Ken Grauer, MD

OCTOBER 13, 2023

As a result — IF no "fixable" cause is found ( ie, ischemia/infarction — electrolyte disturbance — rate-slowing medication ) — then because of the AV block and very slow heart rate, this patient will probably need a pacemaker. There are also twice as many P waves as QRS complexes — so at the least, there is 2nd-degree AV block.

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Blog Arrhythmia Bradycardia Download 160

Dr. Smith's ECG Blog

MARCH 22, 2022

There is no ischemia, certainly no concern at all for OMI. These ER patients did not have ischemia — and the variation in ST elevation was not related to either heart rate or QRS amplitudes ( Variation in ST-Segment Elevation in Early Repolarization: Electrocardiography 40:10,2007 ).

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Blog Ischemia Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

JUNE 30, 2023

And ECGs can change and evolve even when there is no ischemia. Although this is not a common phenomenon — You will see it on occasion ( See the July 24, 2013 post , among others — in Dr. Smith's ECG Blog ). LEARNING POINT : 1. Morphology matters. Pattern recognition is essential. AI does a great job at this but most humans do not.

Chest Pain 52

Chest Pain Blog Ischemia Document 52

Ken Grauer, MD

JULY 22, 2023

Although this " Imbalance " of precordial T waves is not see n very often — in the “right” clinical setting, it has been associated with recent OMI ( O cclusion-based MI ) , most often from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM — and ECG Blog #350 ).

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Blog Chest Pain STEMI AFIB 78

Dr. Smith's ECG Blog

MAY 6, 2019

Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. Ischemia/infarction. Acute febrile illness. Hypothermia.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

Computer read: "Non-specific ST abnormality, consider anterior subendocardial ischemia" There are very poor R-waves in V1-V4 suggesting old anterior MI. Firstly, subendocardial ischemia does not localize on 12-Lead ECG. But the real question at hand is: Are these precordial ST-depressions a result of subendocardial ischemia?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. There is 1 mm of ST segment elevation in lead aVR — which in the context of ST segment flattening in most other leads, suggests that there may be a component of subendocardial ischemia from underlying coronary disease. Detailed coronary artery evaluation not performed. Downstream vasospasm?

Coronary Angiogram 101

Coronary Angiogram Plaque Thrombosis STEMI 101

DAIC

JANUARY 23, 2024

mg reduced the risk of cardiovascular death, MI or heart attack, ischemic stroke, or ischemia-driven coronary revascularization by 31% compared with placebo.34 2013;368(21):2004-2013. Published 2013 Apr 4. This in turn leads to an overall reduction in IL-6 production and CRP concentration.12 12 Colchicine, 0.5 N Engl J Med.

Cardiovascular Disease 111

Cardiovascular Disease Heart Attack Heart attacks Coronary Artery Disease 111

Ken Grauer, MD

APRIL 29, 2023

The overall ST-T wave appearance in this lead looks more like LV “strain” than ischemia. ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL ( featured in Audio Pearl #2 in this blog post ). T waves are upright and peaked in anterior leads V1,V2,V3.

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Blog Chest Pain STEMI Ischemia 78

Dr. Smith's ECG Blog

JUNE 1, 2020

COMPARE ECG #1 with ECG #2: I think the easiest way to make the case for Pleomorphic VT is to compare the 2 tracings in Figure-3: I took ECG #2 in Figure-2, from the October 12, 2013 post in Dr. Smith’s ECG Blog. Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia.

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Tachycardia AFIB Blog Heart Disease 52

Dr. Smith's ECG Blog

MAY 8, 2023

EKG shown here: LAFB with no clear signs of OMI or ischemia. 8 , 9 The most recent American College of Cardiology and American Heart Association ST-elevation myocardial infarction (STEMI) guidelines (2013) give no direction on diagnosing occlusion myocardial infarction in patients with ventricular paced rhythm. No labs were performed.

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

2013 Sep;26(9):965-1012.e15. Alternation in ST segment appearance ( or in the amount of ST elevation or depression ) — is often linked to ischemia. J Am Soc Echocardiogr. doi: 10.1016/j.echo.2013.06.023. 2013.06.023. PMID: 23998693. Appleton C, Gillam L, Koulogiannis K. Cardiac Tamponade. Cardiol Clin. 2017 Nov;35(4):525-537.

Pericarditis 52

Pericarditis Tachycardia Ultrasound Blood Pressure 52

Dr. Smith's ECG Blog

JUNE 1, 2022

Here is his ECG: There is no clear evidence of OMI or ischemia. This " imbalance of precordial T waves" is not seen very often — and in the “right” clinical setting, has been associated with recent OMI from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM ).

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Bradycardia 52

Ken Grauer, MD

OCTOBER 27, 2023

This suggests ischemia of uncertain duration. Section 20 ( 54 pages = the " long " Answer ) from my ACLS-2013-Arrhythmias Expanded Version provides detailed discussion of WHAT th e AV Blocks are — and what they are not ! There is deep, symmetric T wave inversion with a prolonged QTc interval in anterior leads V1,V2,V3.

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Blog Pacemaker Bradycardia Arrhythmia 103

Dr. Smith's ECG Blog

JULY 22, 2023

This definition was changed following an expert consensus panel in 2013 — so that all that is currently needed to diagnose Brugada Syndrome is a spontaneous or induced Brugada-1 ECG pattern, without need for additional criteria. Panel B in Figure-1 illustrates the Brugada Type-2 or “Saddle-back” ECG pattern.

Chest Pain 70

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 70

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

Ischemic ST-segment depression maximal in V1-V4 (versus V5-V6) of any amplitude is specific for Occlusion Myocardial Infarction (versus nonocclusive ischemia). Arch Cardiovasc Dis 2013 Khan AR et al. JAHA 2022 Grosmaitre P et al.

STEMI 40

STEMI Myocardial Infarction Chest Pain Angina 40

Stroke Journal

FEBRUARY 1, 2024

Objective:To investigate the treatment outcomes of MT in tVBO.Method:This international, multicenter, retrospective cohort included patients with MT for tVBO and isolated BAO from 2013 to 2023. Secondary outcomes included complete recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] ≥ 2C) and 90-day mortality rate.

Outcomes 40

Outcomes Thrombolysis Ischemia Strokes 40

EMS 12-Lead

APRIL 2, 2022

Below is a refresher on appropriate precordial lead placement. [6] 6] A more robust examination of lead malposition can be found at the Emergency Medicine Cases website by the great Dr. Jesse McLaren. link] Also, do not miss Dr. Grauer's great explanations on -- LAFB [link] RBBB-LBBB-IVCD [link] LBBB-Sgarbossa-LVH-MI [link] [1] Ravi, S.,

Myocardial Infarction 52

Myocardial Infarction Stent Stents STEMI 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

This definition was changed following an expert consensus panel in 2013 — so that at the present time, all that is needed to diagnose Brugada Syndrome is a spontaneous or induced Brugada-1 ECG pattern, without need for additional criteria.

Heart Rhythm 52

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

MAY 5, 2022

This definition was changed following an expert consensus panel in 2013 — so that at the present time, all that is needed to diagnose Brugada Syndrome is a spontaneous or induced Brugada-1 ECG pattern, without need for additional criteria. Panel B in Figure-5 illustrates the Brugada Type-2 or “Saddle-back” ECG pattern.

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52