Dr. Smith's ECG Blog

JULY 21, 2024

There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( Some residual ischemia in the infarct border might still be present. Both episodes are initiated by an "R-on-T" phenomenon.

Arrhythmia 116

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 116

Dr. Smith's ECG Blog

NOVEMBER 9, 2018

For instance, if there were inappropriate sinus bradycardia at less than 60 bpm, the atrial pacer would take over if it is programmed to wait 1 second before firing. The T-waves of both of these beats have, coincidentally , a superimposed P-wave Clinical course: The potassium was normal, there was no ischemia or drug toxicity.

Bradycardia 52

Bradycardia Pacemaker Ischemia 52

Dr. Smith's ECG Blog

MARCH 22, 2024

I will leave more detailed rhythm discussion to the illustrious Dr. Ken Grauer below, but this use of calipers shows that the rhythm interpretation is: Sinus bradycardia with a competing (most likely junctional) rhythm. The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible.

Chest Pain 113

Chest Pain STEMI Bradycardia Ischemia 113

Ken Grauer, MD

OCTOBER 13, 2023

To do this — I apply the P s, Q s, 3 R Approach ( See ECG Blog #185 — for review of my system ). Even if we stopped here — We could conclude the following: There is marked bradycardia in today's rhythm ( ie, Heart rate in the low 30s ). Figure-4: This is the laddergram I favor for illustrating the mechanism of today's rhythm.

Blog 140

Blog Arrhythmia Bradycardia Download 140

Dr. Smith's ECG Blog

AUGUST 11, 2024

Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. There’s competing sinus bradycardia and junctional rhythm, with otherwise normal conduction, borderline right axis, normal R wave progression and voltages. What do you think?

Chest Pain 76

Chest Pain STEMI Bradycardia Stents 76

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. The patient has active chest pain, so if these are abnormally large T-waves This link shows 13 blog posts of Posterior Reperfusion T-waves.

Chest Pain 105

Chest Pain Bradycardia Blog Electrocardiogram 105

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. PEARL # 1: As I've emphasized often in this ECG Blog — the course of acute MI from acute coronary occlusion — is often staggered. PEARL # 1: As I've emphasized often in this ECG Blog — the course of acute MI from acute coronary occlusion — is often staggered.

Blog 129

Blog Chest Pain STEMI Ischemia 129

Ken Grauer, MD

OCTOBER 27, 2023

That said — obvious findings include: i ) Marked bradycardia! — This suggests ischemia of uncertain duration. Given this patient's older age — if nothing "fixable" is found, she most likely has SSS ( S ick S inus S yndrome ) and will need a pacemaker ( See ECG Blog #342 for more on SSS ). be regular! —

Blog 104

Blog Pacemaker Bradycardia Arrhythmia 104

Dr. Smith's ECG Blog

OCTOBER 18, 2023

During the night, while on telemetry, the patient became bradycardic, with periods of isorhythmic AV dissociation (nodal escape rhythm alternating with sinus bradycardia), and there were sporadic PVCs. Most such rhythms in the setting of ischemia are VF and will not convert without defibrillation. Acute ischemia?

Cardiac Arrest 107

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 107

Dr. Smith's ECG Blog

JULY 16, 2022

If you put the inferior and posterior findings together, it is diagnostic of OMI This was read as "inferior ischemia" without any other information by Dr. Richard Gray and as probable reperfused inferior-posterior OMI much later by both me and Pendell Meyers, also without any clinical information.

Chest Pain 52

Chest Pain Bradycardia Blog Critical Care 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. 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 109

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 109

Dr. Smith's ECG Blog

JUNE 19, 2023

Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. The Queen of Hearts agrees: Around this time his initial high sensitivity troponin I resulted at 231 ng/L.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI.

Blog 52

Blog Bradycardia Exercise Ischemia 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. 2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. What do you think? But it is still STEMI negative.

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

JANUARY 21, 2023

This ECG shows a sinus bradycardia with a normal conduction pattern (normal PR, normal QRS, and normal QTc), normal axis, normal R-wave progression, normal voltages. Hypothermia can also produce bradycardia and J waves, with a pseudo-STEMI pattern. This is the 2nd ECG from the February 8, 2022 post in Dr. Smith's ECG Blog ).

STEMI 52

STEMI Bradycardia Arrhythmia Cardiac Arrest 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

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. The ECG does not show any signs of ischemia. True Positive ECG#2 : Also sinus rhythm. There is ST depression in V1.

Ischemia 112

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 112

Dr. Smith's ECG Blog

DECEMBER 5, 2016

Description Sinus bradycardia. There is ST elevation in V2 and V3 There are inverted T-waves in V2 and V3 There are prominent U-waves in V2 and V3 Many responders were worried about ischemia or hypertrophic cardiomyopathy. This short QT at least makes ischemia all but impossible. There is high voltage. This is a normal variant.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

This has been discussed many times before on this blog. In-depth discussion is beyond the scope of this blog. Possible mechanisms of ventricular arrhythmias elicited by ischemia followed by reperfusion. The rhythm is AIVR -- accelerated idioventricular rhythm. Do not treat AIVR. In fact, use of antidyrhythimcs (e.g., Moffat, M.

Chest Pain 88

Chest Pain Arrhythmia Myocardial Infarction STEMI 88

Dr. Smith's ECG Blog

JANUARY 23, 2023

Triage physician interpretation: -sinus bradycardia -lateral ST depressions While there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). 121.022866.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 28, 2018

Here is his previous ECG: This was my interpretation of the first ECG: Sinus bradycardia with less than 1mm ST elevation in V4-V6, elevated compared to the previous ECG, suggestive of lateral MI. This is his first ECG in the department, which I saw as it was being printed: What do you think? Notice how useful serial ECGs are!

