Blog, Bradycardia and Outcomes - Cardiovascular Update

Normal angiogram one week prior. Must be myocarditis then?

Dr. Smith's ECG Blog

JUNE 5, 2024

IMPRESSION: The finding of sinus bradycardia with 1st-degree AV block + marked sinus arrhythmia + the change in PR interval from beat #5-to-beat #6 — suggests a form of vagotonic block ( See My Comment in the October 9, 2020 post in Dr. Smith's ECG Blog ). Initial high sensitivity troponin I returned at 6ng/L (normal 0.20

Chest Pain

Chest Pain Blog Cardiac Arrest Cardiomyopathy

Is there OMI on this ECG?

Dr. Smith's ECG Blog

DECEMBER 22, 2023

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. I did not think that the T-waves in V2 and V3 are hyperacute and I still do not--I disagree with Ken below--I think they are normal , especially in the context of bradycardia.

Chest Pain

Chest Pain Bradycardia Blog Electrocardiogram

How Wearable Tech Can Help Monitor Your Heart Health

MIBHS

JANUARY 31, 2025

This blog explores the ways wearable technology can help track heart health, the advantages it offers, and how it contributes to better outcomes for those requiring surgical intervention. Early detection of conditions like AFib, bradycardia, or tachycardia allows patients to address issues before they become critical.

Heart Rhythm

Heart Rhythm Technology AFIB Exercise

Webinars

Bridging Innovation & Patient Care: The Growing Role of AI

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Syncope and Atrial fibrillation in a Healthy 70-something Male

Dr. Smith's ECG Blog

JULY 5, 2018

Syncope without prodrome is a significant risk factor for cardiac syncope and poor outcome. 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. The indication for pacemaker placement with SSS is symptomatic bradycardia.

Atrial Fibrillation

Atrial Fibrillation AFIB Bradycardia Pacemaker

A teenager involved in a motor vehicle collision with abnormal ECG

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Atrial fibrillation is also a predictor of worse outcomes in this case (Alborzi). 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. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ).

Tachycardia

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia

The ECG told the whole story, but no one listened: ECG interpretation skills are critical to patient outcomes.

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. Outcome and Analysis: ECG 1 is diagnostic of inferior and right ventricular MI. There is a junctional bradycardia. And they teach me a lot. Troponin was repeated and returned higher still.

Outcomes

Outcomes Cardiogenic Shock STEMI Chest Pain

A 20-something woman with cardiac arrest.

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. This is what T-waves look like when there is a long QT." Below are two ECGs from the telemetry monitoring.

Cardiac Arrest

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia

Texted from a former EM resident: 70 yo with syncope and hypotension, but no chest pain. Make their eyes roll!

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Smith : "What was the outcome?" Former Resident: "They took him but they rolled their eyes at me (Smith editorial comment: how often have they rolled their eyes at YOU?). They said it looked similar to his old one (in my opinion, similar, but not similar enough to be able to say no OMI)." They of course opened and stented it.

Chest Pain

Chest Pain Aneurysm Stents Stent

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. OTHER Examples of Lead Reversal on Dr. Smith's Blog: Technical errors featuring a variety of lead reversal placements remain a surprisingly common “mishap” of everyday practice.

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

A man in his 40s with epigastric pain and ST Elevation

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Here is PM Cardio's Queen of Hearts interpretation (AI ECG interpretation trained by Meyers, Smith, and PM Cardio team using thousands of cases and their outcomes): The output number ranges from 0 to 1, with numbers closer to zero meaning likely NOT OMI, and numbers closer to 1 meaning OMI.

Blog

Blog Bradycardia Ischemia Exercise

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. Selected LINKS on this Topic: ECG Blog #246 — Reviews the concept of the "Mirror Test" with a clinical example. What do you think? There’s primary ST depression in the precordial leads maximal in V3-4, and an inverted T wave in V2.

STEMI

STEMI Myocardial Infarction Chest Pain Ischemia

Chest pain, and Cardiology didn't take the hint from the ICD

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. Ventricular fibrillation is a common outcome in OMI and should greatly heighten the suspicion for ischemic heart disease even in the absence of profound ST elevation. =

Chest Pain

Chest Pain Blog Stenosis Myocardial Infarction

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

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. In case you were wondering about the T-waves and bradycardia, the K was normal. Why bradycardia? Maybe there is also inferior MI from wraparound LAD with associated sinus bradycardia.

