Dr. Smith's ECG Blog

JUNE 5, 2024

The ECG does not show any definite signs of ischemia. IMPRESSION: The finding of sinus bradycardia with 1st-degree AV block + marked sinus arrhythmia + the change in PR interval from beat #5-to-beat #6 — suggests a form of vagotonic block ( See My Comment in the October 9, 2020 post in Dr. Smith's ECG Blog ).

Chest Pain 122

Chest Pain Blog Cardiac Arrest Cardiomyopathy 122

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. Please see ECG Blog #73 for additional details ).

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Blog Ischemia AFIB Hypertension 156

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 94

Ken Grauer, MD

MAY 20, 2023

The history and associated deep anterior S waves (ie, the reciprocal of tall lateral lead R waves ) will suggest LVH rather than Precordial Swirl ( See ECG Blog #254 and My Comment at the bottom of the page in the February 6, 2020 and June 20, 2020 posts in Dr. Smith's ECG Blog ). Cardiol 27:674-677, 2004 ).

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Blog Chest Pain Ischemia STEMI 141

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

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.

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Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

AUGUST 2, 2024

In this patient's case, the RV ischemia manifested as dramatic anterior hyperacute T waves. This degree of STE is a bit atypical for LAD ischemia. Remember that the RV is the most anterior chamber. Here is a transverse image of a CT showing this. A few clues that might have suggested this are: There is marked STE in V1.

STEMI 119

STEMI Ischemia Blog Chest Pain 119

DAIC

JULY 18, 2024

The company is also pursuing an indication for non-invasive measurement of fractional flow reserve (FFR CT ), uniquely derived from its plaque algorithm, to measure coronary blockages and the extent of ischemia. 2017 23, April 2020; Available from: [link]. Cardiovasc. 6 (3) (2019).

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Plaque Heart Attack Heart attacks Cardiovascular Disease 105

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.) I interpret tracings systematically in "real time" ( including my assessment for acute ischemia ). The February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ).

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Blog Ischemia Tachycardia Physiology 111

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 98

Dr. Smith's ECG Blog

JULY 21, 2024

There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( Some residual ischemia in the infarct border might still be present. Both episodes are initiated by an "R-on-T" phenomenon.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The baseline ECG is basically normal with no ischemia. You can see in the lead-specific analysis that she "sees" the STD in V5, V5, and II, with STE in aVR as signs of "Not OMI", because subendocardial ischemia pattern is not the same as OMI. In my opinion, I think it looks more like subendocardial ischemia.

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Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

JANUARY 9, 2024

Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Do you agree with this strategy? How can you better assess the ST segments?

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Tachycardia Electrophysiology Atrial Flutter Ischemia 119

Dr. Smith's ECG Blog

APRIL 24, 2020

Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Subendocardial ischemia results in ST depression, but unfortunately, and rather mysteriously, it does not localize to the ischemic wall. Similarly, STD in aVL is usually reciprocal to inferior ST elevation, not "lateral ischemia."

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

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. The February 11, 2020 post ( LA-RA reversal ).

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Atrial Fibrillation Ischemia AFIB Tachycardia 52

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Alternation in ST segment appearance ( or in the amount of ST elevation or depression ) — is often linked to ischemia. In practice — It appears that electrical alternans is most often seen in association with regular SVT rhythms ( See the example in My Comment at the bottom of the page, in the September 7, 2020 post in Dr. Smith's ECG Blog ).

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Tachycardia Cardiac Arrest ICU Blog 131

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%.

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Risk Factors Ischemia Myocardial Infarction Outcomes 40

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.

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Blog Cardiac Arrest Atrial Fibrillation Bradycardia 138

Ken Grauer, MD

JUNE 7, 2024

I thought this finding consistent with the finding of ST depression in lateral leads I; V4,V5,V6 — and possibly indicative of multivessel disease ( ie, Diffuse Subendocardial Ischemia — as discussed in ECG Blog #400 ). ECG Blog #400 — Reviews the concept of " dynamic " ST-T wave changes ( and also Diffuse Subendocardial Ischemia ).

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Blog Chest Pain STEMI Ischemia 130

Dr. Smith's ECG Blog

APRIL 9, 2024

The same reciprocal relationship is seen in severe subendocardial ischemia, just with opposite vector direction where V1 can show ST elevation) Below you can find the 3D model of the heart and coronary vessels. Each main coronary artery (LAD, RCA and LCx) are shown in separate images.

Chest Pain 108

Chest Pain Pericarditis Blog Tachycardia 108

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.

