Ken Grauer, MD

DECEMBER 15, 2023

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 ). ECG Blog #271 — Reviews determination of the ST segment baseline ( with discussion of the entity of diffuse Subendocardial Ischemia).

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Blog STEMI Ischemia Chest Pain 128

Ken Grauer, MD

DECEMBER 8, 2023

The July 31, 2018 post in Dr. Smith's ECG Blog ( Please scroll down to the bottom of the page to see My Comment ). Smith's ECG Blog ( Please scroll down to the bottom of the page to see My Comment ). This case is remarkable for the d ynamic S T - T w ave c hanges that are seen.

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Blog Chest Pain STEMI Ischemia 138

Dr. Smith's ECG Blog

AUGUST 17, 2022

ACUTE MI (I allowed Acute MI to be in the report because I knew there would be an elevated troponin from ischemia, which is the definition of acute MI -- but in this case it would most likely be a Type 2 MI from tachycardia) There is also LA-RA lead reversal. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ).

Atrial Fibrillation 52

Atrial Fibrillation Ischemia AFIB Tachycardia 52

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. Nevertheless, the clinical situation made other etiologies unlikely.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

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Blog Chest Pain Ischemia STEMI 100

Frontiers in Cardiovascular Medicine

FEBRUARY 29, 2024

Method Between June 2018 and December 2022, 62 patients with type A aortic dissection (TAAD) underwent reoperation after previous surgical treatment. In the TAAR group, 12 patients (92.31%) were successfully revascularized and 1 patient died in the perioperative period.

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Aortic Quality of Life Stents Stent 49

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

His response: “subendocardial ischemia. Smith : It should be noted that, in subendocardial ischemia, in contrast to OMI, absence of wall motion abnormality is common. With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. Anything more on history?

Ischemia 52

Ischemia STEMI Stenosis Coronary Artery Disease 52

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. Many health care providers will simply not attempt to assess ischemia in the presence of a wide QRS. In the ECG above there are several features indicative of ongoing transmural ischemia. What do you think?

Chest Pain 103

Chest Pain Ischemia Pacemaker Stents 103

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] There is evolution from Wellens Pattern A to Pattern B, now inclusive of V6.

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

All About Cardiovascular System and Disorders

APRIL 21, 2024

indicates inducible ischemia while an FFR above 0.80 excludes ischemia in 90% of cases. There is a strong correlation between FFR and inducible myocardial ischemia. It recalculates SYNTAX score by incorporating ischemia producing lesions determined by FFR. 2018 Jul 19;379(3):250-259. Normal FFR is 1.0

Myocardial Infarction 52

Myocardial Infarction Coronary Artery Disease Stent Stents 52

Dr. Paddy Barrett

NOVEMBER 28, 2023

Ischemia Trial In an attempt to clarify this question, a similar trial was done called the Ischemia Trial, which had important differences to the Courage trial but again tried to answer a similar question 3. 2018 Jan-Mar;14(1):7-13. 3 ISCHEMIA Research Group. Current Indications for Stenting: Symptoms or Survival CME.

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Stent Stents Heart Attack Heart attacks 52

Dr. Smith's ECG Blog

JULY 16, 2024

The PEARL is that recognition of a longer-than-expected P wave in a supraventricular tachycardia should bring to mind the “Bix Rule” ( See My Comment at the bottom of the page in the August 3, 2018 post in Dr. Smith's ECG Blog ). Would you give lytics? Yes, but not because of the ECG! Arrhythmia? Electricity, drugs, lytics, cath lab?

Atrial Flutter 61

Atrial Flutter Chest Pain Tachycardia Arrhythmia 61

Dr. Smith's ECG Blog

APRIL 18, 2024

5] Back to the case The patient had serial ECGs over the next hour with no significant change: The first troponin came back at 1,400 ng/L (normal <26 in males and <16 in females), confirming MI – and the patient’s refractory ischemia indicated this was an Occlusion MI.

STEMI 121

STEMI Chest Pain Myocardial Infarction Stents 121

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 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

EMS 12-Lead

MAY 8, 2022

This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2] Chapter 6: Introduction to Myocardial Ischemia and Infarction. 2] But there is also Sinus Tachycardia! Physiology.

ACE Inhibitor 52

ACE Inhibitor Ischemia Physiology STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

Our chief of cardiology, Gautam Shroff, interprets it differently and thinks this is indeed ischemia. She was taken to the cath lab and her coronaries were clean!! There was no MRI, but the presumptive diagnosis is myocarditis. I have seen this pattern in severe acute AI also." Smith — this case was not what I thought.

Cardiogenic Shock 52

Cardiogenic Shock STEMI Pericarditis Ischemia 52

Dr. Paddy Barrett

DECEMBER 5, 2023

Subscribe now 1 ISCHEMIA Research Group. 2018 Jan 6;391(10115):31-40. But sometimes, that is a far more important issue. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. 2 ORBITA investigators.

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Stents Stent Angina Heart Attack 59

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction [link] Abstract Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia.

Chest Pain 111

Chest Pain STEMI Myocardial Infarction Hospital 111

EMS 12-Lead

AUGUST 14, 2022

Accurate identification is absolutely necessary as this pattern can be easily misinterpreted for something less nefarious: for example, generic “subendocardial ischemia.”

STEMI 52

STEMI Sudden Cardiac Death Thrombosis Thrombolysis 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Chest trauma was suspected on initial exam. Here is his initial ECG around 1330: What do you think?

Tachycardia 109

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 109

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

Ken Grauer, MD

JULY 15, 2023

Additional Teaching Points: Type-2 MI ( M yocardial I nfarction ) — is defined by an increase in troponin with evidence of ischemia that is not due acute coronary disease, but which instead results from a mismatch in oxygen supply and demand ( Smilowitz et al — Coron Artery Dis 29(1):46-52, 2018 ).

