Dr. Smith's ECG Blog

JANUARY 9, 2024

She had a single chamber ICD/Pacemaker implanted several years prior due to ventricular tachycardia. She presented to the emergency department after a couple of days of chest discomfort. Answer : The ECG above shows a regular wide complex tachycardia. Cardiac output (CO) was being maintained by the tachycardia.

Tachycardia 118

Tachycardia Electrophysiology Atrial Flutter Ischemia 118

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". He mentioned "cancer" and "chest". There is a narrow complex tachycardia at a rate of 130. I’ll focus my comments on arrhythmia diagnosis. Is is sinus?

Chest Pain 40

Chest Pain Tachycardia Atrial Flutter Ultrasound 40

Dr. Smith's ECG Blog

JULY 25, 2024

Just as important is pretest probability: did the patient report chest pain prior to collapse? Confirmation of sinus tachycardia should be easy to verify when the heart rate slows a little bit ( as the patient's condition improves ) — allowing clearer definition between the T and P waves. Then assume there is ACS.

Cardiac Arrest 123

Cardiac Arrest Ischemia Tachycardia Defibrillator 123

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.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Ken Grauer, MD

MAY 28, 2024

Note the Timed Contents that I detail below facilitate finding specific material. == ECG Podcast #4 — All About Comparison ECGs for 12-Leads and Arrhythmias ( Comparing ECGs seems so "easy" to do — but so often is not done correctly! ) — published by Mayo Clinic CV Podcast Series on 5/21/2024 ( 35 minutes ). What are the problems?

Blog 143

Blog Arrhythmia Tachycardia CME 143

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? He was intubated for altered mental status.

Tachycardia 114

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 114

Dr. Smith's ECG Blog

AUGUST 13, 2020

His previous echo one month prior shows the same thing: “consistent with old infarct in LAD vascular territory, with EF 45%” "I think there is something else causing his tachycardia which is exaggerating his EKG findings and mimicking an acute myocardial infarction." The patient spontaneously converted back to sinus tachycardia.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

This 60-something with h/o COPD and HFrEF (EF 25%) presented with SOB and chest pain. Multifocal Atrial Tachycardia 2. Failure to follow this advice will undoubtedly lead to overlooking subtle acute MIs — and , it will especially lead to misdiagnosing many cardiac arrhythmias ( as was done in this case ). GET a 12-lead!

Atrial Fibrillation 52

Atrial Fibrillation Tachycardia Arrhythmia Pulmonary 52

Dr. Smith's ECG Blog

JULY 24, 2024

22:25 — What if you have a regular SVT ( = narrow-complex tachycardia ) without obvious P waves? ( And regarding arrhythmias: For more on the regular WCT — See My Comment in the May 5, 2020 post and in the April 15, 2020 post in Dr. Smith's ECG Blog. 11:35 — My views on: Will the computer ever be able to interpret complex arrhythmias?

Arrhythmia 52

Arrhythmia Blog Tachycardia CME 52

Dr. Smith's ECG Blog

APRIL 15, 2020

Here is her ED ECG: Here is the ED physician's interpretation: IMPRESSION UNCERTAIN REGULAR RHYTHM, wide complex tachycardia, likely p-waves. LEFT BUNDLE BRANCH BLOCK [120+ ms QRS DURATION, 80+ ms Q/S IN V1/V2, 85+ ms R IN I/aVL/V5/V6] Comparison Summary: LBBB and tachycardia are new. This is clearly ventricular tachycardia.

Tachycardia 52

Tachycardia Nursing Heart Disease Dysrhythmia 52

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?

Atrial Flutter 59

Atrial Flutter Chest Pain Tachycardia Arrhythmia 59

Circulation: Arrhythmia and Electrophysiology

DECEMBER 21, 2023

Circulation: Arrhythmia and Electrophysiology, Ahead of Print. Colchicine did not prevent atrial arrhythmia recurrence at 2 weeks (31% versus 32%; hazard ratio [HR], 0.98 [95% CI, 0.59–1.61];P=0.92) Postablation chest pain consistent with pericarditis was reduced with colchicine (4% versus 15%; HR, 0.26 [95% CI, 0.09–0.77];P=0.02)

Atrial Fibrillation 40

Atrial Fibrillation Ablation Chest Pain Atrial Flutter 40

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. Idioventricular rhythm is a common "reperfusion arrhythmia." Exactly how they relate to ischemia, chest pain, and reperfusion can only be speculated about.

Chest Pain 52

Chest Pain Ischemia Dysrhythmia STEMI 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.

Chest Pain 115

Chest Pain STEMI Echocardiogram Stents 115

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

This strip was obtained: Apparent Wide Complex Tachycardia at a rate of 280 What do you think? Troponins 34>33>43, likely secondary to myocardial injury from tachycardia. Sinus tachycardia does not go this fast. A 60-something ow healthy male had syncope while on treadmill. What do you want to do?

Atrial Flutter 63

Atrial Flutter Exercise AFIB Tachycardia 63

Ken Grauer, MD

FEBRUARY 18, 2023

The presenting complaint was chest pain — and the patient collapsed soon after arrival in the ED. The finding of a fairly regular, wide tachycardia without clear sign of atrial activity ( especially when seen in an acutely symptomatic patient ) — should immediately prompt a diagnosis of VT until proven otherwise.

Blog 78

Blog AFIB Chest Pain STEMI 78

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.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Ken Grauer, MD

FEBRUARY 13, 2023

The ECG in Figure-1 was obtained from an older woman — who presented with chest pain and palpitations over the previous hour. This familial cardiac arrhythmia is the result of gene mutation. These patients are at high risk for malignant arrhythmias. BP = 140/90 mm Hg in association with the rhythm in Figure-1.