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Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Ken Grauer, MD

AUGUST 8, 2024

Recognizing hyperacute T waves — patterns of leads — an OMI ( though not a STEMI ) — See My Comment at the bottom of the page in the November 8, 2020 post on Dr. Smith's ECG Blog. ECG Blog #400 — Reviews the concept of " dynamic " ST-T wave changes ( and also DSI = Diffuse Subendocardial Ischemia ).

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Blog STEMI Ischemia 126

Dr. Smith's ECG Blog

OCTOBER 15, 2022

It is due to transmural ischemia not only of the anterior wall and apex, but due to transmural ischemia of the septum, usually due to occlusion proximal to the first septal perforator. Is this Acute Ischemia? The voltage is high but not huge. Read the case. More on LVH. This is LVH only, not OMI. This is LVH Only, not OMI.

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Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

MARCH 22, 2024

The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible. Back to the assessment of ischemia: Returning to the ECG, the leads that catch my eye first are -- I, II, V4, V5, V6. Ischemia can be disguised by a wide escape rhythm, which decreases the sensitivity of ECG.

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Chest Pain STEMI Bradycardia Ischemia 114

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

JANUARY 1, 2024

Learning Point: Concordant ST segment elevation can arise from profound ischemia triggered by ventricular tachycardia (VT), or it may represent an exaggerated basal ST change accompanying tachycardia. See My Comment at the bottom of the page in the May 19, 2020 post in Dr. Smith's Blog ). A peak troponin level of 70 ng/L was observed.

Tachycardia 112

Tachycardia Blog Heart Failure Ischemia 112

Dr. Smith's ECG Blog

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. For more on the application of this Trace-down; Copy-over technique with Shark Fin ST segment deviations — See My Comment in the May 19, 2020 post in Dr. Smith's ECG Blog.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Ken Grauer, MD

MAY 26, 2023

This ST depression appears to be maximal in leads V3-to-V5 — which could reflect acute posterior OMI ( O cclusion-based M yocardial I nfarction ) — most probably with multi -vessel disease ( ie, diffuse subendocardial ischemia suggested by the ST depression with ST elevation in aVR>V1 ). This patient has new CP — and — he is hypotensive.

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Blog Ischemia STEMI Cardiac Arrest 78

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

Ken Grauer, MD

SEPTEMBER 21, 2024

There is a literature on this subject ( Sood et al — Cureus 15(4):e37102, 2023 — Gulati et al — Mayo Clin Proceed 95(1):136-156, 2020 — GGF van der Schoot et al: Neth Heart J 28(6):301-308, 2020 — and — Egred at al — Postgrad Med 81(962): 741-745, 2005 — to name just a few reports ). That said — acute MI does occur in younger patients.

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Chest Pain Blog Thrombosis Tachycardia 112

Dr. Smith's ECG Blog

MAY 31, 2023

There is probably a trickle of flow which is why there is both subendocardial ischemia (ST depression) and early subepicardial ischemia (hyperacute T-waves). Academic Emergency Medicine 27(S1): S220; May 2020. I sent the last one to the Queen of Hearts #PMCardio app and here is the verdict: My response: "It’s not even subtle.

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STEMI Chest Pain Myocardial Infarction Ischemia 96

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

Time 17 minutes Not much different One month earlier This is Left Bundle Branch Block (LBBB) without any sign of ischemia. If so, one would expect that the chest pain is diminishing or gone & that the culprit would be the LAD. It turns out that she spends much of her time in LBBB (see ECGs below) What is going on??? link] Shvilkin et al.

Chest Pain 78

Chest Pain Echocardiogram Blog Ischemia 78

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."

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Cardiogenic Shock STEMI Pericarditis Blog 52

Ken Grauer, MD

APRIL 14, 2023

The terminology favored to describe these ECG findings is diffuse subendocardial ischemia ( See ECG Blog #271 — for more on diffuse subendocardial ischemia ). I discussed the findings of acute LMain occlusion further in My Comment in the January 16, 2020 post of Dr. Smith's ECG Blog. ECG Blog #316 — The patient died.

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Blog Chest Pain Ischemia Tachycardia 78

Dr. Smith's ECG Blog

APRIL 30, 2024

Here is the only prehospital 12-lead: Sinus tachycardia, somewhat wide QRS, Ischemia Here is the first ED ECG: What is the rhythm here? He was resuscitated into a perfusing rhythm. He went in and out of arrest until arrival at the ED.

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Blog Ischemia Tachycardia Arrhythmia 108

Dr. Smith's ECG Blog

JANUARY 6, 2023

I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Thus, they obscure the last possible indication for emergent reperfusion in "NSTEMI" (all guidelines recommend emergent cath for refractory ischemia in NSTEMI).

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Ken Grauer, MD

MARCH 15, 2024

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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