A middle-aged man with acute chest pain.
A 50-something male had onset of chest pain 1 hour prior to ED arrival. It is constant, 9/10, left-sided CP that radiates into left arm and jaw. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. Has never had this before. Takes metoprolol for HTN. Here is the triage ECG:What do you think?This was not identified as OMI by either the conventional algorithm nor the triage faculty physician.Smith: I think leads V3 and V4 are highly concerning, and all but diagnostic, for acute LAD occlusion. I would activate the cath lab, or at least look f...
Source: Dr. Smith's ECG Blog - September 1, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 70s with chest pain
Case sent by Logan Stark MD, written by Pendell Meyers A woman in her 70s presented with acute chest pain. It started 10 hours prior to arrival, then had improved, then recently returned. No prior ECG was available. Here is her triage ECG:What do you think?The ECG was sent to me with no information, and I replied " OMI " .I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict:V1 and V2 have abnormal STE, and V2 has a hyperacute T wave. There is reciprocal STD in II, III, and aVF. One more thing that should be mentioned: since there are only Q waves from V1 to V3, it is possible that t...
Source: Dr. Smith's ECG Blog - August 30, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
75 year old dialysis patient with nausea, vomiting and lightheadedness
Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal
disease was sent to the ED after dialysis for three days of nausea, vomiting,
loose stool, lightheadedness and fatigue. RR18 sat 99% HR 90 BP 90/60, afebrile. Below is the 15 lead ECG. What do you think? There ’s normal sinus rhythm, normal conduction, normal axis,
normal R wave progression and normal voltages. There’s subtle inferior ST
elevation with straightening of the ST segment, reciprocal ST depression and T
wave inversion in aVL, and ST depression in V2. This is diagnostic of
infero-posterior OMI, but it is falsely n...
Source: Dr. Smith's ECG Blog - August 19, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
What does the ECG show in this patient with chest pain, hypotension, dyspnea, and hypoxemia?
Written by Pendell Meyers, with some edits by SmithA man in his 40s with many comorbidities presented to the ED with chest pain, hypotension, dyspnea, and hypoxemia.The bedside echo showed a large RV (Does this mean there is a pulmonary embolism as the etiology?)Here is his triage ECG:What do you think? Lots of info here.The rhythm is 2:1 atrial flutter. The flutter waves can conceal or mimic ischemic repolarization findings, but here I don ' t see any obvious findings of OMI or subendocardial ischemia.The QRS is around 100 msec wide (narrow), but with very abnormal morphology including a large R-wave in V1, dee...
Source: Dr. Smith's ECG Blog - August 14, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain and T wave inversion, NSTEMI?
Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLarenA 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. The nurse alerted the MD because the patient was still symptomatic, diaphoretic and “looking unwell”. What do you think? ECG interpretation: sinus rhythm, normal conduction (PR, QRS, and QTc), normal axis, delayed R-wave progression, and normal voltages. There ’s primary TWI inferiorly (aVF and III) and V6, with reciprocal tall T-wave in lead I/aVL, and a Q wave in III. The...
Source: Dr. Smith's ECG Blog - August 10, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Lecture by Smith: Selected Cases of Occlusion MI (OMI), or not, on the ECG
This may be my best lecture yet. I gave it virtually to the Kaiser group.You can access it also on the " Lectures and Podcasts " link on the Banner above.https://drive.google.com/file/d/1SSe2AmEyfkrQhRJt1FGmVxvnt3g3c4BN/view?usp=drive_link===================================MY Comment, by KEN GRAUER, MD (8/6/2023):===================================Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI ”. For skeptics (including cardiologists) — Any questions about “Who is Dr. Smith?” are compellingly answered by the several...
Source: Dr. Smith's ECG Blog - August 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
OMI Pocket Guide
📕OMI Pocket Guide TheOMI Pocket Guide (https://omiguide.org) is a user-friendly online resource designed to help healthcare professionals learn how to recognize subtle signs of acute coronary occlusion on the ECG which represent occlusion myocardial infarctions (OMI). Learning to recognize OMIs is an important clinical skill because it helps identify the subpopulation of " NSTEMIs " who are likely to be found with total thrombotic occlusion at the time of cardiac catherization.Although there are more criteria to consider when looking for OMIs compared to STEMIs, anyone can learn them, and this guid...
Source: Dr. Smith's ECG Blog - August 3, 2023 Category: Cardiology Authors: Mark Hellerman Source Type: blogs
Profound ST depression in II, III, aVF
Conclusion:Type II MI probable due to hypoxia and tachycardia from resp arrest and amphetamine use. Whether the ST Depression on the ECG represents ischemia or not is uncertain, but it does not represent acute coronary syndrome.===================================MY Comment, by KEN GRAUER, MD (7/26/2023):===================================The most interesting aspects of today ’s case are: i) The tale told by the 6 ECGs; and, ii) The surprise finding of positive troponins! The Sum is More than Each of its Parts:If we look back at the initial ECG&nb...
