Ken Grauer, MD

SEPTEMBER 22, 2023

The rhythm is sinus bradycardia at a rate just over 50/minute. The May 13, 2023 post ( LA-RA reversal ). The May 30, 2023 post ( LA-RA reversal ). Figure-2: The repeat ECG in today's case — recorded as soon as the treating clinician recognized the lead misplacement. ( All intervals ( PR,QRS,QTc ) are normal.

Blog 176

Blog Chest Pain Bradycardia Physiology 176

Dr. Smith's ECG Blog

DECEMBER 22, 2023

I did not think that the T-waves in V2 and V3 are hyperacute and I still do not--I disagree with Ken below--I think they are normal , especially in the context of bradycardia. Their apparently excessive length (QT interval) is due to bradycardia. They do not have much bulk. A corrected QT would be normal.

Chest Pain 115

Chest Pain Bradycardia Blog Electrocardiogram 115

Dr. Smith's ECG Blog

OCTOBER 18, 2023

During the night, while on telemetry, the patient became bradycardic, with periods of isorhythmic AV dissociation (nodal escape rhythm alternating with sinus bradycardia), and there were sporadic PVCs. This is what T-waves look like when there is a long QT." Below are two ECGs from the telemetry monitoring.

Cardiac Arrest 121

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 121

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ).

Blog 145

Blog Chest Pain STEMI Ischemia 145

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Acute MI per se usually does not depress cardiac function and blood pressure enough to cause syncope ( Mostafa et al — J Com Hosp Intern Med Perspect 13(4):9-12, 2023 - ). Other cardiac-related causes for syncope associated with acute MI may include malignant ventricular arrhythmias and bradyarrhythmias including AV block.

Chest Pain 113

Chest Pain Aneurysm Stents Stent 113

Journal of Cardiovascular Electrophysiology

APRIL 10, 2025

Methods The TriNetX database (Jan 2015June 2023) was queried to include adults receiving their first single-chamber ventricular pacemaker for heart block, bradycardia, sick sinus syndrome, atrial fibrillation, or syncope, excluding those with prior pacemakers, heart failure or enrolled for research settings.

Pacemaker 40

Pacemaker Heart Failure Atrial Fibrillation Bradycardia 40

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

link] == MY Comment , by K EN G RAUER, MD ( 11/11 /2023 ): == From a learning standpoint — I LOVED this case because it illustrates in many ways how some patients simply "do not read the textbook before they come to the ED". It is not yet available, but this is your way to get on the list.

Strokes 69

Strokes Stroke Chest Pain Cardiomyopathy 69

Journal of Cardiovascular Electrophysiology

MARCH 31, 2025

ABSTRACT Introduction Leadless pacemakers (LPs) are a valuable treatment for bradycardia, with the Aveir offering advanced features, including a protective sleeve and active fixation. The higher impedance during the implantation was a strong predictor of a midterm favorable PCT. A PCT elevation was defined as that >1.5V/0.4ms

Pacemaker 40

Pacemaker Bradycardia Outcomes Article 40

Dr. Smith's ECG Blog

MAY 26, 2023

Severely ill patients from any etiology can have very abnormal ECGs = My Comment by K EN G RAUER, MD ( 5/26 /2023 ): = There are more questions than answers in today's case. If the situation is not right for acute coronary occlusion, then the ECG findings probably do not represent acute coronary occlusion.

Cardiogenic Shock 98

Cardiogenic Shock Arrhythmia Blog Education 98

Ken Grauer, MD

OCTOBER 27, 2023

That said — obvious findings include: i ) Marked bradycardia! — A DDENDUM ( 10/28/2023 ) : This 15 -minute ECG Video ( M edia P EARL # 52) — Reviews the 3 Types of 2nd-Degree AV Block — plus — the hard-to-define term of "high-grade" AV block. The rhythm in Figure-1 is complex — and defies precise interpretation without careful study.

Blog 101

Blog Pacemaker Bradycardia Arrhythmia 101

Ken Grauer, MD

DECEMBER 23, 2023

The August 17, 2020 post by me in Dr. Smith's ECG Blog — in which I review the phenomenon of Bradycardia-dependent BBB ( sometimes called "Phase 4" or "paradoxical" block ). A DDENDUM ( 12/23/2023 ) : I've presented this material before — but it bears repeating for reference. ECG Blog #242 — Reviews rate -related BBB.

Blog 175

Blog Tachycardia Tricuspid Atrial Flutter 175

Dr. Smith's ECG Blog

JANUARY 13, 2024

He suffered from symptomatic bradycardia and falls for over a month and was seen by another cardiologist specifically for presyncope, and still the problem went unrecognized despite ongoing ECG evidence of pacemaker malfunction, and imaging proving lead dislodgement.

