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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Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The baseline ECG is basically normal with no ischemia. In my opinion, I think it looks more like subendocardial ischemia.

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Dr. Smith's ECG Blog

JULY 30, 2023

The STD maximal in V1-V4 is diagnostic of acute transmural posterior wall ischemia, most likely due to posterior OMI. Subendocardial ischemia does not localize, and subendocardial ischemia presents with STD maximal in V5-6, II, and STE in aVR. Subendocardial ischemia does not localize. Finally the OMI was realized.

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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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Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI. Eur Heart J Digital Health 2024 5.

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Ken Grauer, MD

AUGUST 26, 2023

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 ). This point is discussed in detail in the March 24, 2023 post of Dr. Smith’s ECG Blog ).

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Dr. Smith's ECG Blog

OCTOBER 8, 2023

The patient was referred immediately for cath which revealed RCA occlusion that was stented. Remember, in diffuse subendocardial ischemia with widespread ST-depression there may b e ST-E in lead s aVR and V1. There are well formed R-waves with good voltage/amplitude which is uncommon for ischemia. There is ST depression in V1.

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Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. 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)? The last echocardiography 12 months ago showed HFmrEF.

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Coronary Artery Disease Journal

MARCH 7, 2024

Background Untreated multivessel disease (MVD) in acute myocardial infarction (AMI) has been linked to a higher risk of recurrent ischemia and death within one year. Databases were searched for relevant articles published before 10 November 2023. Pertinent data from the included studies were extracted and analyzed using RevMan v5.4.

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Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

I would expect TIMI-3 flow (normal flow, no persistent ischemia) with a culprit in the RCA (or possibly Circumflex). I would expect that a stent would be placed. The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. What would I expect the angiogram to show?

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Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

Stroke: Vascular and Interventional Neurology, Volume 3, Issue S2 , November 1, 2023. 5 ICSS‐ MRI study (International Carotid Stenting Study Magnetic Resonance Imaging Study), indicated that patients with periprocedural hemodynamic depression had decreased cerebral blood flow and increased the risk of new lesions in imaging.6

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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 ! Just before 10 AM, the patient received a stent to the culprit OM. link] == MY Comment , by K EN G RAUER, MD ( 12/26/ 2023 ): == Interesting case by Dr. Frick — with superb illustration by him of cardiac cath findings!

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Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

Stroke: Vascular and Interventional Neurology, Volume 3, Issue S2 , November 1, 2023. Interventional approaches may include ECA‐ICA stenting with a covered stent or stent‐assisted coil embolization of the proximal stump.

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Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

The patient’s angiogram should have been expedited, but the EKG change was not recognized as recurrence of transmural ischemia. RAO Caudal View Post PCI This is the RAO Caudal view after thrombectomy and stent placement. For more on use of Opiates with acute ischemic CP — See the January 6, 2023 post in Dr. Smith's ECG Blog ).

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Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

Stroke: Vascular and Interventional Neurology, Volume 3, Issue S2 , November 1, 2023. Secondary outcomes included favorable functional outcome and periprocedural hemorrhagic/ischemia‐related complications.

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Dr. Smith's ECG Blog

JANUARY 25, 2024

LAD: severe in-stent restenosis in the mid (80%) and distal (90%) segment and diffuse disease distally. Ramus intermedius: large, severe in-stent restenosis at the distal stent edge (90%) and severe de-novo stenosis at the ostial segment (90%). The pain did not resolve with NTG, and so he went to emergent angiography: 1.

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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. A single DES stent was placed, and the patient did well post-procedure. Abstract 556. You can't use absence of WMA to rule out need for emergent angiography!

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Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

The patient, albeit very delayed was referred for angiography where a 99% stenosed pRCA was stented. For example — I've seen fast AFib be associated with significant ST elevation and depression that resolves after heart rate slows, and which was not a result of ischemia. Figure-1: The initial ECG in today's case. (

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Dr. Smith's ECG Blog

JANUARY 28, 2023

Prior ECG available on file from 2 months before: We do not know the clinical events happening during this ECG, but there is borderline tachycardia, PVCs, and likely some evidence of subendocardial ischemia with small STDs maximal in V5-6/II, slight reciprocal STE in aVR. Culprit lesion was reduced to 0% and stented.

