Is OMI an ECG Diagnosis?
Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency
department with 2 weeks of increasing exertional chest pain radiating to the
left arm, associated with nausea. The pain recurred at rest 90 minutes prior to
presentation, felt like the patient ’s prior MIs, and was not relieved by 6
sprays of nitro. Paramedics provided another 3 sprays of nitro, and 6mg of
morphine, which reduced but did not resolve the pain. What do you think of the ECG, and does it
matter?There ’s normal sinus rhythm, LAFB, old anterior Q waves,
and no diagnostic sign of OMI. I sent th...
Source: Dr. Smith's ECG Blog - April 18, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
The current STEMI paradigm: Because STEMI criteria are not met, let's wait until the myocardium is dead!!
This was sent to me by an inpatient nurse who reads this blog but wants to remain anonymous.An inpatient rapid response was called for a patient with hypotension. The patient was originally admitted for pneumonia and had been transferred out of
the ICU a day prior. He had a history of HFrEF, HTN, and AML. " When I
arrived his blood pressure was 70s/40s and he was pale and profusely
diaphoretic. " " He spoke Spanish but we did deduce that he had 7/10 chest pain radiating to the
back. " " We couldn ’t initially get a hold of the primary physician but our
hospital allows the rapid response nur...
Source: Dr. Smith's ECG Blog - April 16, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
56 year old male had 5/10 chest pain for several hours, then presented to the ED in the middle of the night with 1/10 pain.
A 56 year old male with PMHx significant for hypertension had chest pain for several hours, then presented to the ED in the middle of the night.He reported chest pain that developed several hours prior to arrival and was 5/10 in intensity. The pain was located in the mid to left chest and developed after riding his bike. There was associated fatigue when symptoms developed and mild shortness of breath at onset of chest pain however that has since resolved. The patient states he experienced similar 7/10 chest pain 2 days prior when he had to hurry to catch the bus. He states he experience...
Source: Dr. Smith's ECG Blog - April 14, 2024 Category: Cardiology Authors: Steve Smith 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
A young woman with chest pain, cath lab activated
This case came from a friend whose sister was the patient. She knew I was interested in ECGs, so she took a photo of this one.A young woman presented with acute chest pain.This was her presenting ECG:What do you think?This is clearly Brugada phenotype. There is downsloping ST Elevation in V1 and V2. To an experienced interpreter, it is clearly not due to OMI. And it is clearly Brugada phenotype.The conventional algorithm did not interpret Brugada. In fact, it read: ** **ACUTE MI / STEMI ** **The physicians caring for the patient activated the cath lab for " STEMI " .The interventionalist and cath tea...
Source: Dr. Smith's ECG Blog - April 6, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ventricular Fibrillation, ICD, LBBB, QRS of 210 ms, Positive Smith Modified Sgarbossa Criteria, and Pacemaker-Mediated Tachycardia
An elderly man collapsed. There was no bystander CPR. Medics found him in ventricular fibrillation. He was defibrillated, but they also noticed that he was being internally defibrillated and then found that he had an implantable ICD.He was unidentified and there were no records availableAfter 7 shocks, he was successfully defibrillated and brought to the ED.Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines.Here is the initial ED ECG. What do you think?Rhythm: Residents asked me why it is not VT. If you use calipers (or equvalent), it is clear that the rhythm...
Source: Dr. Smith's ECG Blog - April 2, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
What happened after the Cath lab was activated for a chest pain patient with this ECG?
Sent by anonymous, written by Pendell MeyersI received a text with this image and no other information:What do you think?I simply texted back: " Definite posterior OMI. " The person I was texting knows implicitly based on our experience together that I mean " Definite posterior OMI, assuming the patient ' s clinical presentation is consistent with ACS. "The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation.Queen of Hearts:You can see that the Queen is most concerned with the ST depression in V2 and V3The physician activated ...
Source: Dr. Smith's ECG Blog - March 31, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
Wide Complex Tachycardia -- VT, SVT, or A Fib with RVR? If SVT, is it AVNRT or AVRT?
A 69 y.o. male with pertinent past medical history including Atrial fibrillation, atrial flutter, cardiomyopathy, Pulmonary Embolism, and hypertension presented to the Emergency Department via ambulance for respiratory distress and tachycardia. Per EMS report, patient believes he has been in atrial fibrillation for 5 days, since coming down with flu-like illness with rhinorrhea, productive cough, SOB. Patient is on rivaroxaben, carvedilol, and dofetilide (to suppress atrial fib -- rhythm control). He states that he maybe missed a dose or two during recent illness. On EMS arrival, patient ' s oxygen sat...
Source: Dr. Smith's ECG Blog - March 28, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 50s with shortness of breath
Sent by Tom Fiero, written by Pendell Meyers A man in his 50s presented with acute shortness of breath. Unfortunately we do not have access to the patients presenting vital signs.Here is his ECG:Original image, suboptimal qualityQuality improved with PM Cardio digitizationThe ECG is highly suggestive of acute right heart strain, with sinus tachycardia, S1Q3T3, and T wave inversions in anterior and inferior with morphology consistent with acute right heart strain. There is also STE in lead III with reciprocal depression in aVL and I, as well as some subendocardial ischemia pattern with STD in V5-V6 and STE in aVR. Thus...
Source: Dr. Smith's ECG Blog - March 26, 2024 Category: Cardiology Authors: Pendell 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
A 50-something with chest pain. Is there OMI? And what is the rhythm?
Written by Willy FrickA man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. His ECG is shown:What do you think?The history thus far is highly suggestive of OMI, so we must study the ECG very closely to see if we can confirm this. Looking at the rhythm strip, we see there is more going on than simple sinus rhythm, and in fact there are two different morphologies of QRS complexes. Take a closer look at the rhythm by itself and see if you can figure out what ' s going on before scrolling further....
Source: Dr. Smith's ECG Blog - March 22, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain
This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System.The patient presented to an outside hospitalAn 80yo female per triage “patient presents with chest pain, also hurts to breathe”PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB.HPI:
Abrupt onset of substernal chest pain associated with nausea/vomiting
30 min PTA. She reports associated SOB but no dizziness or LOC. She
was given NTG
at home before coming to the hospital. This was the ECG obtained at triage.This ECG was recorded and was reviewed remotely by a...
Source: Dr. Smith's ECG Blog - March 19, 2024 Category: Cardiology Authors: Steve Smith 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
Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?
This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG. The fact that not a single one of these patients had ACS shows that the population studied could not possibly support their conclusion. It should never have been published.According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion.This is obviously unreliable
data, as Dr. Smith ’s Blog has published51
cases of OMI with ECGs labeled ‘normal’, 35 of which were identified by the
Queen ...
Source: Dr. Smith's ECG Blog - March 14, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 40s with 3 days of stuttering chest pain
Written byWilly FrickA man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:What do you...
Source: Dr. Smith's ECG Blog - March 13, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