Pacemaker 110

Pacemaker Bicuspid/Mitral Blood Pressure Bradycardia 110

Dr. Smith's ECG Blog

JANUARY 5, 2024

The ECG shows sinus bradycardia but is otherwise normal. Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The documentation does not describe any additional details of the history. The following ECG was obtained. ECG 1 What do you think?

Angina 119

Angina Plaque Document Stents 119

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

For example — marked bradycardia with unusual forms of advanced AV block — or marked bradycardia without evident P waves — or marked QRS widening with "shapeless" morphology — are all ECG indication of the need for immediate IV calcium until improvement of these ECG patterns.

Tachycardia 52

Tachycardia Document Blog Bradycardia 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. Hint: there are 2 etiologies) = Comment by K EN G RAUER, MD ( 2/23 /2023 ): = As today's case was contributed by Dr. Nossen, who practices in Norway — today's ECG uses the Cabrera Format.

Blog 52

Blog Bradycardia Ischemia Exercise 52

Dr. Smith's ECG Blog

JULY 5, 2023

Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. In this case, QOH was incorrect , saying "OMI High confidence." Smith's — in that despite the alarming ST-T wave changes, I did not think ECG #1 was the result of an acute event.

Chest Pain 52

Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

I have periodically called attention to examples of the Ashman phenomenon as they occur in Dr. Smith's ECG Blog ( See My Comments in the January 5, 2020 post — the June 17, 2020 post — and the March 30, 2023 post , among others ).

Cardiac Arrest 67

Cardiac Arrest Cardiomyopathy Arrhythmia Atrial Fibrillation 67

Dr. Smith's ECG Blog

JULY 26, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: == MY Comment , by K EN G RAUER, MD ( 7/26 /2023 ): == As regular followers of Dr. Smith’s ECG Blog have seen — some of the best cases that we post come from tracings that Dr. Smith or Meyers see while simply checking out “tracings on the system”.

Aneurysm 52

Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Triage physician interpretation: -sinus bradycardia -lateral ST depressions While there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. My Comment by K EN G RAUER, MD ( 1/23 /2023 ): = The importance of today's case by Drs. Triage EKG: What do you think?

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 15, 2023

My Comment by K EN G RAUER, MD ( 3/15 /2023 ): = I found today’s case highly instructive in highlighting a number of important aspects regarding the presentation and initial treatment of a patient who presents to the ED with new AFib. Baseline bradycardia in endurance athletes limits the use of ß-blockers.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 52

Dr. Smith's ECG Blog

JUNE 23, 2023

The patient later settled into sinus bradycardia. The amiodarone was discontinued and the patient did well. == MY Comment , by K EN G RAUER, MD ( 6/23 /2023 ): == From an academic standpoint — I love WCT ( W ide- C omplex T achycardia ) rhythms.

Tachycardia 52

Tachycardia Cardiomyopathy Arrhythmia Diabetes 52

Dr. Smith's ECG Blog

JANUARY 15, 2023

My Comment by K EN G RAUER, MD ( 1/15 /2023 ): = For many reasons — I thought today's post by Dr. Smith to be highly insightful and extremely useful to any provider charged with interpreting emergency ECGs. The rhythm in ECG #1 is sinus bradycardia and arrhythmia. Hillinger et al. The lead that immediately caught my eye — is lead aVL.

Chest Pain 52

Chest Pain Blog Bradycardia Stents 52

Dr. Smith's ECG Blog

JULY 30, 2023

The RCA usually supplies the SA and AV nodes, so RCA OMIs can present with heart blocks and bradycardias like in this case. == MY Comment , by K EN G RAUER, MD ( 7/30 /2023 ): == There are numerous important points that are brought out by today’s case. Subendocardial ischemia does not localize.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 52

DAIC

JANUARY 19, 2024

milla1cf Fri, 01/19/2024 - 10:55 January 19, 2024 — Orchestra BioMed , a biomedical company accelerating high-impact technologies to patients through risk-reward sharing partnerships, today announced the first patient was randomized in the BACKBEAT pivotal study in late December 2023. Kowal, M.D.,

Pacemaker 105

Pacemaker Hypertension Blood Pressure Kidney Disease 105

Dr. Smith's ECG Blog

JANUARY 23, 2024

For example — bradycardia and AV conduction disturbances are not uncommon with Hyperkalemia , with these conduction disturbances most often resolving once serum K+ is corrected. A DDENDUM: There are many potential causes of AV block.

Tachycardia 106

Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death 106

Dr. Smith's ECG Blog

OCTOBER 20, 2024

As per Dr. Nossen — today's initial ECG ( LEFT tracing in Figure-2 ) shows sinus bradycardia with QRS widening due to bifascicular block ( RBBB/LAHB ). And although severe underlying coronary disease is often the cause — non-coronary causes may be seen ( See My Comment in the March 1, 2023 post for the common causes of DSI ).