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Dr. Smith's ECG Blog

FEBRUARY 6, 2023

The ECG was incorrectly interpreted as no signs of ischemia. Artificial intelligence can be trained to recognize subtle OMI = My Comment by K EN G RAUER, MD ( 2/6 /2023 ): = The initial ECG in today's case was incorrectly interpreted as, "No signs of ischemia". No further ECG were ever recorded.

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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. The culprit lesion was opened and stented. Most notably the ST depression in the inferior leads is slightly more upsloping. The QoH interpretation however was the same for both ECGs.

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Dr. Smith's ECG Blog

MARCH 20, 2023

Angiogram soon after (around 4 hrs after presentation) showed multi vessel CAD, with culprit lesion total occlusion of the first obtuse marginal branch (OM1), which was stented. My Comment by K EN G RAUER, MD ( 3/21 /2023 ): = Today's case provides one more example of an acute OMI not initially recognized by the On-Call interventionist.

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Dr. Smith's ECG Blog

DECEMBER 29, 2015

All these factors, again, support an ECG diagnosis of LVH The patient was nonetheless taken for emergency angiography, and a 99% mid-LAD lesion was found and stented. However, the ST segments in patients with LVH may show significant variation over time in the absence of ischemia. 2023;Available from: [link] Am J Cardiol.

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Dr. Smith's ECG Blog

MARCH 19, 2023

It was opened and stented. As a result — we do not know if ECG #2 represents a stable “baseline” tracing — or whether it might have been obtained during a period of ischemia in this patient with a history of known coronary disease. Formal bubble contrast echo: The estimated left ventricular ejection fraction 57%.

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Dr. Smith's ECG Blog

MAY 8, 2023

So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent. EKG shown here: LAFB with no clear signs of OMI or ischemia. Queen of Hearts interpretation: Now the cardiologist considered it "STEMI"! No labs were performed. EKG and CT head were performed.

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Dr. Anish Koka

MAY 16, 2023

The diagnosis typically requires classic clinical features, with no evidence of obstructive coronary disease, and typical findings of ischemia on functional studies. But these are words you won’t find in the chest pain guidelines of 2023. This happens. But its rare!

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Dr. Smith's ECG Blog

AUGUST 10, 2023

Even though they were passed the 12 hour mark traditionally associated with reperfusion benefits, ongoing ischemia requires emergent angiogram On assessment, the patient appeared uncomfortable, leaning forward in his chair. ACS with refractory ischemia and electrical instability are indications for emergent cath regardless of the ECG!

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Dr. Smith's ECG Blog

NOVEMBER 17, 2024

The operator performed intravascular ultrasound and visualized acute plaque rupture with thrombus formation and placed a stent. There was reperfusion ischemia superimposed on benign T-wave inversion. He is very lucky that he spontaneously reperfused and was stented before he had the chance to re-occlude.

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Dr. S. Venkatesan MD

JANUARY 14, 2025

doi: 10.1136/jnis-2023-021243. Management The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Current treatment is with anti-thrombotics and/or anticoagulation.Lesser option is to alter the flow disturbance caused by the web (surgery or stent).

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Dr. Smith's ECG Blog

NOVEMBER 23, 2024

It was opened and stented. Compared to TTE from 7/3/24: the anterior regional wall motion abnormality is new and is consistent with ischemia/infarction in the LAD territory == MY Comment , by K EN G RAUER, MD ( 11/20 /2024 ): == There are several insightful aspects of today's case. The March 17, 2023 post — for PTA.

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Dr. Smith's ECG Blog

MARCH 8, 2025

After stent deployment, we often see improvement in the ST-T within seconds or minutes. Here is the final angiogram following placement of a stent in the ostial RCA. 2:04 PM, post stent deployment You can see that even after complete restoration of flow, the ECG still looks terrible, V most of all. link] Jentzer, J. Kashou, A.

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