AFIB, Blog and Ischemia - Cardiovascular Update

ECG Blog #412 — Is Cardiac Cath Indicated?

Ken Grauer, MD

JANUARY 13, 2024

For more regarding ECG criteria for LVH — See the ADDENDUM below and/or ECG Blog #73 and ECG Blog #245. My written interpretation on a tracing such as this one would read, "Marked LVH and 'strain' and/or ischemia — with need for clinical correlation." WPW Cardiac arrhythmias ( including AFib ).

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Blog Ischemia AFIB Hypertension

ECG Blog #371 — Palpitations Since Childhood.

Ken Grauer, MD

MARCH 29, 2023

M Y T houghts on the ECG in Figure-1: I have presented similar ECGs to the one in today's tracing on several occasions ( most recently in ECG Blog #284 ). M y I MPRESSION : The rhythm in Figure -1 is almost certain to be very rapid AFib in a patient with WPW. The patient was hemodynamically stable in association with this rhythm. (

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Blog AFIB Arrhythmia Download

ECG Blog #381 — Why was the Troponin Normal?

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 ). ECG Blog #316 — The patient died.

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Blog Ischemia STEMI Cardiac Arrest

ECG Blog #364 — VT in Need of Cardioversion?

Ken Grauer, MD

FEBRUARY 18, 2023

These findings suggest that instead of VT — the rhythm in Figure-1 is AFib with a fairly rapid ventricular response. Since the rhythm is supraventricular (ie, AFib ) — we can accurately assess QRS morphology. Shark Fin" ST segment elevation is most often a sign of severe transmural ischemia that results from acute coronary occlusion.

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Blog AFIB Chest Pain STEMI

ECG Blog #387 — 2 Minutes Later.

Ken Grauer, MD

JULY 22, 2023

I see the following: Although there is no long lead rhythm strip — we can see that the rhythm is AFib with a controlled ventricular response ( ie, irregularly irregular rhythm without P waves — and with a heart rate between ~70-110/minute ). Regarding Intervals: There is no PR interval ( since the rhythm is AFib ).

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Blog Chest Pain STEMI AFIB

What is this ECG finding? Do you understand it before you hear the clinical context?

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

See our other blog posts of hypothermia and Osborn waves -- Massive Osborn Waves of Severe Hypothermia (23.6 The rhythm is irregularly irregular, and appears to be AFib with a fairly slow ventricular response ( overall rate <70/minute ) — although marked baseline artifact renders the search for atrial activity futile.

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Blog Cardiac Arrest Atrial Fibrillation Bradycardia

Which of these, if either, is OMI? Which of these underwent emergent angiography and PCI? Which should have?

Dr. Smith's ECG Blog

JULY 14, 2024

In addition — there is transmural ischemia of the septum , most often resulting from occlusion proximal to the 1st septal perforator branch of the LAD. The rhythm in both tracings in Case #2 shows AFib with a controlled ventricular response ( with a PVC in the 2nd tracing ).

AFIB

AFIB Stents Stent Chest Pain

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished. First , there can simply be diffuse ST depressions (which obligates reciprocal STE in aVR) associated with tachycardia which are not indicative of ischemia.

Ischemia

Ischemia Atrial Flutter Arrhythmia Tachycardia

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

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

Tachycardia Electrophysiology Atrial Flutter Ischemia

Sudden shock with a Nasty looking ECG. What is it?

Dr. Smith's ECG Blog

MAY 3, 2024

When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI). There is STE in aVR. Thus, there is high lateral OMI with diffuse ST depression. Moreover, left main occlusion often presents near death.

Cardiogenic Shock

Cardiogenic Shock Cardiac Arrest Hospital Ischemia

An elderly patient with stuttering chest pain. Don't jump to conclusions.

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

Chest Pain Cardiomyopathy Blog AFIB

Syncope and Atrial fibrillation in a Healthy 70-something Male

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. Many patients have a T achy- B rady syndrome in which tachyarrhythmias ( most commonly rapid AFib ) alternate with periods of bradycardia. second in duration.

