Dr. Smith's ECG Blog

JULY 30, 2023

Written by Pendell Meyers A woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. 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. AI can do it too.

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Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

JULY 25, 2024

The ECG shows severe ischemia, possibly posterior OMI. But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. It takes time for that ischemia to resolve. Just as important is pretest probability: did the patient report chest pain prior to collapse?

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Cardiac Arrest Ischemia Tachycardia Defibrillator 124

Dr. Smith's ECG Blog

MARCH 8, 2019

A previously healthy middle-aged male presented shortly after the acute onset of chest pain very shortly before calling 911. On arrival, he was pain free: What do you think? Jerry Jones commented: "Any ST depression on the ECG of a patient with chest pain credible for ACS represents a reciprocal change until proved otherwise."

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Chest Pain STEMI Plaque Ischemia 52

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada.

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 22, 2019

The computer called it a normal ECG Algorithm unknown Aside : [There is some "sinus arrhythmia", which is indeed a normal finding. Sinus arrhythmia is sinus rhythm whose rate varies with respiration. If the longest P-P interval is 120 ms greater than the shortest, it is sinus arrhythmia. Burning pain subxiphoid and into throat."

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Chest Pain Arrhythmia Ischemia STEMI 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

Written by Jesse McLaren, with edits from Smith and Grauer A 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. 2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia.

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Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. However, he suddenly developed a series of malignant ventricular arrhythmias.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. Here was my answer: "Not ischemia. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. Tall R wave in lead V1 and/or early transition in the chest leads ( reflecting increased "septal" forces ).

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Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. A prior ECG was available for comparison: Normal One might be tempted to interpret the ST depression as ischemia, but as Smith says, "when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave." Chest pain in high risk patient. Is it STEMI?

Chest Pain 124

Chest Pain Ischemia Cardiac Arrest Blog 124

Ken Grauer, MD

OCTOBER 13, 2023

She was hemodynamically stable — and did not have chest pain, lightheadedness or syncope. With P waves labeled — Isn't it now much easier to appreciate that the atrial rhythm is quite regular ( with no more than a slight sinus arrhythmia )? For those with a special interest in cardiac arrhythmias — READ ON! —

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Blog Arrhythmia Bradycardia Download 159

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. Chest pain was resolved upon arrival in the ED. Is there ischemia? Idioventricular rhythm is a common "reperfusion arrhythmia." His previous ECG was normal. What is it? Answer below. But it is not conclusive.

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Chest Pain Ischemia Dysrhythmia STEMI 52

Dr. Smith's ECG Blog

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. The arrhythmia spontaneously converted before defibrillation was achieved. What do you think? What do you think?

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 128

Dr. Smith's ECG Blog

AUGUST 3, 2018

In the evening, a middle-aged man complained of chest pain at the nursing home. His chest pain was vague. He mentioned "cancer" and "chest". I’ll focus my comments on arrhythmia diagnosis. P EARL # 2 : In my experience — the most commonly overlooked arrhythmia ( by far! ) Fluids were started.

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Chest Pain Tachycardia Atrial Flutter Ultrasound 40

Dr. Smith's ECG Blog

AUGUST 28, 2020

This is ischemia until proven otherwise. A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock. I learned that the patient is on Sotalol for control of PVCs. This explains the long QT.

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Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Ken Grauer, MD

JANUARY 13, 2024

My written interpretation on a tracing such as this one would read, "Marked LVH and 'strain' and/or ischemia — with need for clinical correlation." BOTTOM Line: Today's patient presented with a 2-3 day history of chest pain and the ECG shown in Figure-1. WPW Cardiac arrhythmias ( including AFib ).

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Blog Ischemia AFIB Hypertension 159

MIBHS

OCTOBER 31, 2024

This may result in ischemia (lack of oxygen to the heart muscle), causing parts of the heart to weaken and enlarge. Arrhythmias (Irregular Heartbeats) Persistent abnormal heart rhythms can disrupt the heart’s pumping efficiency, eventually causing it to enlarge to maintain blood flow.

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Blood Pressure Blood Clot Heart Valves Heart Rhythm 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

All of the patients presented with chest pain , and they are all in triage. 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. True Positive ECG#2 : Also sinus rhythm.

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Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 123

Dr. Smith's ECG Blog

JULY 22, 2023

He denied chest pain or shortness of breath. In the clinical context of weakness and fever, without chest pain or shortness of breath, the likelihood of Brugada pattern is obviously much higher. Prior to Mizusawa's study, it was thought that the incidence of syncope, arrhythmia, or SCD in this cohort was low [7].