Blog 78

Blog Arrhythmia Exercise Chest Pain 78

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. ( L ADDERGRAM I llustration : Clarification of the mechanism in today's arrhythmia is best explained by laddergram illustration ( Figure-5 ). How would YOU interpret the ECG in Figure-1 ?

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

OCTOBER 25, 2022

She reports that she is now unable to vagal out of her palpitations and is having shortness of breath and dull chest pain. We see a regular tachycardia with a narrow QRS complex and no evidence of OMI or subendocardial ischemia. Now the patient is in sinus tachycardia. Sinus tachycardia, AFlutter and ATach do not do this.

Tachycardia 52

Tachycardia Atrial Flutter Dysrhythmia Ablation 52

Ken Grauer, MD

JUNE 2, 2023

This makes sense given that the underlying rhythm in today's case appears to be marked sinus bradycardia and arrhythmia , with a ventricular escape rhythm appearing when the SA node rate drops below 33/minute. ie, with syncope-presyncope, fatigue, dyspnea, chest pain? ). 2 short runs of SVT ( presumably atrial tachycardia ).

Blog 78

Blog Bradycardia Arrhythmia Tachycardia 78

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

He has a family history concerning for arrhythmia. Given the circumstances of his car crash, we presume it was due to an underlying arrhythmia. He has a family history concerning for arrhythmia with his father requiring some sort of device (PPM, ICD, unclear) at a young age. ST depression. Myocardial Contusion?

Arrhythmia 52

Arrhythmia Blog Chest Pain Cardiac Arrest 52

Ken Grauer, MD

JULY 15, 2023

This should result in at least some positivity of QRS complexes as one moves toward the lateral chest leads. The finding of all negative QRS complexes in leads V3-thru- V6 therefore strongly suggests that the arrhythmia-associated impulse is not traveling over an AP ( Steurer et al — Clin. Cardiol 17:306-308, 1994 ).

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

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. A slightly prolonged QTc ( although this is difficult to assess given the tachycardia ).

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

APRIL 29, 2020

A recent similar case: A 40-something with chest pain. Therefore, she underwent temporary pacemaker placement and overdrive pacing at a rate of 90 bpm to keep the heart rate up in order to prevent these PVCs triggering ventricular arrhythmia. Is this inferior MI? There is a bigeminy with very Bizarre looking PVCs.

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The patient continued having chest pain. There are three mechanisms of arrhythmia: automatic, re-entry, and triggered.

Chest Pain 106

Chest Pain Arrhythmia Myocardial Infarction STEMI 106

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? It is difficult to tell if there is collapse during diastole due to the patient’s tachycardia. MY Thoughts on the ECG in Figure-1: The rhythm in ECG #1 — is sinus tachycardia at ~125/minute.

Tachycardia 40

Tachycardia Pericarditis Ultrasound Blood Pressure 40

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. myocardial infarction), arrhythmias, valvular pathology, shunts, or outflow obstructions. The patient’s mental status was altered and his skin was pale and dusky.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

JANUARY 23, 2024

There was no chest pain. Shortly after isoprenalin infusion was initiated, there were short runs of ventricular tachycardia. VT is the second most common presenting arrhythmia. Vaso or inotropic medications are not harmless, and can precipitate life threatening arrhythmias. She had no known heart condition.

Tachycardia 106

Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death 106

Dr. Smith's ECG Blog

JUNE 2, 2023

She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? She was awake, alert, well perfused, with normal mental status and overall unremarkable physical exam except for a regular tachycardia, possible rales at both bases, some mild RUQ abdominal tenderness.

Tachycardia 96

Tachycardia Cardiomyopathy Electrocardiogram Article 96

Dr. Smith's ECG Blog

JANUARY 15, 2024

They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They described the chest pain as severe, crushing, and non-radiating. We can see enough to make out that the rhythm is sinus tachycardia. It was not worse with exertion or relieved by rest.

Chest Pain 63

Chest Pain Blog Arrhythmia Critical Care 63

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.

Arrhythmia 130

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 130

Open Heart

APRIL 20, 2022

Clinical contexts leading to diagnosis were SCD in 3 (6%), ventricular arrhythmias in 15 (29%), chest pain in 8 (15%), heart failure in 6 (12%) and familial screening in 20 (38%). Significant right ventricular involvement was an exclusion criterion.

Cardiomyopathy 52

Cardiomyopathy Chest Pain Sudden Cardiac Death Heart Failure 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. ECG is consistent with severe hypokalemia and/or hypomagnesemia causing prolonged QT (QU) at high risk of Torsades (which is polymorphic ventricular tachycardia in the setting of a long QT interval). Chest pain in high risk patient. Here is his triage ECG: What do you think? Is it STEMI?

Chest Pain 123

Chest Pain Ischemia Cardiac Arrest Blog 123

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 history in today's case with sudden loss of consciousness followed by chest pain is very suggestive of ACS and type I ischemia as the cause of the ECG changes. What do you think?

Cardiogenic Shock 127

Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 127

Dr. Smith's ECG Blog

OCTOBER 8, 2023

All of the patients presented with chest pain , and they are all in triage. I completely agree with Dr. Nossen that in this patient with new CP and sinus tachycardia with LAHB — that the T waves in each of the inferior leads are hyperacute ( ie, clearly disproportionately "bulky" given size of the QRS in these leads ).

Ischemia 121

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 121

Dr. Smith's ECG Blog

MARCH 6, 2020

This middle-aged man with no cardiac history but with significant history of methamphetamin and alcohol use presented with chest pain and SOB, worsening over days, with orthopnea. Here was his ED ECG: There is sinus tachycardia (rate about 114) with nonspecific ST-T abnormalities. BP:143/99, Pulse 109, Temp 37.2 °C

Heart Failure 52

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy 52