A 40-something woman with severe chest pain and ST Elevation
This 40-something woman presented with severe anterior chest pain.Theprehospital ECG looked the same and the medics were worried about the ST Elevation and about STEMI/OMI.What do you think?There is ST Elevation thatmeets STEMI criteria in 3 consecutive leads V2-V4. The T-waves in V2-V4 appear hyperacute. The heart rate is 125!!But, as we have discussed often, when there istachycardia, you must doubt the diagnosis of acute OMI. Unless the OMI is resulting in decreased stroke volume, or there is an additional disorder, there should not be tachycardia. There must be another etiology or an addition...
Source: Dr. Smith's ECG Blog - March 3, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Missing ECG signs of OMI is associated with early death
Written by Sean Trostel MD, with edits by Smith and MeyersA man in his 80s with history of CAD, MI s/p PCI, HTN, HLD, Afib, and HFrEF, presented with sudden onset, aching, central chest pain radiating to the left arm and shortness of breath that began in the morning, 1 hour prior to arrival to the ED. This was his initial triage ECG, recorded one hour after onset of symptoms, and a baseline ECG below for comparison:What do you think?Baseline on file: This ECG was interpreted as sinus bradycardia with no acute ST or T wave changes compared to prior. Despite the very poor quality and wanderin...
Source: Dr. Smith's ECG Blog - February 25, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Humanoid Robot Measures Blood Pressure with a Touch
Researchers at Simon Fraser University in Canada unveiled a humanoid robot that can measure blood pressure by touching a patient’s chest. The robot uses sensors on its fingertips to perform the measurements. Inspired by blood-sucking leeches, the dry electrode sensors infer blood pressure by combining electrocardiogram (ECG) and photoplethysmogram (PPG) readings, although happily, they don’t suck blood. The Canadian team hopes that the technology could help in automating routine medical procedures, and also provide a measure of safety for patients and healthcare staff by reducing in-person interactions during the COVID...
Source: Medgadget - February 23, 2022 Category: Medical Devices Authors: Conn Hastings Tags: Cardiology Geriatrics Medicine Source Type: blogs
A 40-something man with very elevated blood pressure and acute severe chest pain
This 40-something male whose only medical history was hypertension presented with acute chest pain.A 12-lead ECG was immediately recorded within minutes of arrival at triage: What do you think? Is the STE in V2-V4 due to normal variant ST Elevation (so called " Early repolarization " ) or is the STE due to LAD Occlusion (OMI)?The very astute triage physician immediately recognized LAD Occlusion (LAD Occlusion MI or OMI). Why?There is some ST elevation, but it does not meet " STEMI criteria " . But there are hyperacute T-waves (wide and " bulky " in proportion to the QRS). There are also down-up ...
Source: Dr. Smith's ECG Blog - February 22, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A comatose patient with a carbon monoxide level over 50%
A young man had an accidental exposure to carbon monoxide (CO). He was comatose and intubated and his initial Carboxyhemoglobin level was over 50%.An ECG is always recorded for CO toxicity. This was his ECG. It was shown to me with worry for ischemic ST elevation, which is certainly possible from severe CO toxicity, or concomitant ACS. In fact, there is laboratory evidence that CO toxicity increases Platelet –neutrophil aggregates and plasma myeloperoxidase (MPO) concentration and thus may precipitate ACS (though this is by no means clinically proven). Intravasc...
Source: Dr. Smith's ECG Blog - February 18, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
The Slimmest ECG Ever Created: A Review
A couple of weeks ago, AliveCor, a leading innovator in the FDA-cleared personal electrocardiogram (ECG) technology space, announced the launch of the KardiaMobile Card.
The KardiaMobile Card is the slimmest and smallest self-contained, commercially available ECG that has been created to date. It is the size of a standard credit card, and is able to deliver a medical-grade, single-lead ECG in 30 seconds.
It’s very empowering that such a small device has been cleared for use by the FDA, as this puts the power of real-time ECG analysis directly into patients’ wallets or purses and provides the user with a...
Source: Medgadget - February 14, 2022 Category: Medical Devices Authors: Alice Ferng Tags: Cardiology Exclusive OTC kardia Source Type: blogs
A 40-something without past history presents with wide complex tachycardia and crushing chest pain
See Ken Grauer ' s important and detailed ECG analysis at the bottom.CaseA 40-something with no PMH presented with palpitations, tachycardia, and crushing chest pain.This was the prehospital ECG.Sustained wide complex tachycardia. Is it VT or SVT with Aberrancy?Also: there is no concordant ST segments or clearly excessively discordant ST segments, so superimposed Occlusion MI (OMI) is unlikely.There is a regular wide complex tachycardia, without P-waves, and anLBBB configuration andinferior axis. [LBBB "configuration" is different from LBBB: it means that there is a predominant S-wave in V1 and V2 and...
Source: Dr. Smith's ECG Blog - February 14, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 50s with " no reciprocal ST depression " and " diffuse " ST elevation. What does diffuse actually mean?