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Ken Grauer, MD

APRIL 5, 2024

As a result, the ST elevation ( with especially tall, peaked T wave in lead V2) — is not indication of acute ischemia. As suggested by Figure-4 below in the ADDENDUM — assessment of the ST-T waves in leads V2,V3 and V5,V6 — is consistent with ischemia and / or LV "strain".

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Blog Ischemia Chest Pain Hypertension 96

Ken Grauer, MD

JANUARY 13, 2024

My written interpretation on a tracing such as this one would read, "Marked LVH and 'strain' and/or ischemia — with need for clinical correlation." BOTTOM LINE: ECG changes of LV "strain" and/or ischemia that we see on today's initial ECG — were not present 9 years earlier. ECG Blog #73 — Reviews "My Take" on the ECG Diagnosis of LVH.

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Blog Ischemia AFIB Hypertension 148

Dr. Smith's ECG Blog

DECEMBER 26, 2023

The unique " shape " of the prominent ST-T wave abnormalities in this tracing — that are much more suggestive of some significant form of LVH ( L eft V entricular H ypertophy ) rather than ischemia. Voltage for LVH ( the R wave in lead aVL easily surpassing 12 mm ).

Chest Pain 117

Chest Pain Cardiomyopathy Blog AFIB 117

Dr. Smith's ECG Blog

JULY 31, 2018

Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. It they are static, then they are not due to ischemia. This is better evidence for ischemia than any other data point. Again, cath lab was not activated. What does this troponin level mean? 2012;5:134–137.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 24, 2023

And superimposed subendocardial ischemia pattern, of course. As noted in My Comment of the June 17, 2018 post in Dr. Smith's ECG Blog — the presence of an almost “null vector” in standard lead I ( ie, P wave, QRS complex and T wave all under 2mm in size ) — is highly suggestive of longstanding and severe pulmonary disease.

Atrial Flutter 128

Atrial Flutter Blog Aortic Aortic valve 128

Dr. Paddy Barrett

AUGUST 1, 2023

2018 Sep 6;379(10):924-933. 5 ISCHEMIA Research Group. 5 ISCHEMIA Research Group. Subscribe now 1 Radiation dose and image quality of CT coronary angiography in patients with high heart rate or irregular heart rhythm using a 16-cm wide detector CT scanner. Medicine (Baltimore). 2022 Sep 16;101(37):e30583. N Engl J Med.

Coronary Angiogram 52

Coronary Angiogram Plaque Coronary Artery Disease Chest Pain 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

This ST-T wave appearance in the lateral chest leads of ECG #2 is consistent with L V “ S train” vs ischemia. The complete lack of chest pain in the history in this patient who has longstanding hypertension strongly suggests that rather than ischemia, this symmetric T wave inversion reflects LV “strain” from marked LVH.

Chest Pain 52

Chest Pain Ischemia Angina Electrocardiogram 52

Dr. Smith's ECG Blog

NOVEMBER 9, 2018

The T-waves of both of these beats have, coincidentally , a superimposed P-wave Clinical course: The potassium was normal, there was no ischemia or drug toxicity. Treat ischemia (Cath lab) 3. These are beats in which the pacer captured. She went for emergent pacemaker revision. Treat hyperkalemia or drug toxicity 2. External pacing 5.

Bradycardia 52

Bradycardia Pacemaker Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Here is our abstract from SAEM 2018. The MSC were highly sensitive and specific for the diagnosis of ACO in patients presenting to the ED with VPR and symptoms of acute coronary syndrome. == MY Comment , by K EN G RAUER, MD ( 10/3 /2018 ): == How good are paced tracings for detecting ACO ( A cute C oronary O cclusion ) ?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. S. Venkatesan MD

AUGUST 19, 2024

Relationship between Ischemia and arrhythmia While the relationship between Ischemia and VT is really complex, the term “Ischemic VT” itself adds more twists. Even here, it is the associated factors, like hypoxia or acidosis are the triggers which of course are resultant of Ischemia. 2018 Jul;11(7):e006120.

Ischemia 52

Ischemia Sudden Cardiac Death Ablation Arrhythmia 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. Smith. But maybe not. You can see the deficiency of the definition of MI.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 52

EMS 12-Lead

JUNE 20, 2022

It’s important to stress the presence of a normal QRS (i.e., A new 4-variable formula to differentiate normal variant ST-segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion – adding QRS amplitude of V2 improves the model. Journal of Electrocardiology, 50 , 561-569. 3] Aslanger, E.,

STEMI 52

STEMI Stents Stent Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 6, 2024

In the days before I learned to look for OMI, back when I was counting ST elevation boxes, I used to save ischemia for last.) In the 500+ Comments I have written on Dr. Smith's ECG Blog since becoming an Associate Editor in 2018 — I do not believe we have had a case of RA-LL lead reversal. The July 29, 2018 post ( LA-RA reversal ).

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Blog Ischemia Tachycardia Physiology 93

Dr. Smith's ECG Blog

DECEMBER 19, 2018

This confirms that there were dynamic signs of ischemia on the initial ECG. Here are many other cases in which the computer algorithm called the ECG completely normal when it was in fact dangerously abnormal. -- Comment by K EN G RAUER, MD ( 12/19/2018 ): -- Illustrative case by Dr. Brooks Walsh regarding a number of important concepts!

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). In there ECG evidence of possible ongoing ischemia? (ie, IMPRESSION: I’d interpret this tracing as consistent with LVH and/or “strain” and/or ischemia. THANK YOU Dr. Lee!

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52