2015 and Ischemia - Cardiovascular Update

What is this ECG finding? Do you understand it before you hear the clinical context?

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

Osborn waves have been reported with hypercalcemia, brain injury, subarachnoid hemorrhage, Brugada syndrome, cardiac arrest from VFib — and — severe, acute ischemia resulting in acute MI ( See My Comment in the November 22, 2019 post on Dr. Smith’s Blog ). Rituparna et al — as well as Chauhan and Brahma ( Int. Smith’s ECG Blog ).

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Blog Cardiac Arrest Atrial Fibrillation Bradycardia

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

DISCUSSION: The 12-lead EKG EMS initially obtained for this patient showed severe ischemia, with profound "infero-lateral" ST depression and reciprocal ST elevation in lead aVR. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology. 2015 Oct; 66(4):355-362.

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

Abstract 254: Imaging Findings of Stroke Following Treatment of Ruptured Cerebral Aneurysm Increases Risk of Postoperative Delirium

Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

This is secondary to delayed postoperative cerebral ischemia and infarction caused by vasospasm.7 7 Clinical indicators like delirium can play a role in evaluating for delayed cerebral ischemia and infarction leading to timely management of vasospasms.5,8,9

Aneurysm

Aneurysm Strokes Stroke Ischemia

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Abstract 4143007: Pericoronary fat attenuation index as a Novel Tool to predict the morbidity of new-onset atrial fibrillation in patients with myocardial infarction with nonobstructive coronary artery disease

Circulation

NOVEMBER 11, 2024

Background:Myocardial infarction with nonobstructive coronary artery disease (MINOCA) is a special syndrome with clear evidence of myocardial ischemia, but no clear stenosis of coronary artery imaging sign. Circulation, Volume 150, Issue Suppl_1 , Page A4143007-A4143007, November 12, 2024.

Coronary Artery Disease

Coronary Artery Disease Atrial Fibrillation Myocardial Infarction Ischemia

Abstract 261: Mechanical thrombectomy in patients with large?territory acute ischemic stroke requiring a decompressive hemicraniectomy

Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

However, despite successful recanalization, certain patients still experience large hemispheric ischemia (LHI), necessitating decompressive hemicraniectomy (DHC). These individuals were then matched into two groups: a study group who had undergone decompressive hemicraniectomy (38) and a control group of individuals who had not (79).

Strokes

Strokes Stroke Outcomes Ischemia

A teenager involved in a motor vehicle collision with abnormal ECG

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. 2015, March 1). Chest trauma was suspected on initial exam. Here is his initial ECG around 1330: What do you think? Dyer From the Division of Cardiology, Thankavel, P. Myocardial contusion in an 8-year-old boy. Cramer, M.

Tachycardia

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia

Right precordial ST depression in a patient with chest pain

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

Chest Pain Myocardial Infarction STEMI Ischemia

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Dr. Smith's ECG Blog

APRIL 22, 2022

Lancet 2015 6. We are told that the Stress Echo that was performed showed objective evidence of inducible ischemia ( confirmed apparently by both wall motion abnormalities and ECG changes ). Was this objective evidence of inducible ischemia accompanied by chest pain? Am J Med 2021 5. Shah ASV, Anand A, Sandoval Y, et al.

Chest Pain

Chest Pain Ischemia Myocardial Infarction Angina

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This is the initial ECG: The QRS is widened with a regular cadence, and there are no discernable P waves.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

A comatose patient with a carbon monoxide level over 50%

Dr. Smith's ECG Blog

FEBRUARY 18, 2022

So this relatively long QT interval is NOT due to ischemia but may be a result of CO Toxicity. Read more about CO poisoning and cardiac ischemia here (ECG is pasted below): What is the treatment for this subendocardial ischemia? Yelken B et al. Routine ECG recorded before hyperbaric therapy.Are they related?

Ischemia

Ischemia Blog Chest Pain Laboratory

Hypothermia at 18 Celsius in V Fib arrest: CPR, then ECMO rewarming, for 3 hours, then Defib with ROSC. Interpret the ECG.

Dr. Smith's ECG Blog

FEBRUARY 8, 2022

Osborn waves have been reported with hypercalcemia, brain injury, subarachnoid hemorrhage, Brugada syndrome, cardiac arrest from VFib — and — severe, acute ischemia resulting in acute MI ( See My Comment in the November 22, 2019 post on Dr. Smith’s Blog ). Rituparna et al — as well as Chauhan and Brahma ( Int.

Cardiac Arrest

Cardiac Arrest Bradycardia Chest Pain Ischemia

Acute OMI or "Benign" Early Repolarization?

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The pain will resolve and you will think the ischemia is gone when it is only hidden ! Smith comment: this troponin alone should be enough data to activate the cath lab, regardless of the ECG. Also: As we always say, do not give morphine until you are committed to the cath lab. Clinical Cardiology, 45(4), 359–369. link] Macfarlane, P.

Chest Pain

Chest Pain Myocardial Infarction Blog Stents

A man in his 40s with epigastric pain and ST Elevation

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI. If you can safely and easily increase the patient's heart rate, you can convert the patient to sinus and repeat the ECG to see if the atrial repolarization wave was the cause of the concern for ischemia.

