How Significant is First Degree Heart Block?
First degree heart block is an abnormality in the electrical conduction of the heart noted on the ECG, the recording of the electrical activity of the heart. It is not a block in the blood vessels of the heart which we are more familiar with. The waves on an ECG are P, QRS complex and the T wave.
Normal interval between the onset of the P wave and the onset of QRS complex is up to one fifth of a second (0.2 seconds). When this interval is increased, it is called first degree heart block or first degree atrioventricular or AV block to be specific. Atria are the upper chambers of the heart and ventricles the lower chambers.
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Source: Cardiophile MD - April 23, 2024 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
A 29 year old male with chest pain, ST Elevation, and very elevated troponin T
By Magnus NossenThis ECG is from a young man with no risk factors for CAD, he presented with chest pain. How would you assess this ECG? How confident are you in your assessment? What is your next step? Note: lead format is CabreraI was sent this ECG in real time. The patient is a young adult male with chest pain. The chest pain was described as pressure like and radiation to both arms and the jaw. Symptoms were on and off. The pain was worse in the night and better when moving. The patient sought medical attention when the pain recurred for a second straight night accompanied by arm numbness as well as radiating pain. The ...
Source: Dr. Smith's ECG Blog - April 9, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Palpitations and presyncope in a 40-something
Discussion: Putting all of the information together this patient is most likely suffering from arrhythmogenic cardiomyopathy (AC) better known as ARVC. The medical hx is typical, with sudden onset tachydysrhythmia during physical exertion. It is not uncommon for the initial presentation to be sudden cardiac death (SCD). In fact it is one of the leading causes of SCD in people age less than 40 years. Thus it is very important to identify this disorder. AC is a disease in which myocardium is replaced by fibrofatty tissue. This usually and predominantly affects the RV free wall and apical regions, but it can affect the left v...
Source: Dr. Smith's ECG Blog - March 24, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Why is the angiogram normal?
Written byWilly FrickA man in his 50s with a 15 pack-year smoking history presented to his primary care physician ' s office complaining of intermittent headache. He also complained of intermittent mild chest pain radiating into into both shoulders and his back, as well as occasional unexplained sweating. (Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive). The primary care physician ' s note indicates low suspicion for cardiac ischemia, but " for completion, check troponin and ECG. " If an ECG was obtained in the office,...
Source: Dr. Smith's ECG Blog - March 17, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Concerning EKG with a Non-obstructive angiogram. What happened?
CONCLUSION: Given resolution of severe CP in association with the above marked improvement of ST-T wave abnormalities in virtually all leads during the less than 1 hour between the recording of ECGs #1 and #2 — this strongly suggests reopening of a " culprit " vessel (whichever vessel this was) — regardless of the fact that " no obstructive lesion was seen " at the time the cardiac catheterization happened to be done.The more than doubling of Troponin (even though " normal limits " for Troponin were not surpassed) — is consistent with a brief OMI, with only...
Source: Dr. Smith's ECG Blog - December 19, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.
Acute coronary syndrome in a pediatric patient?Written by Kirsten Morrissey, MD with edits by Bracey,
Grauer, Meyers, and Smith An older teen was transferred from an outside hospital
with elevated serum troponin and and ECG demonstrating ST elevations. The patient was obese and had a medical history of only recurrent tonsillitis status post tonsillectomy and adenoidectomy but was otherwise healthy and fully vaccinated. He reported 1.5 days of chest pain that started as substernal and crushing in nature awakening him from sleep and occasionally traveling to right side of neck. The pain ...
Source: Dr. Smith's ECG Blog - December 5, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?
A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest. She said this was midsternal and felt like a tightness. This originally radiated into her left arm. Over some time and the pain moved into her other arm as well as her jaw. She also had some shortness of breath. She was brought in by ambulance and re...
Source: Dr. Smith's ECG Blog - November 15, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
How important are old ECGs in Non-obvious cases of potential OMI?
Conclusion: As per Dr. Smith — the cath lab was initially activated on the basis of the history of changing symptoms occurring in association with dynamic ST-T wave changes on these 3 serial ECGs shown in Figure-1.BUT — Review of this patient ' s medical chart revealed previous ECGs showing a similar pattern of labile ECG changes. Some patients do this ... that is, show a pattern of labile ST-T wave changes not due to an acute coronary event.Despite the seemingly worrisome ST-T wave changes on serial tracings shown in Figure-1 — an acute event was definitively ruled out b...
Source: Dr. Smith's ECG Blog - November 14, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
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
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
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
What clinical scenario fits best?
Below are 4 ECGs from the same patient. Accompanying the ECGs is some clinical information. Look at the ECGs and consider the timeline and other information. At the bottom will be five alternative clinical scenarios to explain the findings.Which one do you think fits better with the ECGs and their timeline? The patient is a 60 something female. She was admitted to the hospital with clinical signs of infection. She was febrile and hypotensive at presentation. As part of her work up in the ED an ECG was recorded.What do you think?ECG#1 - day 1The above ECG shows sinus rhythm with a narrow QRS and normal axis. There is B...
Source: Dr. Smith's ECG Blog - October 12, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Should we activate the cath lab? A Quiz on 5 Cases.
Imagine you just started your ED shift. It ' s a busy Friday afternoon. Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECGs that has not been overread by a physician. All of the patients presented with chest pain, and they are all in triage.Which, if any, of these patients has OMI, with myocardium at risk and need for emergent PCI?ECG#1ECG#2ECG#3ECG#4ECG#5See outcomes of all 5 below, with the Queen of Hearts AI Bot interpretation.YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)If you want this bot to help you make the early diagnosis of OMI and...
Source: Dr. Smith's ECG Blog - October 8, 2023 Category: Cardiology Authors: Magnus Nossen 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
