Nonspecific symptoms with RBBB and New ST Elevation. Anterior STEMI, right? What does the echo show?
A 50-something male with a history of COPD and substance use disorder who presented with generalized weakness and exacerbation of chronic back pain that is now radiating to his neck, and headache. He also developed nausea, alternating " hot and cold flashes " , and generalized weakness the previous evening. He became anxious about his symptoms and then used crack cocaine as well as drank alcohol last night. His symptoms have persisted since then. He states he has felt short of breath since last night. He denies any chest pain, though notes he has a " odd " sensation in his chest. Vital signs w...
Source: Dr. Smith's ECG Blog - March 28, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
Acute chest pain, ST Depression in V2 and V3, relief with Nitroglycerine, " normal " coronaries, and apical ballooning. Is it takotsubo?
This was submitted by Michael Fischer, one of our outstanding2nd year EM residents at Hennepin Healthcare.CaseA previously healthy female in her 40s presented 1 hour after abrupt onset 10/10 crushing chest pain that started while brushing her hair that morning. The pain radiated to her bilateral jaw and right shoulder, and did not seem to be exertional or pleuritic in nature. Here is her pre-hospital ECG: What do you think?Smith: V2 and V3 have some minimal ST depression with downsloping. This is highly suggestive of posterior MI.This was read by EMS as non-specific. Aspirin 324mg was given by EMS. Ni...
Source: Dr. Smith's ECG Blog - January 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
ECG with Aslanger's Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory.
A 52 y.o. male presented with persistent central chest pressure, without radiation, SOB or diaphoresis, which began at rest approximately one hour prior to arrival. He had never had pain like this before. He felt slightly nauseous earlier but no vomiting. He is denying any back pain or abdominal pain. An ECG was recorded during pain:What do you think?This shows significant ST depression in I, II, and V4-V6, with reciprocal ST Elevation in aVR. This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with...
Source: Dr. Smith's ECG Blog - January 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
The Diagnosis of OMI does not depend on the ECG. But if you recognize it, that's great.
An elderly woman presented with 4 days of waxing and waning epigastric/substernal chest pain, worse on the day she presented. She described the pain as a constant chest pressure, 6/10, without radiation to left arm, jaw or back, and without change in with breathing or movement.Here is her ED ECG:This was read as non-specific. What do you think?I found this case while looking through a stack of ECGs, without clinical information. I immediately thought " Acute LAD occlusion. " Why? There are QS-waves in V2-V4. These suggest old anterior MI, or subacute MI. But as we ' ve de...
Source: Dr. Smith's ECG Blog - December 6, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
Dynamic ST Change in a mid-50s Man with Chest Pain
===================================MY Comment by KEN GRAUER, MD (8/21/2020):===================================The patient is a mid-50s man who presented to the ED for new-onset chest pain of ~1 hour duration. His symptoms awakened him from sleep. He was still having chest pain in the ED at the time ECG #1 was done (Figure-1).QUESTION:HOW would YOU interpret his initial ECG that is shown in Figure-1?Figure-1: The initial ECG in this case (See text).MY THOUGHTS on ECG #1: Although significant baseline artifact is seen (especially in the limb leads) — the tra...
Source: Dr. Smith's ECG Blog - August 21, 2020 Category: Cardiology Authors: ECG Interpretation Source Type: blogs
What is a useful next step in the evaluation of this patient with Chest pain and this ECG?
Written by Pendell Meyers, submitted by Daryl Williams, edits by Steve SmithA man in his sixties with prior CAD and CABG experienced chest pain and pressure off and on for three days. He saw his primary doctor during this time who had suspected GI related symptoms and increased his PPI medication. On the third day it became more intense and had associated radiation to his neck and left arm, and this reminded the patient of his prior MI symptoms, so he presented to the Emergency Department. It is unclear how long he had constant symptoms during those three days.Here is his triage ECG (no prior was available in our system):W...
Source: Dr. Smith's ECG Blog - July 18, 2020 Category: Cardiology Authors: Pendell Source Type: blogs
Serial ECGs highly suspicious for inferior OMI: Give thrombolytics prior to transfer for PCI?
One of my former residents texted this info to me with the EKGs:" I have here a 50 something-year-old female with multiple stents who presents with a concerning pain history. Pain relief with nitroglycerin, and I am starting a nitroglycerin drip. " I ’m worried about a hyperacute RCA infarct. " There is no old ECG available." I have to transfer for PCI, and am wondering if I should give thrombolytics first. "Here is the initial ECG:Inferior STE less than 1 mm, with reciprocal inverted T-wave and STD in aVL I recorded this one 15 minutes later:Now with straightening of the ST segmentsLooking at it now...
Source: Dr. Smith's ECG Blog - June 11, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
What's new in midwifery - 12th February 2020
Some recent things you might need.CoronavirusI am compilingcoronavirus resources. In the newsIs it impossible to breastfeed and have a full-time job? (Guardian)Part of the Guardian ' s Feminist economics series, looking particularly at the United States.Research (ask your librarian about access to full text)Found through EvidenceAlerts, a McMaster University alert service that alerts you to recent research that practitioners have found relevant.Prospective evaluation of screening performance of first-trimester prediction models for preterm preeclampsia in an Asian population (published in American Journal of Obstetric...
