DAIC

MAY 8, 2024

6 This novel study marks a significant milestone in the field, evaluating the effectiveness of FFR CT in detecting ischemia-producing coronary stenosis in patients with severe PAD. Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery.” 2024, [link].

Coronary Artery Disease 111

Coronary Artery Disease Chest Pain Myocardial Infarction Ischemia 111

DAIC

FEBRUARY 14, 2024

2 An estimated 10% of patients with PAOD have its most severe form: chronic limb-threatening ischemia (CLTI). Determinants of long-term outcomes and costs in the management of critical limb ischemia: A population-based cohort study. Eur J Vasc Endovasc Surg. 2012;43:55-61. J Am Heart Assoc. DOI: 10.1161/JAHA.118.009724. 118.009724.

Heart Attack 111

Heart Attack Heart attacks Peripheral Arterial Disease Ischemia 111

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".

Blog 95

Blog Ischemia Chest Pain Hypertension 95

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). What do you think?

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 132

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 98

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 108

Chest Pain Ischemia Pacemaker Stents 108

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 ).

Blog 99

Blog Chest Pain Ischemia STEMI 99

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

Dr. Smith's ECG Blog

NOVEMBER 1, 2018

European Heart Journal , ehy651, [link] Published: 26 October 2018 [link] Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial. However, and this is a big however , 4 patients in the delayed group had recurrent ischemia and needed to go emergently to the cath lab.

STEMI 52

STEMI Myocardial Infarction Ischemia Outcomes 52

Circulation

NOVEMBER 11, 2024

The primary endpoint of this study was major adverse cardiovascular and cerebrovascular events (MACCEs) that included all-cause mortality, non-fatal myocardial infarction, non-fatal ischemic stroke, and ischemia-driven revascularization.Results:The average age of the study participants was 59.55 ± 10.98 years, and men accounted for 61.8%.

Risk Factors 40

Risk Factors Ischemia Myocardial Infarction Outcomes 40

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

Journal of the American Heart Association

DECEMBER 29, 2023

This study aimed to compare outcomes using propensity score matching.Methods and ResultsSixty‐five patients with dan‐SAH and 857 patients with aSAH admitted between January 2018 and December 2022 were retrospectively reviewed. 60.12];P=0.042), or delayed cerebral ischemia (12.3% versus 0%,P=0.027), death (11.2% 18.95];P=0.045).

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Hemorrhage Aneurysm Outcomes Ischemia 40

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

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 Chest Pain 52

Dr. Smith's ECG Blog

MAY 3, 2024

When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI). There is STE in aVR. Thus, there is high lateral OMI with diffuse ST depression. Moreover, left main occlusion often presents near death.

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Cardiogenic Shock Cardiac Arrest Hospital Ischemia 122

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

MARCH 27, 2023

--The STD in V2-V6 might be interpreted as subendocardial ischemia, but with the inferior STE, it is far more likely to represent posterior OMI. In subendocardial ischemia, cath lab is indicated if the pain persists in spite of medical therapy (aspirin, anticoagulant, IV nitro). At 100 minutes, the above ECG was recorded.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 52

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 124

STEMI Chest Pain Myocardial Infarction Stents 124

Dr. S. Venkatesan MD

SEPTEMBER 23, 2024

So, we desperately required to break this inappropriate menace with evidence base like COURAGE, ISCHEMIA, BARI-2D, These studies tried to apply some breaks, but the force was weak and couldn’t abolish a pseudo-academic vice. Something happened in 2018 , the ORBITA trial.It sent real shock waves to the Interventional community.

Angina 52

Angina Academic Stenosis Innovation 52

Stroke Journal

FEBRUARY 1, 2024

Objective:Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. Stroke, Volume 55, Issue Suppl_1 , Page ATP252-ATP252, February 1, 2024. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established.

Risk Factors 40

Risk Factors Circulation Atrial Fibrillation Stroke 40

Ken Grauer, MD

JUNE 6, 2023

Part of the ST depression with deep T wave inversion in the lateral chest leads clearly reflects LV "strain" from the marked LVH — but despite the very large QRS amplitudes, this ST-T wave appearance looks disproportionate, suggesting at least a component of ischemia. E CG F indings in Today's Tracing N ow M ake S ense !

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Blog Pulmonary Hypertension Aortic 78

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.

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Chest Pain STEMI Myocardial Infarction Hospital 116

Dr. Smith's ECG Blog

DECEMBER 14, 2018

This was my interpretation: although most ischemic T-wave inversion is post -ischemic like Wellens, sometime active ischemia results in isolated T-wave inversion. In such cases, if there is no infarction (necrosis), when the ischemia resolves, the T-wave may normalize (in contrast to Pseudo-normalize).

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 52

Dr. Smith's ECG Blog

JULY 11, 2018

Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI. In view of the lack of J waves in the pre-hospital tracing — it would certainly seen that these J waves were ischemia-induced , and markers of the “culprit artery”.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 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 Stents Stent 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 114

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 114

DAIC

JANUARY 3, 2024

Traditional methods of non-invasive ischemia testing (stress EKG , stress echo, SPECT , PET , direct-to-cath) can result in false negatives 20-30 percent of the time, which can lead to undetected disease, and false positives over 50 percent of the time, which can lead to unnecessary invasive procedures. Neth Heart J 2018. Patel et al.

Coronary Artery Disease 59

Coronary Artery Disease Chest Pain Plaque Technology 59

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 Blog 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.

Stent 52

Stent Stents Heart Attack Heart attacks 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 130

Atrial Flutter Blog Aortic Dysrhythmia 130

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.

Chest Pain 125

Chest Pain Myocardial Infarction Blog Stents 125

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

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

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 ).

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Chest Pain Cardiomyopathy Blog AFIB 94

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

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

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.

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SCAD Chest Pain Myocardial Infarction Ischemia 52