Dr. Smith's ECG Blog

APRIL 14, 2024

No ischemia. Case continued Another ECG was recorded 3 hours later, still 1/10 pain: There is sinus bradycardia with RBBB. This is a conundrum, because it is clear that the patient is having an acute MI, the ECG is dynamic, but the pain is very mild and there is no ECG evidence of active transmural ischemia.

Chest Pain 120

Chest Pain Ischemia Myocardial Infarction Ultrasound 120

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.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 132

Dr. Smith's ECG Blog

MAY 5, 2023

Common explanations for unusual rhythms such as this one include: i ) Hyperkalemia ( or other severe electrolyte disorder ); ii ) Recent infarction/ischemia; iii ) Sleep apnea; iv ) Severe hypothyroidism; v ) Acute neurologic catastrophe (ie, stroke, bleed, trauma, tumor ); vi ) Some other toxicity.

Bradycardia 52

Bradycardia Cardiac Arrest Arrhythmia Pacemaker 52

Dr. Smith's ECG Blog

JANUARY 26, 2020

Her vital signs were within normal limits except for bradycardia at 55 bpm. It is probably sinus bradycardia with very small/depressed P-waves and prolonged PR interval. P EARL # 4 In my opinion, it is not worth wasting time trying to figure out the specific rhythm diagnosis of a bradycardia when there is hyperkalemia.

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Bradycardia Ischemia Cardiac Arrest AFIB 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 116

Chest Pain STEMI Bradycardia Ischemia 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.

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Bradycardia Pacemaker Ischemia 52

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.

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Chest Pain Bradycardia Blog Electrocardiogram 118

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 125

Ischemia Chest Pain Cardiac Arrest Blog 125

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Both of these features make inferior + RV MI by far the most likely ( Pseudoanteroseptal MI is another name for this ) There is also sinus bradycardia and t he patient is in shock with hypotension. A narrow complex bradycardia without any P-waves is also likely to respond to atropine, as it may be a junctional rhythm.

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Bradycardia Cardiogenic Shock STEMI Ischemia 40

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?

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Chest Pain STEMI Bradycardia Article 100

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). What do you think?

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 130

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?

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Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 124

Dr. Smith's ECG Blog

JULY 30, 2023

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, and subendocardial ischemia presents with STD maximal in V5-6, II, and STE in aVR. Subendocardial ischemia does not localize.

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Chest Pain Ischemia STEMI Arrhythmia 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 116

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 116

Dr. Smith's ECG Blog

OCTOBER 26, 2015

Due to bradycardia, a 12-lead ECG was obtained: There is atrial fibrillation at a rate of 54. But because of bradycardia, a 12-lead was obtained, which gave the critical diagnosis. Slow atrial fibrillation implies an sick AV node, or one affected by electrolytes, ischemia, or medications/drugs. His breath alcohol was 0.259.

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Atrial Fibrillation Bradycardia Ischemia 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 124

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 124

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. during which sinus bradycardia and arrhythmia are seen but not to a degree that produces symptoms. The indication for pacemaker placement with SSS is symptomatic bradycardia.

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Atrial Fibrillation AFIB Bradycardia Pacemaker 52

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

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.

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Chest Pain Bradycardia Blog Critical Care 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 108

Chest Pain Arrhythmia Myocardial Infarction STEMI 108

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.

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STEMI Myocardial Infarction Chest Pain 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.

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Blog Bradycardia Ischemia Exercise 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.

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Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death 108

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 Bradycardia 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls. He had multiple episodes of bradycardia and nonsustained ventricular tachycardia. The patient had none of these conditions. Patient 1 remained in the hospital overnight.

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Chest Pain STEMI Echocardiogram Stents 117

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 40

Cardiac Arrest Bradycardia Chest Pain Ischemia 40

Dr. Smith's ECG Blog

JANUARY 22, 2020

There are 3 etiologies I always think of with bradycardia and AV block: 1. There was no evidence of ischemia. In addition to ruling out rate-slowing medication serum electrolyte disorders and/or ischemia/infarction as potential causes of bradyarrhythmias one should also rule out hypothyroidism + sleep apnea. Hyperkalemia.

Pulmonary 52

Pulmonary AFIB Atrial Fibrillation Pacemaker 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

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.

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Outcomes Cardiogenic Shock STEMI Chest Pain 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

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.

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Chest Pain STEMI Ischemia Myocardial Infarction 52

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 2, 2019

Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? Ischemia b. ST depression: is it ischemia? In my experience, Ive seen U waves not only with low K+/low Mg++ but also in patients with bradycardia, LVH, and sometimes in normal subjects.

Sickle Cell Disease 52

Sickle Cell Disease Ischemia Dysrhythmia Chest Pain 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 40

STEMI Embolism Pulmonary Ultrasound 40

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

FEBRUARY 15, 2018

Here are inferior leads, and aVL, magnified: A closer inspection of the inferior leads and aVL Sinus bradycardia. I had no history on the case and no prior ECG for comparison. What do you think? The T-wave in lead III is slightly tall and broad (increased area under the curve) compared to its QRS complex.

Chest Pain 52

Chest Pain Critical Care Article Pacemaker 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.

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Chest Pain STEMI Myocardial Infarction Bradycardia 52