Source: Browsing - February 12, 2020 Category: Databases & Libraries Tags: midwifery Source Type: blogs
Medications as effective as stents for most with coronary artery disease
This study suggests that for most, managing CAD with medications alone (the conservative approach) is as safe and effective as the more invasive strategy of cardiac catheterization and opening of the blocked artery.
Findings of the ISCHEMIA trial
ISCHEMIA followed over 5,000 patients with significant narrowing in one or more coronary arteries. Half of the patients were randomly selected to receive conservative treatment with optimal medical therapy (OMT) and lifestyle changes to treat risk factors such as high blood pressure and high cholesterol. The other half were given OMT and also sent for cardiac catheterization (thre...
Source: Harvard Health Blog - December 9, 2019 Category: Consumer Health News Authors: Dara K. Lee Lewis, MD Tags: Health Source Type: blogs
Unusual: Troponin Trajectory to Help Determine Ongoing/Recurrent Infarction vs. Completed Infarction.
A 40-something male with no PMH of any kind presented to urgent care on a weekend (cath team is at home) with cough starting 2 weeks prior and SOB one week prior.He underwent a chest x-ray:As this was consistent with " pulmonary edema vs. viral infection, " and he was transferred to the EDThe faculty physician did an immediate cardiac and lung ultrasound:Many B lines (probable pulmonary edema)Parasternal short axis cardiac ultrasound:The anterior wall is closest to the transducer and shows an obvious wall motion abnormalityFurther history:The patient denied chest pain but stated that he had had about 3 epis...
Source: Dr. Smith's ECG Blog - September 16, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Landmark Results Achieved in Aging and Chronic Disease: Danish Group Extends Disease-free Life by 8 Years
By WILLIAM H. BESTERMANN JR., MD
New Scientific Breakthroughs Can
Provide a Longer Healthier Life
Twenty-one years of follow-up comparing usual care with a protocol-driven team-based intervention in diabetes proved that healthy life in humans can be prolonged by 8 years. These results were achieved at a lower per patient per year cost. Aging researchers have been confident that we will soon be able to prolong healthy life. This landmark study shows this ambitious goal can be achieved now with lifestyle intervention and a few highly effective proven medications. These medications interfere with the core molecular biol...
Source: The Health Care Blog - July 11, 2019 Category: Consumer Health News Authors: Christina Liu Tags: Medical Practice Patients aging chronic disease Denmark Diabetes William Bestermann Source Type: blogs
The computer and the cardiologist called this a " Normal EKG "
This was sent by Cam Mosley, LSU-Baton Rouge Residency.A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. The patient looked ill. Here is the ED ECG (no previous ECG was available for comparison).Computer interpretation: Normal ECGCardiology overread: Normal ECGQTc-Bazett by computer = 479 ms What do you think?It is interesting that the computer measured a long QT but did not put " long QT " in the interpretation--it gave a diagnosis of " Normal EKG. " This is a systematic failure that has been documented in the f...
Source: Dr. Smith's ECG Blog - June 3, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his sixties with chest pain at midnight with undetectable troponin
Written by Pendell MeyersA male in his 60s with no known past medical history presented at midnight with chest pain over the past 3 hours. The pain started just after eating, and at first he thought it was " reflux, " however he decided to call 911 after a few hours when it did not improve.Here is his presenting ECG:What do you think?Here are the relevant findings:Slight STE in V12.5 mm STE in V2Slight STD in V4-V6Definite STD in II, III, and aVFHyperacute T-waves in V2, and likely also in aVLThese findings are highly specific for LAD occlusion. We have many cases of this pattern on this blog, involving STE and hyperacute ...
Source: Dr. Smith's ECG Blog - May 25, 2019 Category: Cardiology Authors: Pendell Source Type: blogs
Epigastric pain radiating to the chest for 18 hours. ECG makes the Dx. Troponin makes the Dx. CT makes the Dx!
I was shown this ECG with no other information:What do you think?Hint: try to see through the artifact!I answered immediately: " High lateral MI with posterior MI. OMI. " (Occlusion Myocardial Infarction)I asked, " Did the patient present with chest pain? "Here is the history:" A middle-aged male complained of about 18 hours of epigastric pain that radiated to the chest. He also had an apparently new facial droop of equal duration. A stroke code was called, NIH stroke scale was only 1, and attention was turned to the chest pain. " BP was 148/83.How did I make this ECG diagnosis?There is subtle STE in aVL ...
Source: Dr. Smith's ECG Blog - March 28, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
What will you do for this patient transferred to you who is now asymptomatic?
A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath.This ECG was recorded on arrival:What do you think?This is technically a STEMI, with 1.5 mm STE in V1 and 1.5-2.0 mm in V2. The current criteria only require 1mm in V1 and 1.5mm in V2 for a female. However, I think many practitioners might not see this as a clear STEMI, and would instead call this " borderline. " The normal QRS complex with STE and large volume underneath the T-waves in V1-V3 confirm Occlusion MI (OMI). There is not technically STD in V6 and I, however the m...
Source: Dr. Smith's ECG Blog - March 5, 2019 Category: Cardiology Authors: Pendell Source Type: blogs