Atrial Fibrillation

Atrial Fibrillation AFIB Bradycardia Pacemaker

What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?

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. I focus my comment on a few additional aspects regarding new AFib.

Atrial Fibrillation

Atrial Fibrillation AFIB Arrhythmia Exercise

Does this ST Depression Maximal in V3 Represent Posterior OMI?

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 rhythm is rapid AFib. Atrial fib may cause Occlusion mimic."

Atrial Fibrillation

Atrial Fibrillation Ischemia AFIB Tachycardia

This middle-aged patient presented with SOB, weakness, and mild pulmonary edema.

Dr. Smith's ECG Blog

JANUARY 22, 2020

There was no evidence of ischemia. C linical P oints R egarding E CG # 1 : We are told that the patient is a middle-aged woman and that she previously had been in AFib with LBBB. While I agree that AFib + complete AV block is the most likely rhythm diagnosis I'd like to see additional monitoring strips to be sure.

Pulmonary

Pulmonary AFIB Atrial Fibrillation Pacemaker

Morphine + OMI is a bad combination

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

This is written by Magnus Nossen, with some edits by Smith This ECG diagnosis will be obvious to the majority of the readers of this blog. Thoughts about Today's CASE: On occasion — a patient may present for acute care because of CP ( C hest P ain ) due solely to a tachyarrhythmia ( including new AFib, a reentry SVT or VT ).

Chest Pain

Chest Pain Atrial Fibrillation AFIB Myocardial Infarction

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

In terms of ischemia, there is both a signal of subendocardial ischemia (STD max in V5-V6 with reciprocal STE in aVR) AND a signal of transmural infarction of the inferior wall with Q wave and STE in lead III with reciprocal STD in I and aVL. The rhythm is atrial fibrillation. The QRS complex is within normal limits. These include.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

A teenager involved in a motor vehicle collision with abnormal ECG

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. I've copied KEY points from My Comment in the August 6, 2022 post in Dr. Smith's ECG Blog — regarding the answer to this question. Chest trauma was suspected on initial exam. Figure-1: The initial ECG in today's case.

Tachycardia

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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?

Ischemia

Ischemia STEMI Stenosis Chest Pain

A woman in her 60s with palpitations

Dr. Smith's ECG Blog

APRIL 24, 2022

Here is her post-cardioversion ECG: ECG#2 - Immediately post cardioversion: Appropriate ST depression maximal in V5-6 and lead II, secondary to subendocardial ischemia, likely residual from the preceding tachycardia. Patient was referred to electrophysiologic testing due to suspicion of afib and WPW. She was sedated and cardioverted.

AFIB

AFIB Tachycardia Atrial Fibrillation Blog

A Different Kind of Wide Rhythm -- Pleomorphic Ventricular Tachycardia

Dr. Smith's ECG Blog

JUNE 1, 2020

MY THOUGHTS on ECG #1: My initial impression on looking at the ECG in Figure-1 — was that the rhythm was either rapid AFib in a patient with WPW — or — PMVT ( P oly M orphic VT ). The reason I initially thought the underlying rhythm was AFib — is that no atrial activity is seen in any lead and the rhythm “looks” irregular. See text ).

Tachycardia

Tachycardia AFIB Blog Heart Disease

Of Twists and Turns

EMS 12-Lead

APRIL 28, 2022

The QRS is wide in B — but the rhythm is irregularly irregular with no sinus P waves — so this most probably represents rapid AFib with an atypical RBBB/LPHB morphology. We now see that QRS morphology in lead II during sinus rhythm is similar to the QRS morphology in lead II during rapid AFib (beats #1-5 in lead II in A).