Pericarditis 52

Pericarditis Ischemia STEMI Chest Pain 52

Dr. Smith's ECG Blog

MAY 6, 2019

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. Ischemia/infarction. Bradycardia. Hypothermia.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 1, 2022

Here is his ECG: There is no clear evidence of OMI or ischemia. The Initial ECG in Today's Case: ECG #1 showed sinus bradycardia at a rate slightly under 60/minute — normal intervals — slight left axis ( about -15 degrees ) — and no chamber enlargement. A 40-something male with no previous cardiac disease presented with chest pain.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

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." QUESTION #2: If it were not for the markedly prolonged QTc — Wouldn't ECG #1 look like diffuse subendocardial ischemia?

Ischemia 115

Ischemia Chest Pain Cardiac Arrest Blog 115

Dr. Smith's ECG Blog

MARCH 15, 2023

Baseline bradycardia in endurance athletes limits the use of ß-blockers. These include: i ) Use of rate-slowing medication ( ie, ß-blockers, digoxin, verapamil/diltiazem, etc. ) ; ii ) Acute or recent infarction or ischemia; iii ) Hypothyroidism; iv ) Neurologic injury; v ) Electrolyte disturbance; and , vi ) Sleep apnea.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 52

Dr. Smith's ECG Blog

MARCH 30, 2014

My most talented blog readers are paramedics because they have to put themselves on the line every time they activate the cath lab. There is a junctional bradycardia. Furthermore, there are T-wave changes in V2 and V3 which are highly suggestive of ischemia, but difficult to localize: anterior? And they teach me a lot.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

JUNE 23, 2023

The patient later settled into sinus bradycardia. He was started on amiodarone and had no more events. Next day, the cardiologists were convinced (I think correctly) that this was SVT with aberrancy that was triggered by DKA.

Tachycardia 52

Tachycardia Cardiomyopathy Arrhythmia Diabetes 52

Dr. Smith's ECG Blog

DECEMBER 15, 2015

In any case, there is bradycardia. There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. due to PE) may result in STEMI (and, if anterior, it can be from anterior LV or anterior RV ischemia, or both) from low coronary pressure and flow, simply due to the shock.

STEMI 52

STEMI Embolism Pulmonary Ultrasound 52

Dr. Smith's ECG Blog

APRIL 15, 2019

But when the clinical presentation is sepsis, one must entertain the possibility that the ST elevation is due to demand ischemia, or some other process, and exacerbated by tachycardia. It is prudent to treat the other conditions, get the heart rate controlled, and repeat the ECG.

Tachycardia 52

Tachycardia STEMI Chest Pain Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Patient presentation is important This was a 60-something with acute chest pain: There is sinus bradycardia at a rate of 44. To me, this makes the ECG nearly diagnostic of ischemia, though if it is LAD occlusion, there should be ST depression in III and aVL, so it is a bit confusing. Why bradycardia? 100% distal LAD occlusion.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

JUNE 28, 2019

For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%. This is sinus bradycardia. More likely, these T waves probably reflect ischemia of uncertain age.

Chest Pain 52

Chest Pain Pericarditis Stents Stent 52

Dr. Smith's ECG Blog

MAY 5, 2022

Hyperkalemia causes peaked T waves and the "killer B's of hyperkalemia", including bradycardia, broad QRS complexes, blocks of the AV node and bundle branches, Brugada morphology, and otherwise bizarre morphology including sine wave. With a twist. Do you recognize this ECG yet? Right Bundle Branch Block with ST Elevation in V1?

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2022

Osborn waves have been reported with hypercalcemia, brain injury, subarachnoid hemorrhage, Brugada syndrome, cardiac arrest from VFib — and — severe, acute ischemia resulting in acute MI ( See My Comment in the November 22, 2019 post on Dr. Smith’s Blog ). Rituparna et al — as well as Chauhan and Brahma ( Int.

Cardiac Arrest 52

Cardiac Arrest Bradycardia Chest Pain Ischemia 52

Dr. Smith's ECG Blog

JANUARY 23, 2024

Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc). For example — bradycardia and AV conduction disturbances are not uncommon with Hyperkalemia , with these conduction disturbances most often resolving once serum K+ is corrected.

Tachycardia 88

Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death 88

Dr. Smith's ECG Blog

OCTOBER 13, 2022

2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia. 3] So a patient with WPW can have the pattern induced by ischemia, and there is also a report of a patient with pre-existing WPW which was “ablated” by myocardial infarction after an LAD occlusion.[4]

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

MARCH 24, 2023

There’s sinus bradycardia, first degree AV block, normal axis, delayed R wave progression, and normal voltages. Hyperacute T waves are deflating, suggesting reperfusion but there is still reciprocal change in I/aVL and ST depression in V2, and the bradycardia is worse. Below is the ECG. What do you think? Take home 1.

Chest Pain 52

Chest Pain STEMI Bradycardia Ischemia 52

Dr. Smith's ECG Blog

APRIL 29, 2020

Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia. Acute ischemia? ECG #5 — This is the 4th ECG done on the patient in this case ( obtained ~6 hours after arrival in the ED ). Use of QT-prolonging drugs?

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Dr. Smith's ECG Blog

JULY 5, 2023

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. 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.

Chest Pain 52

Chest Pain STEMI Congenital Heart Disease Heart Disease 52