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

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). Here are some cases of RBBB with LAFB: What is the Diagnosis in this 70-something with Chest Pain? There is STE in aVR.

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Cardiogenic Shock Cardiac Arrest Hospital Ischemia 127

Ken Grauer, MD

MARCH 15, 2024

This includes sinus arrhythmia — in which there is often slight variation in the P-P interval. This slight variation in sinus P wave regularity tends to be greater when a 2nd- or 3rd-degree AV block is present ( called ventriculophasic sinus arrhythmia — as shown in ECG Blog #344 ). For clarity — I have done this in Figure-4.

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Blog Arrhythmia STEMI Ischemia 160

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology.

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Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

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STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. Patient 2 was seen immediately after patient 1 by the same cardiologist.

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Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

JULY 16, 2024

This is the prehospital ECG from an 81 year old man with acute chest pain. Arrhythmia? Today’s case recalled that scenario for me, in that it features recognition of an arrhythmia that fooled ED staff into thinking the ECG was showing an acute infarction. The medics did NOT activate the cath lab. Would you give lytics?

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Atrial Flutter Chest Pain Tachycardia Arrhythmia 59

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? ST depression. Myocardial Contusion?

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

Ken Grauer, MD

FEBRUARY 18, 2023

The presenting complaint was chest pain — and the patient collapsed soon after arrival in the ED. Shark Fin" ST segment elevation is most often a sign of severe transmural ischemia that results from acute coronary occlusion. QUESTION: A cardiologist interpreted the rhythm in Figure-1 as VT ( V entricular T achycardia ).

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Blog AFIB Chest Pain STEMI 78

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?

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Tachycardia Electrophysiology Atrial Flutter Ischemia 119

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The initial troponin I returned at 1500 ng/L and another ECG was recorded as the patient complained of 9/10 chest pain at 10 hours after the first Now the T-wave in III is fully upright, suggesting re-occlusion.

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Chest Pain Bradycardia Blog Critical Care 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia. Anything more on history?

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 23, 2024

There was no chest pain. Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc). VT is the second most common presenting arrhythmia. Vaso or inotropic medications are not harmless, and can precipitate life threatening arrhythmias.

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Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death 107

Wellnest

DECEMBER 21, 2022

If you experience any symptoms, such as chest pain, dizziness, unusual tiredness or fatigue, shortness of breath, or irregular heartbeat, your doctor would want you to go for an ECG test to find out the underlying cause. Arrhythmia In simple words, arrhythmia refers to an irregular heartbeat.

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Cardiac Arrest Heart Attack Heart attacks Atrial Fibrillation 52

Ken Grauer, MD

APRIL 9, 2023

No chest pain. Figure-1: The initial ECG in today's case — obtained from an 86-year old man with presyncope, but no chest pain. ( The other main consideration — is to take another look at the 12-lead ECG, and assess this for recent ischemia or infarction. Figure-5: Laddergram illustration of today's arrhythmia. =

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Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

JUNE 28, 2023

RVOT VT: A 40-something without past history presents with wide complex tachycardia and crushing chest pain Regular Wide Complex Tachycardia. He got an MR, however that showed no scar or evidence of AVRD and he had a stress test with no evidence of inducible ischemia with almost 20 METs." There is no inferior axis.

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Tachycardia Ultrasound Heart Disease Atrial Fibrillation 98

Dr. Smith's ECG Blog

NOVEMBER 24, 2018

If it is a chest pain patient, I would get a formal echo and serial ECGs. There were no others: Notice the similarities to the ECG above, confirming that they are baseline Then he sent the clinical history, which was of a malfunctioning ICD, but without any chest pain or SOB. And look for an old EKG."

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Chest Pain Exercise Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. Figure-1: Initial ECG, obtained pre-hospital from this 40-ish year old woman with new-onset chest pain ( See text ). The presence of such J waves may be associated with malignant ventricular arrhythmias. She called 911. But which myocardial walls are affected?

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Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

MARCH 15, 2023

She did notice something slightly wrong subjectively, but had no palpitations, chest pain, or SOB, or any other symptom. The Role of Sinus Arrhythmia: I found it interesting to compare the long lead II rhythm strips in the 3 serial tracings from today’s case ( Figure-1 ). She was on no medications. Potassium was normal.

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Atrial Fibrillation AFIB Arrhythmia Exercise 52