Tachycardia

Tachycardia AFIB Arrhythmia Coronary Artery Bypass Graft

A woman in her 50s with dyspnea and bradycardia

Dr. Smith's ECG Blog

JANUARY 26, 2020

Is This a Simple Right Bundle Branch Block? == MY Comment , by K EN G RAUER, MD ( 1/26/2020 ): == Dr. Smiths ECG Blog has presented too-numerous-to-count cases of hyperkalemia ( See My Comment in the 12/11/2018 post there are many others! ). Is this just right bundle branch block?

Bradycardia

Bradycardia Ischemia Cardiac Arrest AFIB

Patient in Single Vehicle Crash: What is this ST Elevation, with Peak Troponin of 6500 ng/L?

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

As we've discussed on numerous other posts in Dr. Smith's ECG Blog ( See My Comment at the bottom of the page in the May 5, 2022 post) — a growing number of conditions other than Brugada Syndrome have been found to temporarily produce a Brugada-1 ECG pattern. What are the ECG Findings of Cardiac Contusion?

Arrhythmia

Arrhythmia Blog Chest Pain Cardiac Arrest

This was texted to me in real time. The patient has acute chest pain.

Dr. Smith's ECG Blog

JULY 5, 2023

Here was my answer: "Not ischemia. WPW Cardiac arrhythmias ( especially AFib ). This was texted to me in real time. The patient has acute chest pain. What do you think? Maybe HOCM or another form of LVH. I would not activate cath lab. Abnormal ST-T wave abnormalities. Conduction defects (ie, LBBB, IVCD ).

Chest Pain

Chest Pain STEMI Congenital Heart Disease Heart Disease

New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?

Dr. Smith's ECG Blog

MARCH 6, 2020

There is no evidence of infarction or ischemia. I focus My Comment on determination of the e tiology of this patient’s tachyarrhythmia — and compare it to other SVT rhythms previously published in Dr. Smith’s ECG Blog. E CG # 2 in Figure-1 is from the October 16, 2019 post on Dr. Smith’s Blog. H eart R ate C an H elp !

Heart Failure

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy

A woman in her 40s with acute chest pain and shortness of breath

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

Meyers' discussion — he lists more than 20 links to cases that we've presented related to this entity on Dr. Smith's ECG Blog. That said — the diagnosis of acute PE continues to be overlooked ( and the ECGs of such patients continue to be misinterpreted as acute ischemia or infarction — instead of being recognized as diagnostic of acute PE ).

Chest Pain

Chest Pain Embolism Pulmonary Tachycardia

Chest (or abdominal?) pain and ECG artifact.

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

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. Regional wall motion abnormality--mid anterior akinesis.

Blog

Blog Chest Pain Myocardial Infarction Critical Care

ECG Blog #412 — Is Cardiac Cath Indicated?

ECG Blog #371 — Palpitations Since Childhood.

ECG Blog #381 — Why was the Troponin Normal?

ECG Blog #364 — VT in Need of Cardioversion?

ECG Blog #387 — 2 Minutes Later.

What is this ECG finding? Do you understand it before you hear the clinical context?

Which of these, if either, is OMI? Which of these underwent emergent angiography and PCI? Which should have?

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Sudden shock with a Nasty looking ECG. What is it?

An elderly patient with stuttering chest pain. Don't jump to conclusions.

Syncope and Atrial fibrillation in a Healthy 70-something Male

What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?

Does this ST Depression Maximal in V3 Represent Posterior OMI?

This middle-aged patient presented with SOB, weakness, and mild pulmonary edema.

Morphine + OMI is a bad combination

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

A teenager involved in a motor vehicle collision with abnormal ECG

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

A woman in her 60s with palpitations

A Different Kind of Wide Rhythm -- Pleomorphic Ventricular Tachycardia

Of Twists and Turns

A woman in her 50s with dyspnea and bradycardia

Patient in Single Vehicle Crash: What is this ST Elevation, with Peak Troponin of 6500 ng/L?

This was texted to me in real time. The patient has acute chest pain.

New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?

A woman in her 40s with acute chest pain and shortness of breath

Chest (or abdominal?) pain and ECG artifact.

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