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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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?

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Chest Pain Pacemaker Ischemia Stents 111

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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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.

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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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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 ).

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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?

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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.

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Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

MARCH 27, 2025

But it was interpreted as no acute ischemia and the patient was referred to cardiology as Non-STEMI. But clearly this 'Non-STEMI' patient with OMI would have benefited from immediate cath lab activation on arrival, when their first troponin was 11ng/L, rather than after after it rose to 12,000ng/L after 12 hours of refractory ischemia.

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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.

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STEMI Chest Pain Myocardial Infarction Blog 121

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.

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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 Electrocardiogram 119

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).

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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”.

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Chest Pain STEMI Ischemia Blog 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.

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Risk Factors Circulation Atrial Fibrillation Ischemia 40

Stroke Journal

JANUARY 30, 2025

However, its utilization in the pediatric/young adult population is not well characterized.Methods:We queried the RAPID Insights database from 10/05/2018-09/29/2023 for unique patients between 2-25 years with a CTP.

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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.

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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?

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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.

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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.

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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.

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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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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?

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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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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 ).

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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.

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Dr. Smith's ECG Blog

DECEMBER 5, 2022

Incredibly , this case was just published in Circulation on January 22, 2018 (thanks to Brooks Walsh for finding this!) 2018; 137: 402-404. Originally published January 22, 2018 Here is a case from Circulation year 2000 that was misdiagnosed as due to pancreatitis. Journal of Electrocardiology. 2012;45(1):15-17. 2010.12.162.

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Article Chest Pain Circulation Electrocardiogram 52

Dr. Smith's ECG Blog

DECEMBER 29, 2018

Repeat ECGs make difficult decisions easier. -- Comment by K EN G RAUER, MD ( 12/29/2018 ): -- Superb case by Dr. Pendell Meyers, which highlights recognition of subtle acute findings. Although I arrived at the same conclusion as Drs.

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Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. There is also a Q-wave in III. There is also subtle STD in V3-V5. The initial troponin I was elevated at 0.75

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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!

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Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

JULY 5, 2018

My Comment , by K EN G RAUER, MD ( 7/5/2018 ): This blog post provides an excellent example of how a patient with SSS ( = S ick S inus S yndrome ) may present. These include rate-slowing medication recent ischemia/infarction hypothyroidism sleep apnea. This may be another reason for pacer implantation.

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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.

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Dr. Smith's ECG Blog

DECEMBER 15, 2023

In other words, the inferior ST segments in the first ECG show more straightening which is more concerning for ischemia. In this context, patient pain free — post-PCI and with the previous ECGs in mind— the large inferior T waves represent reciprocal change from lateral reperfusion T waves and are not hyperacute T waves of ischemia.

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Dr. Smith's ECG Blog

MAY 1, 2023

Learning Points: Atrial flutter can be very tricky to identify, and can cause all kinds of problems such as mimicking or concealing ischemia and OMI. The March 20, 2018 post on Dr. Smith’s ECG Blog illustrates application of a Lewis Lead in a patient in a regular SVT rhythm. She was discharged home.

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Dr. Smith's ECG Blog

JUNE 20, 2018

I know from reading your blog that you "diagnose pericarditis at your own peril", but are there any signs on that initial ECG that would make you think ischemia? Journal of Electrocardiology 2018. "TnI peaked at 67.10 ng/mL post PCI." "I No PR depression, no Spodicks sign, but concave segments which are diffusely elevated.

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Dr. Smith's ECG Blog

APRIL 15, 2019

But when the clinical presentation is sepsis, one must entertain the possibility that the ST elevation is due to demand ischemia, or some other process, and exacerbated by tachycardia. CLICK HERE — for the ESC/ACC/AHA/WHF 2018 Consensus Document on the 4th Universal Definition of MI, in which these concepts are discussed and illustrated.

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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.,

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