Cardiogenic Shock 127

Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 127

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

That is what Emergency Medicine is all about. == MY Comment , by K EN G RAUER, MD ( 9/3 /2023 ): == I’ve seen a “common theme” with many of the ECGs that Drs. MY Thoughts on the ECG in Figure-1: The rhythm in ECG #1 is sinus bradycardia at ~50-55/minute. Figure-1: The initial ECG in today's case. Intervals ( PR, QRS, QTc ) are normal.

Chest Pain 134

Chest Pain Defibrillator STEMI Coronary Artery Disease 134

Dr. Smith's ECG Blog

MARCH 24, 2023

There’s sinus bradycardia, first degree AV block, normal axis, delayed R wave progression, and normal voltages. Hyperacute T waves are deflating, suggesting reperfusion but there is still reciprocal change in I/aVL and ST depression in V2, and the bradycardia is worse. Below is the ECG. What do you think? Take home 1.

Chest Pain 52

Chest Pain STEMI Bradycardia Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

The rhythm is uncertain ( ie, We only see 4 beats — because the same 4 beats are repeated in limb and chest leads — but in lead II there appears to be sinus bradycardia and arrhythmia plus a P wave with a PR interval too short to conduct preceding beat #1 — therefore need for a longer period of monitoring ).

Ischemia 121

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 121

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Syncope and Bradycardia Syncope in a 20-something woman Long QT: Do not trust the computerized QT interval when the QT is long An Alcoholic Patient with Syncope Cardiac Arrest. Another diagnostic ECG of a potentially deadly condition == MY Comment , by K EN G RAUER, MD ( 10/19 /2023 ): == Today's excellent case discussion by Drs.

Chest Pain 123

Chest Pain Ischemia Cardiac Arrest Blog 123

Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

Stroke: Vascular and Interventional Neurology, Volume 3, Issue S2 , November 1, 2023. Six patients (17.1%) experienced perioperative complications including stent occlusion, bradycardia, and hematoma. IntroductionIntracranial atherosclerosis (ICAS) is a leading global cause of stroke.

Stents 40

Stents Stent Outcomes Angioplasty 40

Ken Grauer, MD

OCTOBER 4, 2024

To improve visualization — I've digitized the original ECG using PMcardio ) MY Thoughts on the ECG in Figure-1: This is a challenging tracing to interpret — because there is marked bradycardia with an irregular rhythm and a change in QRS morphology. Figure-1: The initial ECG in today's case. ( The QRS complex is wide ( ie, >0.10

Blog 101

Blog Bradycardia Arrhythmia Pacemaker 101

Dr. Smith's ECG Blog

FEBRUARY 10, 2025

Theres sinus bradycardia, borderline PR interval, narrow QRS; normal axis/R wave progression; low precordial voltages, and subtle peaked T waves (most obvious in V2, but all T waves are symmetric with a narrow base). Theres no prior ECG to compare - but the bradycardia, prolonged PR and peaked T waves could all be from hyperkalemia.

Bradycardia 117

Bradycardia Cardiac Arrest Hypertension ICU 117

Dr. Smith's ECG Blog

MAY 23, 2022

Patient 2 : 55 year old with 5 hours of chest pain radiating to the shoulder, with nausea and shortness of breath ECG: sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. Smith : The fact that the ECG did not evolve is further proof that this was the baseline ECG. nearly identical to the first case).

Chest Pain 52

Chest Pain Pericarditis STEMI Arrhythmia 52

Dr. Smith's ECG Blog

APRIL 13, 2025

There is also STE in V1 which is diagnostic of right ventricular OMI in this situation , and partly explains the syncope and hypotension (along with the bradycardia). As I wrote in My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog "I suspect that the entity known as MINOCA is not fully appreciated by many clinicians."

Chest Pain 83

Chest Pain Embolism STEMI Plaque 83

Dr. Smith's ECG Blog

FEBRUARY 18, 2025

As I emphasized in My Comment in the February 27, 2023 post in Dr. Smith's ECG Blog some patients may develop everything except QRS widening. Among the "lessons" from today's case are the following: Although many patients follow the "textbook sequence" of ECG changes with their hyperkalemia a significant percentage of patients do not.

Blood Pressure 62

Blood Pressure Blog Cardiac Arrest Bradycardia 62

Dr. S. Venkatesan MD

NOVEMBER 22, 2024

2023 Sep 29;15(9). Simple measures, optimal BP, like weight reduction, (Atrial interstitial fat shedding) , relaxation can prevent 90% of AF burden. Ahammed MR et al Impact of Weight Loss on Atrial Fibrillation. Regarding pharmaco-therapy, the celebrated vintage days of anti-arrhythmic drugs have almost gone.

Atrial Fibrillation 52

Atrial Fibrillation Arrhythmia Risk Factors Bradycardia 52