A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?
A 90-something year old woman presented with an acute mild stroke.She had a routine ECG as part of her workup:What do you think?This was shown to me in real time.I thought it had to be an inferior-lateral-posterior OMI. But the patient had no symptoms. Later, she did admit to some vague chest discomfort, but that could be due to the power of suggestion.The one strange thing that I noted at the time is that there is no reciprocal ST depression in aVL. This is extremely unusual in inferior OMI, even if there is simultaneous STE in V5-6.We studied this: In this paper on the importance of lead aVL f...
Source: Dr. Smith's ECG Blog - November 11, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Explain this ECG in the context of active chest pain, slightly elevated troponin without a delta, RCA culprit, and previous with LBBB
A 60-something yo female presented w/ exertional chest pain for 3 days. She had a recent positive stress test about one week ago. Pain was 8/10 and constant. She has been experiencing progressively worsening exertional dyspnea and chest tightness mostly when climbing up flights of stairs since early September. She underwent exercise echocardiogram in mid October where she exercised for nearly 7 minutes on the standard Bruce protocol and had typical anginal pain and shortness of breath. Baseline echocardiogram showed moderate LV systolic dysfunction with no wall motion abnormalities. Over the last...
Source: Dr. Smith's ECG Blog - November 9, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Fight Aging! Newsletter, November 6th 2023
This study aimed to gather valuable insights from pharmaceutical experts and healthcare practitioners regarding the potential and challenges of translating senolytic drugs for treatment of vascular aging-related disorders. This study employed a qualitative approach by conducting in-depth interviews with healthcare practitioners and pharmaceutical experts. Participants were selected through purposeful sampling. Thematic analysis was used to identify themes from the interview transcripts. A total of six individuals were interviewed, with three being pharmaceutical experts and the remaining three healthcare practitioners.
...
Source: Fight Aging! - November 5, 2023 Category: Research Authors: Reason Tags: Newsletters Source Type: blogs
Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?
By Magnus Nossen, edits by Grauer and SmithThe patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. She ' s had multiple PCI procedures. She also has sick sinus syndrome (SSS) and intermittent high grade AV block for which she had a dual chamber pacemaker implanted. On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. Just from the medical hx and clinical presentation this patient is very likely to be having an MI. The question is, does she need to go urgently to the cath lab or can she wait....
Source: Dr. Smith's ECG Blog - November 5, 2023 Category: Cardiology Authors: Magnus Nossen 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
Accelerated Epigenetic Age and Cardiovascular Risk Factors
Epigenetic patterns determine the behavior of a cell, and change constantly in response to cell state and the surrounding tissue environment. Epigenetic state can be used to measure biological age, the epigenetic clock. When an epigenetic clock indicates an age older than chronological age, that is referred to as epigenetic age acceleration. While the clocks are not fully understood in detail, it is thought that the specific epigenetic changes measured are reflective of the burden of cell and tissue damage and dysfunction that causes aging. This acceleration has been shown to correlate with risk and status of a number of a...
Source: Fight Aging! - November 2, 2023 Category: Research Authors: Reason Tags: Medicine, Biotech, Research 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
" Non-STEMI " is a worthless term.
A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. He had no h/o heart failure. Here is the first prehospital ECG (time 0, after one hour of pain): I do not see evidence of OMI, and neither did the Queen of HeartsHere is the 2nd prehospital ECG (time 10 minutes, after 70 minutes of pain): No changeOn arrival, the first ED ECG was recorded 20 minutes after the last one (90 minutes after pain onset): What do you think?Here is his most recent previous ECG:This was recorded after intervention for inferior STEMI (with massive ST Elevation, see below), and shows inf...
Source: Dr. Smith's ECG Blog - October 30, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?
A young man presented with continuous prolonged generalized weakness, lightheadedness, and presyncope. There was some dyspnea but no chest pain. Here is his ECG. This shows LVH, with high voltage.LVH can have very thick-walled ventricles and a correspondingly small LV cavity. LVH is a common etiology of heart failure with preserved ejection fraction, as it may results in a stiff ventricle with poor diastolic relaxation.See this articles: Heart Failure with Preserved Ejection Fraction (NEJM review)One etiology of LVH on the ECG is Hypertrophic Cardiolmyopathy (HOCM), and sometimes ECGs in pa...
Source: Dr. Smith's ECG Blog - October 28, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 60s with syncope and ST depression. What does the ECG mean?
Written by Sean Trostel MD, peer reviewed by Meyers, Smith, Grauer, etc.A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store.He did not have chest pain.Here is his triage ECG: What do you think?My interpretation:Sinus rhythm, normal QRS, widespread wavy ST depression leading into late T/U-waves with very prolonged QT. No evidence of OMI. QTc/QUc is in the range of 630 msec.What is the most likely cause of the patient ’s ECG findings, and wha...
Source: Dr. Smith's ECG Blog - October 25, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Does this T wave pattern mean anything?
Written by Michael Doyle DO and Timothy Palmieri MD. Edited by Bracey, Meyers, Grauer, and SmithA 50-something-year-old female with a history of an unknown
personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return
of spontaneous circulation. The described rhythm was an irregular, wide complex
rhythm. By EMS report, open pill bottles were found nearby at the scene, including quetiapine, fluoxetine, hydroxyzine, and gabapentin. She was successfully revived
after several rounds of ACLS including defibrillation and amiodarone.On arrival to the ED the patient was intubated with normal vi...
Source: Dr. Smith's ECG Blog - October 23, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?
Conclusions are identical to those of Dr. McLaren, namely:It isnot safe toavoid interrupting emergency physicians— simply because prior to the QOH (Queen Of Hearts) AI application — no computer interpretation of " normal " from an ECG of a patient with new or recent CP symptoms could be relied on. Emergency physiciansmustbe interrupted to take a quick look atall ECGs of patients who present with new or recent CP.Emergency physicians should (and can!) be expected with training to be able to identify non-stemi OMIs that elude the computer. It is essential that they be ab...
Source: Dr. Smith's ECG Blog - October 19, 2023 Category: Cardiology Authors: Jesse McLaren 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
Repost from Saturday Oct 14: The Queen gets it right with a better image
This is a case I posted Saturday, October 14.This ECG was texted to me after the fact with no information. What do you think?This is the ECG that I used for the post. It is high quality screenshot of a pdf:I had said that the Queen said this is Not OMI with low confidenceHowever, the image that had been texted to me and submitted to the Queen was not this one above. It was this one below: (photo of computer screen, lower quality):This is the image for which the Queen interpreted " Not OMI with Low Confidence "After posting, I wanted to getexplainability for the ECG, and I was unable to get the explainability fr...
Source: Dr. Smith's ECG Blog - October 17, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
This ECG was handed over at triage. See how the Queen of Hearts AI does with these explainability images.
Submitted by anonymous, written by Pendell MeyersI was at triage when this ECG was presented to me.What do you think?Here ' s what the Queen of Hearts thinks:Note that the Queen has " HIGH " confidence that this is OMI. As noticed by the AI,if the patient presented with chest pain, then even this subtle ECG is diagnostic of OMI. Specifically, this ECG is diagnostic of acuteLAD OMI, with hyperacute T waves likely in V3 and V4, very small but abnormal STE in V2-V4 (because of its there is a lot of STErelative to the very small QRS), and there is also some terminal T wave inversion in V4 which may suggest some elem...
Source: Dr. Smith's ECG Blog - October 15, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
