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 94

Blog Ischemia Chest Pain Hypertension 94

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

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 98

Blog Chest Pain Ischemia STEMI 98

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 ).

Blog 111

Blog Ischemia Tachycardia Physiology 111

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.

Chest Pain 82

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 82

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?

Tachycardia 119

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 ).

Atrial Fibrillation 52

Atrial Fibrillation Ischemia AFIB Tachycardia 52

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 ).

Blog 135

Blog Chest Pain STEMI Ischemia 135

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 ).

Tachycardia 130

Tachycardia Cardiac Arrest ICU Blog 130

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.

Blog 137

Blog Cardiac Arrest Atrial Fibrillation Bradycardia 137

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 ).

Blog 126

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.

Chest Pain 52

Chest Pain STEMI Blog Ischemia 52

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

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.

Chest Pain 114

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

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.

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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

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 Blog 121

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."

Cardiogenic Shock 52

Cardiogenic Shock STEMI Pericarditis Blog 52

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.

STEMI 96

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

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).

Blog 160

Blog Arrhythmia STEMI Ischemia 160

Dr. Smith's ECG Blog

JANUARY 3, 2022

2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. The absence of STE in V7-V9 is often due to resolution of ischemia, as seen by resolution of ST depression in V7-V9. non-occlusive ischemia) JAHA 2021 3. -- Meyers HP, Bracey A, Lee D, et al.

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Stroke Journal

FEBRUARY 1, 2024

Final diagnosis of cerebral ischemia was made in 662/1043 patients (63.5%) and stroke mimic was diagnosed in 381/1043 patients (36.5%). Detailed chart review was conducted to extract both the variables needed to apply the mimic scales the final diagnosis confirmed by final imaging and discharge diagnosis (cerebral ischemic vs stroke mimic).

Academic 40

Academic Stroke Strokes Ischemia 40

Ken Grauer, MD

AUGUST 26, 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).

Blog 145

Blog Chest Pain STEMI Ischemia 145

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. For more on Giant T waves — See My Comment at the bottom of the page in the June 22, 2020 and September 19, 2022 posts in Dr. Smith's ECG Blog ).

Chest Pain 93

Chest Pain Cardiomyopathy Blog AFIB 93

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

Does this mean that the ST depression in V3 represents "anterior" subendocardial ischemia, and not posterior OMI? This is most consistent with ischemia/infarction in the distribution of the left circumflex coronary artery. non-occlusive ischemia) 2. Thus, they have much less voltage. They have ZERO ST Elevation.

Chest Pain 52

Chest Pain Blog Ischemia STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Smith : the profound persistent STE suggests either persistent occlusion or " no reflow " with persistent downstream ischemia. It makes you think you have done something for the ischemia when you have not! Academic Emergency Medicine 27(S1): S220; May 2020. Long term outcome unknown but obviously bleak. Abstract 556.

STEMI 78

STEMI Myocardial Infarction Ischemia Academic 78

Dr. Smith's ECG Blog

APRIL 22, 2022

Am J Emerg Med 2020 3. 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? Int J Cardiol 2013 2. Shin YS, Ahn S, Kim YJ.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Ken Grauer, MD

MARCH 7, 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).

Blog 78

Blog Chest Pain STEMI Ischemia 78

Dr. Smith's ECG Blog

AUGUST 11, 2024

Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. As Smith and Meyers explained in a 2020 article in EM News : “What should we do in the meantime while we are still stuck in the STEMI paradigm in daily practice? What do you think?

Chest Pain 100

Chest Pain STEMI Bradycardia Article 100

Dr. Smith's ECG Blog

AUGUST 1, 2020

The Queen was not able to see this one: Of course we do not know for certain that the inferior findings represent ischemia. The only way to PROVE that ECG findings are due to the alleged OMI/ischemia is to show evolution in that territory. It could have been a false positive ECG, but if it had been, no harm done. It was not.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. There is 1 mm of ST segment elevation in lead aVR — which in the context of ST segment flattening in most other leads, suggests that there may be a component of subendocardial ischemia from underlying coronary disease. Detailed coronary artery evaluation not performed. Downstream vasospasm?

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

DAIC

FEBRUARY 29, 2024

24: Joint American College of Cardiology/Journal of the American College of Cardiology Late-Breaking Clinical Trials (Session 402) Saturday, April 6 9:30 – 10:30 a.m. ET Main Tent (Hall B1) This session offers more insights from key clinical trials presented at ACC.24 24 and find out what it all means for your patients.

Aortic valve 103

Aortic valve Myocardial Infarction Aortic Blood Pressure 103

Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

Santa Clara, CA, USA) semi compliant balloon adapted from cardiovascular literature which showed a pre‐dilation angioplasty capability in coronary stenotic lesions.MethodsWe performed a retrospective review of prospectively maintained mechanical thrombectomy (MT) databases of 2 comprehensive stroke centers between November 2020, and May 2023.

Angioplasty 40

Angioplasty Stents Stent Strokes 40