CONCLUSION: I completely agree with Dr. Meyers that ST-T wave changes in thisinitial ECG shown inFigure-1 are definitely not “diffuse”.The “beauty” of medicine — is that there is often more than a single appropriate answer or approach to any clinical situation. As a result — I choose to continue my use of the term“diffuse”for those selective situations that I describe above. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - February 12, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Occlusion/reperfusion through 6 ‘normal’ ECGs
This is written and contributed by Jesse McLaren (@ECGCases), with comments and edits by Smith, and commentary by Ken Grauer (@EKGPress)An 80 year-old female presented with weakness and a fall, with normal vitals and no injuries. The ECG was labeled ‘normal’ by the computer, later confirmed by the cardiologist. What do you think? There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages. There’s usually a small amount of concave ST elevation in V2-3 but here there is horizontal ST depression in V2 and possibly V1. Smith: without any furt...
Source: Dr. Smith's ECG Blog - February 10, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??
This study looked at less than 1000 cases, which is not nearly enough (see below for analysis) and they used cardiologists as the gold standard (a very poor gold standard), NOT presence or absence of Occlusion MI (which we have done in all of our ECG studies, and must be ascertained by 1) TIMI 0/2 flow on angiogram or 2) culprit + TIMI 3 flow and very high troponin. So this study is worthless and must be ignored. And the Clay Smith at Journal Feed comment was right on.In our case, the emergency physician was well trained in identifying subtle LAD Occlusion MI and ignored the computer.I have here30 cases of " Com...
Source: Dr. Smith's ECG Blog - February 4, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Subtle ECG Signs of OMI in LBBB
A 70 yo F with no previous cardiac history, but with a h/o hypertension, hyperlipidemia, and strong family history of ACS, presented with one hour of classic chest pain and appeared uncomfortable.Her systolic BP was 210. The ECG is here:Atypical LBBB (see explanation below)As for Occlusion MI (OMI), what do you think?A bedside echo was normal to that provider ' s eye (no bubble contrast).She had a CT for dissection that was negative.A 2nd ECG was recorded:There is an atypical left bundle branch block (LBBB) -- atypical because the R-wave in V6 is not all upright. But the Smith Modified Sgarbossa criteria w...
Source: Dr. Smith's ECG Blog - January 31, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 60s with syncope. In syncope, what are we looking for on the ECG, and why?
Submitted and written by Rachel Plate M.D., with some edits by Smith and Meyers A man in his 60s with history of type 2 diabetes, obesity, obstructive sleep apnea requiring nightly CPAP, and hypertension presented for evaluation following a witnessed syncopal episode at home. The patient noted this occurred after standing and he did have prodromal symptoms including lightheadedness. EKG was obtained and shown below.What do you think? The ECG shows sinus rhythm a bifascicular block, both a right bundle branch block and a left anterior fascicular block. The P waves are hard to discern with the artifact ...
Source: Dr. Smith's ECG Blog - January 28, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 40s with chest pain and T wave inversion
Written by Pendell Meyers with edits by SmithA man in his early 40s with history of HTN presented to the ED for feeling lightheadedness and mild " beating " chest pain off and on last night, but resolved at the time of ED presentation. He still felt some lightheadedness during evaluation. He stated that he used ecstasy yesterday prior to the onset of symptoms. Vitals were within normal limits on arrival.Here is his ED ECG on arrival:What do you think?Sinus rhythm. The narrow QRS with relatively high voltage is overall most consistent with a young healthy heart, less likely pathologic LVH (including HOCM). There are no sign...
Source: Dr. Smith's ECG Blog - January 22, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Which ACS had more myocardial damage? The one that meets STEMI criteria, or the one with the'normal' ECG?
Discussion According to the current paradigm based on ECG millimeter criteria, the first patient had STEMI requiring emergent reperfusion while the second did not have STEMI so could have been treated with delayed reperfusion. But the second patient had a totally occluded artery leading to a large MI despite rapid reperfusion, and admitting them as “NSTEMI” with next day angiography could have been fatal. According to the discharge summaries, which seemed to be based on culprit lesions that received rapid reperfusion, both patients had “STEMI” despite the first never having a rise in troponin and the sec...
Source: Dr. Smith's ECG Blog - January 18, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.
Written by Pendell Meyers with edits by SmithA man in his 60s called EMS apparently for shortness of breath. EMS found him in distress and hypoxemic requiring 4 L nasal cannula to maintain oxygen saturation greater than 93%.Here is his triage ECG:What do you think?An old ECG was available on file, from 2 years ago:RBBB, otherwise normal.The triage ECG is diagnostic of life threatening hyperkalemia (sodium channel blockade would also produce this pattern, but the patient was not known to be on any sodium blocking medications). There is the very common brugada pattern STEMI mimic seen in V1 and partially in V3 and aVR....
Source: Dr. Smith's ECG Blog - January 16, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