Chest Pain

Chest Pain STEMI Bradycardia Stenosis

Status epilepticus. What is this ECG pathognomonic of?

Dr. Smith's ECG Blog

NOVEMBER 18, 2019

Case outcome The Na was 109. U waves may also be found in patients with LVH and/or bradycardia , or occasionally as a normal variant. Of course this is not a difficult case because one will always measure the K in such a case, but it does show that the K is markedly affecting cardiac electrical activity.

Chest Pain

Chest Pain Cardiac Arrest Bradycardia Ischemia

46 year old with chest pain develops a wide complex rhythm -- see many examples

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. Opioids associate with worse outcomes in myocardial infarction , probably because they eliminate the pain signal that informs the clinician of the urgency of revascularization. Do not treat AIVR. Washam, J. Peacock, W.

Chest Pain

Chest Pain Arrhythmia Myocardial Infarction STEMI

Transcutaneous Pacing: Part I

EMS 12-Lead

MARCH 30, 2024

Josh Kimbrell, NRP @joshkimbre Judah Kreinbrook, EMT-P @JMedic2JDoc This is the first installment of a blog series showing how transcutaneous pacing (TCP) can be difficult, and how you can improve your skills. The patient was ultimately discharged with a poor neurologic outcome.

Cardiac Arrest

Cardiac Arrest Pacemaker Pulmonary Bradycardia

QT Correction Formulas Compared to The Rule of Thumb ("Half the RR")

Dr. Smith's ECG Blog

NOVEMBER 24, 2017

I've been working on this a long time, thought about submitting it to a journal, but decided it gets more readers on this blog. However, none of the formulas have proven to be definitively better than another and none are well correlated with outcomes or events! This article discusses correction of the QT interval for rate.

Bradycardia

Bradycardia Article Atrial Fibrillation Chest Pain

A 50-something with chest pain.

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

I sent it to 5 of my OMI friends without any clinical information or outcome and all 5 independently responded with exactly the same diagnosis: "reperfused inferior OMI". MY Thoughts on the ECG in Figure-1: The rhythm in ECG #1 is sinus bradycardia at ~50-55/minute. There is ischemic ST depression in V4-V6. No chamber enlargement.

Chest Pain

Chest Pain Defibrillator STEMI Coronary Artery Disease

Should we activate the cath lab? A Quiz on 5 Cases.

Dr. Smith's ECG Blog

OCTOBER 8, 2023

ECG#1 ECG#2 ECG#3 ECG#4 ECG#5 See outcomes of all 5 below, with the Queen of Hearts AI Bot interpretation. All of the patients presented with chest pain , and they are all in triage. Which, if any, of these patients has OMI, with myocardium at risk and need for emergent PCI? YOU TOO CAN HAVE THE PM Cardio AI BOT!!

Ischemia

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest

85 year old with chest pain, STEMI negative, then normal troponin but with relatively large delta: discharge?

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

Chest Pain STEMI Bradycardia Ischemia

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

Dr. Smith's ECG Blog

APRIL 8, 2016

There is also bradycardia. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. Torsades in acquired long QT is much more likely in bradycardia because the QT interval following a long pause is longer still. The patient stabilized and had a good outcome. There is atrial fibrillation.

STEMI

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia

Cardiologist declines taking patient to the cath lab. Patient dies.

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Like other cases on this blog who died before cath was done, I cannot prove that this patient had OMI. Could this outcome have been prevented with emergent cath? We have countless cases of missed posterior MI on this blog, including these: Interventionalist at the Receiving Hospital: "No STEMI, no cath. Were they right?

Chest Pain

Chest Pain STEMI Blog Tachycardia

A middle aged man with unwitnessed cardiac arrest

Dr. Smith's ECG Blog

APRIL 6, 2018

Because hyperkalemia kills by either VT or VF arrest, or by bradycardia with PEA arrest, this should be assumed to be VT until proven otherwise. While the outcome is disheartening, I think this case highlights some important management principles of a fairly common cardiac arrest phenotype. Learning Points: 1.