Source: Dr. Smith's ECG Blog - July 27, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Patient with Vertigo
This patient presented with vertigo and had an ECG recordedWhat do you think?I saw this and was worried about inferior OMI due to some subtle STE in III with very worrisome reciprocal findings in aVL. But the well-formed Q-wave and the presence of a normal T-wave in inferior leads led me to believe this was Old Inferior MI with persistent ST Elevation, otherwise known as inferior LV aneurysm.Anterior LV aneurysm is much easier to recognize because the Q-wave is usually a QS-wave (no R-wave at all), in at least one lead. Or at least only a very tiny r-wave (1 mm or so).Thus, acute inferior OMI and inferior LV an...
Source: Dr. Smith's ECG Blog - July 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 70s with weakness and syncope
DiscussionBrugada Type 1 ECG changes are associated with sudden cardiac death (SCD) and the occurrence of ventricular dysrhythmias. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% per year. In patients that only have this pattern induced by a sodium channel blocking agent have a lower rate of SCD (0 - 0.35% per year)[1]. Drugs that have been associated with Brugada ECG patterns include tricyclic antidepressants, anesthetics, cocaine, methadone, antihistamines, electrolyte derangements, and even tramadol. [2]. Our patient had a Brugada Type ...
Source: Dr. Smith's ECG Blog - July 22, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Pulmonary Arterial Hypertension: Unraveling Its Impact On Heart And Lungs
Conclusion
Navigating the complexities of Pulmonary Arterial Hypertension (PAH) might seem daunting. However, with the right knowledge and proactive approach, it’s possible to manage the condition and maintain a good quality of life.
PAH, a unique type of high blood pressure affecting the arteries in the lungs, can put extra strain on the heart. Over time, this can lead to heart failure. The condition’s root cause may vary, from genetic factors to other health issues like heart defects, liver disease, or autoimmune diseases. Remember, sometimes the cause remains unknown, resulting in idiopathic pulmonary ...
Source: The EMT Spot - July 19, 2023 Category: Emergency Medicine Authors: Michael Rotman, MD, FRCPC, PhD Tags: Blood Pressure Source Type: blogs
A young man with tachycardia. Should We Try Adenosine?
A young man presented with weakness and fever. His pulse was 186. An ECG was recorded:What do you think?There is a regular narrow complex tachycardia. Thus, it is supraventricular tachycardia. It is important to remember thatSVT includes Sinus Tachycardia! That is why I like to call re-entrant SVT " Paroxysmal " SVT, or PSVT). The sinus node is " supraventricular " and in young people it can beat VERY fast. Especially when there is fever.You must look closely for P-waves, and if you do, the P-waves are obvious (if you look at the leads most likely to reveal P-waves: leads II and V1)...
Source: Dr. Smith's ECG Blog - July 19, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
I was reading ECGs on the system when I came across this one, called " normal " by the conventional computer algorithm
I come in early for every shift to read the ECGs on the system that have not yet been " confirmed " . I came across this one:The computer calls is: " SINUS RHYTHM. NORMAL ECG "What do you think? Be VERY careful when the computer calls the ECG " Normal " . I saw the inferior ST depression (which is reciprocal to subtle STE in aVL) and the subtle ST depression in precordial leads and thought:" If this patient came in with chest pain, then it is an acute OMI. "So I looked on the computer. Turns out that it was a 50-something patient with no previous cardiac history who had called 911 for chest pain...
Source: Dr. Smith's ECG Blog - July 12, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
This was texted to me by a former resident. An 80-something woman who presented with chest pain and dyspnea.
This was texted to me. An 80-something woman who presented with chest pain and dyspnea.What do you think?The rhythm appears to be atrial fibrillation. In any case, it is clearly a supraventricular rhythm. There is significant ST depression in V2-V4. Is this posterior OMI?Before jumping to any conclusions about the significance of ST-T abnormalities, you must first be certain that they are not a result of (secondary to) any QRS abnormalities. Do you see any such abnormalities?There is a large R-wave in V1. Is this RBBB? No, it is not RBBB. The QRS is not wide enough, there are no wi...
Source: Dr. Smith's ECG Blog - July 7, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
This was texted to me in real time. The patient has acute chest pain.
This was texted to me in real time. The patient has acute chest pain.What do you think?Here was my answer:" Not ischemia. Chronic. Maybe HOCM or another form of LVH. I would not activate cath lab. Get serial troponins "It is a scary ECG, with a lot of ST Elevation and what appear to be hyperacute T-waves in inferior leads, and profound reciprocal ST Depression in aVL. There are Q-waves in V4-V6, with what appear to be hyperacute T-waves. Any objective, rule-based analysis of this ECG would scream " STEMI " or " OMI " . But, alas, ECGs are like faces. No measurements can t...
Source: Dr. Smith's ECG Blog - July 5, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