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Blog Bradycardia Ischemia Exercise

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

American Heart Journal 170(6):1255-1264; December 2015. EKG shown here: LAFB with no clear signs of OMI or ischemia. Validation of the Modified Sgarbossa Rule for Diagnosis of STEMI in the Presence of Left Bundle Branch Block. Derivation in LBBB: --> Smith SW. No labs were performed. EKG and CT head were performed.

Chest Pain

Chest Pain Myocardial Infarction STEMI Pacemaker

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Dr. Smith's ECG Blog

DECEMBER 16, 2019

Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated. 21, 2015 post by Dr. Smith ). The average highest ST/S ratio in V1-V4 for a normal LBBB is about 0.11. is worrisome! The LAD was 100% occluded.

Chest Pain

Chest Pain Myocardial Infarction Stents Stent

Target Acquired

EMS 12-Lead

APRIL 2, 2022

Terminal QRS distortion is present in anterior myocardial infarction but absent in early repolarization. American Journal of Emergency Medicine, 34 (11), 2182-2185. [4] 4] Baranchuk, A, et al. Differential diagnosis of rSr’ pattern in leads V1-V2: Comprehensive review and proposed algorithm. Annals of Noninvasive Electrocardiology, 20 (1), 7-17. [5]

Myocardial Infarction

Myocardial Infarction Stents Stent STEMI

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Dr. Smith's ECG Blog

APRIL 8, 2015

Evidence of acute ischemia (may be subtle) vii. ST segment and T wave abnormalities consistent with or possibly related to myocardial ischemia. Annals of Emergency Medicine March 2015 ; Volume 65, Issue 3, Pages 268–276.e6 2nd or 3rd degree AV blocks or sinus pause of at least 2 seconds iv. Left BBB vi. Pathologic Q-waves viii.

Arrhythmia

Arrhythmia Outcomes Chest Pain Risk Factors

Acute chest pain with LBBB and obvious OMI, worsening on serial ECGs, but repeatedly missed by physicians and Marquette 12SL

Dr. Smith's ECG Blog

JANUARY 23, 2025

His triage EKG is shown below: There is left bundle branch block, so the EKG must be evaluated for ischemia by Smith-modified Sgarbossa criteria. There is evidence of transmural ischemia of the posterior wall as well. Leads V1 to V4 have down-up shaped T waves typical of ischemia and atypical of LBBB.

Chest Pain

Chest Pain Ischemia STEMI Blog

Carotid web : No longer a new kid in stroke risk

Dr. S. Venkatesan MD

JANUARY 14, 2025

Management The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Fibromuscular hyperplasia of the carotid artery causing positional cerebral ischemia. Ref : Berkhemer OA, Fransen PSS, Beumer D, et al; MR CLEAN Investigators. Christopher R. Reference 1.Rainer

Strokes

Strokes Stroke Ischemia Embolism

What happens when you give morphine for chest pain in ACS? And what is pseudo-normalization of T-waves?

Dr. Smith's ECG Blog

MARCH 14, 2025

This case highlights how T-waves are very important in the assessment of ischemia and dynamic changes in acute coronary syndrome. I have often seen colleagues worry about T-wave inversions as a sign of ongoing ischemia. T-wave inversions in the acute phase of ACS are usually a welcome finding, indicating reperfusion.

Chest Pain

Chest Pain STEMI Myocardial Infarction Ischemia

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Dr. Smith's ECG Blog

MARCH 3, 2025

The patient was started on heparin for possible NSTEMI vs demand ischemia. increasing stenosis, ischemia, volume changes, increased blood pressure, atrial fibrillation, etc.) The EKGs from the ED presentation were felt by cardiology to represent "subendocardial ischemia." Smith : these ECGs do NOT show subendocardial ischemia.

Tachycardia

Tachycardia Pulmonary Chest Pain Stenosis

What is this ECG finding? Do you understand it before you hear the clinical context?

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Abstract 254: Imaging Findings of Stroke Following Treatment of Ruptured Cerebral Aneurysm Increases Risk of Postoperative Delirium

Webinars

Abstract 4143007: Pericoronary fat attenuation index as a Novel Tool to predict the morbidity of new-onset atrial fibrillation in patients with myocardial infarction with nonobstructive coronary artery disease

Abstract 261: Mechanical thrombectomy in patients with large?territory acute ischemic stroke requiring a decompressive hemicraniectomy

A teenager involved in a motor vehicle collision with abnormal ECG

Right precordial ST depression in a patient with chest pain

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Hypertrophic Cardiomyopathy

A comatose patient with a carbon monoxide level over 50%

Hypothermia at 18 Celsius in V Fib arrest: CPR, then ECMO rewarming, for 3 hours, then Defib with ROSC. Interpret the ECG.

Acute OMI or "Benign" Early Repolarization?

A man in his 40s with epigastric pain and ST Elevation

A man in his 70s with acute chest pain and paced rhythm.

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Target Acquired

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Acute chest pain with LBBB and obvious OMI, worsening on serial ECGs, but repeatedly missed by physicians and Marquette 12SL

Carotid web : No longer a new kid in stroke risk

What happens when you give morphine for chest pain in ACS? And what is pseudo-normalization of T-waves?

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

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