Cardiac Arrest

Cardiac Arrest Tachycardia Defibrillator ICU

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Dr. Smith's ECG Blog

APRIL 8, 2015

Cardiac Syncope ("True Syncope") Independent Predictors of Adverse Outcomes condensed from multiple studies 1. PVCs N ot generally considered abnormal ECG findings: Isolated PAC, First Degree AV Block, Sinus bradycardia at a rate of 35-45, and Nonspecific ST-T abnormalities (even if different from a previous ECG).

Arrhythmia

Arrhythmia Outcomes Chest Pain Risk Factors

Potassium 6.2 with narrow QRS: any indication for calcium?

Dr. Smith's ECG Blog

FEBRUARY 10, 2025

Theres sinus bradycardia, borderline PR interval, narrow QRS; normal axis/R wave progression; low precordial voltages, and subtle peaked T waves (most obvious in V2, but all T waves are symmetric with a narrow base). Theres no prior ECG to compare - but the bradycardia, prolonged PR and peaked T waves could all be from hyperkalemia.

Bradycardia

Bradycardia Cardiac Arrest Hypertension ICU

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Dr. Smith's ECG Blog

MARCH 19, 2025

Despite the baseline artifact theres sinus bradycardia, convex ST elevation in III, reciprocal ST depression in aVL and possible anterior ST depression indicating inferoposterior OMI. Prevalence and outcome of patients with non-ST segment elevation myocardial infarction with occluded culprit artery - a systemic review and meta-analysis.

Chest Pain

Chest Pain STEMI Stents Stent

After seeing this ECG, are there any medications you would consider giving?

Dr. Smith's ECG Blog

FEBRUARY 18, 2025

The patient's long term outcome is unknown. Dr. McLaren recently wrote an excellent blog post on a similar case. As I emphasized in My Comment in the February 27, 2023 post in Dr. Smith's ECG Blog some patients may develop everything except QRS widening.

Blood Pressure

Blood Pressure Blog Cardiac Arrest Bradycardia

Unresponsive and Acidotic: OMI? Acute, subacute, or reperfused? What is the rhythm? Why RV dysfunction? Can CT scan help?

Dr. Smith's ECG Blog

APRIL 6, 2025

His rhythm on telemetry seemed to be sinus bradycardia vs junctional rhythm. In short with a very guarded likelihood for a positive outcome. Telemetry initially was interpreted as showing sinus bradycardia vs a junctional rhythm. A quick POCUS which showed significantly reduced ejection fraction and trace B lines.

Blood Pressure

Blood Pressure Cardiogenic Shock Ischemia Cardiac Arrest

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

Within ten minutes, she developed bradycardia, hypotension, and ST changes on monitor. Bradycardia and heart block are very common in RCA OMI. Was her outcome to be expected for ostial RCA OMI? There was indication of parasympathetic overdrive ( the acute inferior STEMI with profound bradycardia and junctional escape ).

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

Normal angiogram one week prior. Must be myocarditis then?

Is there OMI on this ECG?

How Wearable Tech Can Help Monitor Your Heart Health

Webinars

Syncope and Atrial fibrillation in a Healthy 70-something Male

A teenager involved in a motor vehicle collision with abnormal ECG

The ECG told the whole story, but no one listened: ECG interpretation skills are critical to patient outcomes.

A 20-something woman with cardiac arrest.

Texted from a former EM resident: 70 yo with syncope and hypotension, but no chest pain. Make their eyes roll!

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

A man in his 40s with epigastric pain and ST Elevation

7 steps to missing posterior Occlusion MI, and how to avoid them

Chest pain, and Cardiology didn't take the hint from the ICD

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Status epilepticus. What is this ECG pathognomonic of?

46 year old with chest pain develops a wide complex rhythm -- see many examples

Transcutaneous Pacing: Part I

QT Correction Formulas Compared to The Rule of Thumb ("Half the RR")

A 50-something with chest pain.

Should we activate the cath lab? A Quiz on 5 Cases.

85 year old with chest pain, STEMI negative, then normal troponin but with relatively large delta: discharge?

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

Cardiologist declines taking patient to the cath lab. Patient dies.

A middle aged man with unwitnessed cardiac arrest

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Potassium 6.2 with narrow QRS: any indication for calcium?

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

After seeing this ECG, are there any medications you would consider giving?

Unresponsive and Acidotic: OMI? Acute, subacute, or reperfused? What is the rhythm? Why RV dysfunction? Can CT scan help?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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