 seconds, I said: " That is a Fakeout " . (i.e., a STEMI mimic) Everyone was perplexed. This patient had presented with chest pain and had ST Elevation and they were certain this was a STEMI and they were going to activate the cath lab.Interestingly, my very smart partner Richard Gray who also reads all my blog posts, was working in triage and had already seen this ECG just as it was recorded, and immediately recognized this as a STEMI mimic. He went to the ch...
Source: Dr. Smith's ECG Blog - October 6, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain one day after a negative stress test
Discussion Points:The patient ’s ECG transmitted to ED providers by EMS showed T waves that are easily confused with the peaked T waves of hyperkalemia. Sometimes hyperacute T waves have this slimmer, taller appearance, and it can be difficult to distinguish them in these cases. The new STE in anterior leads helps to understan d these as hyperacute. Also, other signs of hyperkalemia were absent, as there was no P wave flattening or QRS broadening, bradycardia, new AV blocks or NSIVCD, bizarre QRS morphology, or Brugada patterning. Additionally the clinical context was clearly ACS in this case, and if there were remaining...
Source: Dr. Smith's ECG Blog - October 3, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
What is Wellens ’ syndrome?
What is Wellens’ syndrome?
The original description of Wellens’ syndrome dates back to 1982 in which they identified a subgroup of patients admitted with unstable angina who are at high risk of development of an extensive anterior wall myocardial infarction. These patients with critical stenosis high in the left anterior descending coronary artery, had characteristic ST-T segment changes in the precordial leads on or shortly after admission. They noted this finding in 26 of their 145 patients admitted because of unstable angina. In spite of symptom control with nitroglycerine and beta blockade, 12 of the 16 pat...
Source: Cardiophile MD - September 26, 2022 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
A 50 year old with chest pain? What is going on? By Emre Aslanger.
Posted by Emre Aslanger, our newest blog Editor. Emre is a distinguished cardiologist in Turkey, and has published widely on the ECG in OMI and other areas.Emre Aslanger Google Scholar ProfileA 50-year-old male with a 20 years ’ history of diabetes mellitus treated with metformin only presents with chest pain that started 20 minutes ago. The pain radiates to left inner arm and is now about to resolve. His admission ECG is given below.What do you think?You can click on it to make it larger, but let ' s make it a bit easier to see here:What do you think?(you can still click on it to make it larger)Although the wa...
Source: Dr. Smith's ECG Blog - September 25, 2022 Category: Cardiology Authors: Emre Aslanger Source Type: blogs
A man in his 50s with acute chest pain without STEMI criteria. Trop negative. Cath lab cancelled. But how about the ECG and echo?
Case submitted by Matt Tanzi MD, written by Pendell MeyersA man in his early 50s presented with substernal chest pain and that started 1 hour prior to arrival. There was some radiation to the left jaw and diaphoresis. He had ongoing pain on arrival.Initial triage ECG:What do you think?I sent this to Dr. Smith who immediately replied that it is diagnostic of OMI, but difficult to tell whether it is1) anterolateral with de Winter morphology, or instead2) A combination of Aslanger ' s pattern (inferior OMI with single lead STE in III and reciprocal STD in I, aVL, plus widespread STD of subendocardial ischemia) with ...
Source: Dr. Smith's ECG Blog - September 22, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
This ECG is nearly pathognomonic. What is it? (hint: it's not Wellens')
I was texted this ECG:What did I say?My response: " takotusubo "Even without a history, this is the likely diagnosis. Later, I obtained the history: 60-something woman who presented with agitation and had taken a benzodiazepine overdose. There was no report of chest pain. She had a respiratory alkalosis, with venous pH of 7.56 (equivalent to an arterial pH of higher than 7.60 and possibly contributing to the long QT and ECG abnormalities). Electrolytes were normal. She was also on Duloxetine, which can prolong the QT, and on Lithium (but her level was very low).This is almost certainly ta...
Source: Dr. Smith's ECG Blog - September 19, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain, peak troponin 100,000 ng/L and this ECG on discharge: what ’s the diagnosis?
Written by Jesse McLaren, with edits by Smith Usually cases are presented in chronological order the way they appear in real life. But this case will be represented in reverse chronological order. At each step we ’ll ask the question, “what’s the diagnosis?” using the STEMI paradigm (was this STEMI or NSTEMI?) and OMI paradigm (was this Occlusion MI or Non-Occlusion MI?). Discharge A 60 year old without prior cardiac history was admitted with chest pain, had a peak troponin of 100,000 ng/L (normal<16 in female and<26 in males), and was discharged with the following ECG (#4). What ’s the...
Source: Dr. Smith's ECG Blog - September 13, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 60s with chest pain and LBBB
Sent by Ali Khan MD, written by Pendell MeyersA man in his 60s with HTN, HLD, known prior LBBB, presented with episodes of chest pain radiating to the left shoulder, with diaphoresis and dyspnea. Episodes started yesterday after starting to exercise, came and went throughout the day, and he decided to present to the ED the next morning after the one of these episodes failed to resolve like the others.Here is his ECG at triage with ongoing pain (prior unavailable):Same image optimized by PM Cardio appWhat do you think?I sent this to Drs. Smith, McLaren, and Grauer all of whom immediately diagnosed LAD occlusion based ...
Source: Dr. Smith's ECG Blog - September 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Weekly Overseas Health IT Links –10th September, 2022.
This article is adapted fromVoices in the Code: A Story About People, Their Values, and the Algorithm They Made,out Sept. 8 from Russell Sage Foundation Press.In May 2021, I got a call I never expected. I was working on abook about A.I. ethics, focused on the algorithm that gives out kidneys to transplant patients in the United States. Darren Stewart —a data scientist from UNOS, the nonprofit that runs the kidney allocation process—was calling to get my take: How many decimal places should they include when calculating each patient’s allocation score? The score is an incredibly important number, given it determines w...
Source: Australian Health Information Technology - September 10, 2022 Category: Information Technology Authors: Dr David G More MB PhD Source Type: blogs
