Dr. Smith's ECG Blog

JULY 5, 2018

Many patients have a T achy- B rady syndrome in which tachyarrhythmias ( most commonly rapid AFib ) alternate with periods of bradycardia. New slow AFib reflects a combination of these rhythm problems. Thus, it is not those episodes of rapid AFib seen in patients with Tachy-Brady that qualify. second in duration.

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Atrial Fibrillation AFIB Bradycardia Pacemaker 52

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 52

Pulmonary AFIB Atrial Fibrillation Pacemaker 52

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

SEPTEMBER 24, 2023

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 ). Figure-1: The initial ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ).

Chest Pain 85

Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 85

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 52

Ischemia STEMI Stenosis Chest Pain 52

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. WPW Cardiac arrhythmias ( including AFib ). Voltage for LVH ( the R wave in lead aVL easily surpassing 12 mm ).

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Chest Pain Cardiomyopathy Blog AFIB 93

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.

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AFIB Tachycardia Atrial Fibrillation Blog 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ). Chest trauma was suspected on initial exam. Here is his initial ECG around 1330: What do you think?

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

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 78

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 ).

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Tachycardia AFIB Blog Heart Disease 52

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 ).

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Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

These include ( among others ) — acute febrile illness — variations in autonomic tone — hypothermia — ischemia-infarction — malignant arrhythmias — cardiac arrest — and especially Hyperkalemia. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ).

Arrhythmia 52

Arrhythmia Blog Chest Pain Cardiac Arrest 52

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 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

Heart 2023 Conference

APRIL 20, 2022

(Harvard University Heart Letter) A clinical polygenic risk score test for diseases ranging from atrial fibrillation (AFib) to breast cancer was piloted by scientists. Stroke) A Danish study indicated that combining nitrates and PDE5 inhibitors isn't always a terrible idea for men with ischemic heart disease and erectile dysfunction.

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Pulmonary Hypertension AFIB COVID-19 52

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.

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Cardiac Arrest Chest Pain Embolism Pulmonary 52

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

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.

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Cardiogenic Shock Cardiac Arrest Hospital Ischemia 126

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).

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Tachycardia AFIB Arrhythmia Coronary Artery Bypass Graft 52

Dr. Smith's ECG Blog

JANUARY 26, 2020

While patients with repolarization variants or acute ischemia ( including the DeWinter T wave pattern ) often manifest peaked T waves the T waves with ischemia or repolarization variants tend not to be as pointed as is seen with hyperkalemia and, the base of those T waves tends not to be as narrow as occurs with hyperkalemia.

Bradycardia 52

Bradycardia Ischemia Cardiac Arrest AFIB 52

Dr. Smith's ECG Blog

MARCH 6, 2020

There is no evidence of infarction or ischemia. There is a large peaked P-wave in lead II (right atrial enlargement) There is left axis deviation consistent with left anterior fascicular block. There are nonspecific ST-T abnormalities. Troponin I was 0.054 ng/mL NT-ProBNP was 8316 (0-900 pg/mL). "

Heart Failure 52

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy 52

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.

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Blog Chest Pain Myocardial Infarction Critical Care 63

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

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 ). Meyers' discussion — he lists more than 20 links to cases that we've presented related to this entity on Dr. Smith's ECG Blog.

Chest Pain 112

Chest Pain Embolism Pulmonary Tachycardia 112

Dr. Smith's ECG Blog

APRIL 16, 2025

Discussion: This patient was very lucky that she had a doctor who understood her initial ECG, advocated for her, performed serial ECGs, and that her serial ECGs happened to have temporary lack of RBBB which reduces the complexity of the ischemia interpretation. Regularity of the rhythm rules out AFib. Many patients are not this lucky.

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Chest Pain STEMI Tachycardia Cardiac Arrest 68