Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. EKG is pictured below: What do you think?

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Bradycardia Cardiogenic Shock STEMI Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later.

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STEMI Chest Pain Myocardial Infarction Electrocardiogram 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. For national registry purposes, this will be incorrectly classified as a STEMI.) Large STEMI are approximately 30-80.

Chest Pain 113

Chest Pain STEMI Bradycardia Ischemia 113

Dr. Smith's ECG Blog

JUNE 19, 2024

Three months prior to this presentation, he received a pacemaker for severe bradycardia and syncope due to sinus node dysfunction. His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”.

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Chest Pain Pericarditis Pacemaker STEMI 63

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There was no evidence bradycardia leading up to the runs of PMVT ( as tends to occur with Torsades ). As we've often emphasized on Dr. Smith's ECG Blog — it is rare in practice to see LMCA occlusion, because most such patients die before reaching the hospital.

Arrhythmia 116

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 116

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ).

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Blog Chest Pain STEMI Ischemia 129

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 105

Chest Pain Bradycardia Blog Electrocardiogram 105

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

He has been following the blog for 4 years. The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria. This case was sent by Dr. Jean-christophe Reiters, an interventionalist in Belgium. He has now implemented the Queen of Hearts in his hospital. He wanted to share one of the first cases.

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Hospital STEMI Blog Chest Pain 104

Dr. Smith's ECG Blog

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1]

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STEMI Myocardial Infarction Chest Pain Ischemia 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. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI? The patient continued having chest pain. Do not treat AIVR. What is the rhythm? Moffat, M.

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Chest Pain Arrhythmia Myocardial Infarction STEMI 88

Dr. Smith's ECG Blog

JUNE 1, 2022

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. Figure-1: I've labeled the 1st, 2nd and 4th tracings in today's case ( See text ).

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Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean. There was no OMI.

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Stroke Strokes Chest Pain Cardiomyopathy 74

Ken Grauer, MD

FEBRUARY 9, 2024

NOTE: As I've commented on in a number of previous blog posts — Wenckebach conduction may occur at more than a single level within the AV Node. R elated E CG B log P osts to Today’s Case : ECG Blog #205 — Reviews my S ystematic A pproach to 12-lead ECG Interpretation. ECG Blog #192 — The 3 Causes of AV Dissociation.

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Blog Arrhythmia STEMI Bradycardia 108

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

We've presented numerous examples of hyperkalemia on Dr. Smith's ECG Blog. As a reminder of why determination of the cardiac rhythm can be so challenging when there is significant hyperkalemia — I've reproduced Figure-1 from My Comment in the January 16, 2022 post in Dr. Smith's ECG Blog. The patient was treated.

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Tachycardia Document Blog Bradycardia 52

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity?

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 81

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 Exercise Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. Sensitivity was 87% for OMI in our validation study (it was 34% for STEMI criteria). MY Thoughts on the ECG in Figure-1: The rhythm in ECG #1 is sinus bradycardia at ~50-55/minute.

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Chest Pain Defibrillator STEMI Coronary Artery Disease 133

Dr. Smith's ECG Blog

JANUARY 5, 2024

The ECG shows sinus bradycardia but is otherwise normal. Evidence regarding intervention to non-culprit plaques is mixed and beyond the scope of this blog post. We have on many occasions in Dr. Smith's ECG Blog, highlighted the downside of indiscriminate use of morphine in patients who present with new ischemic CP ( C hest P ain ).

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Angina Plaque Document Stents 109

Dr. Smith's ECG Blog

DECEMBER 15, 2015

In any case, there is bradycardia. Although most cardiac arrest from MI is due to ventricular fibrillation, some is due to high grade AV block, and so this could indeed be due to large acute STEMI. LV anterior STEMI does not give maximal ST elevation in V1. So this ECG is typical of right ventricular (RV) STEMI.

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STEMI Embolism Pulmonary Ultrasound 52

Dr. Smith's ECG Blog

JULY 26, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: == MY Comment , by K EN G RAUER, MD ( 7/26 /2023 ): == As regular followers of Dr. Smith’s ECG Blog have seen — some of the best cases that we post come from tracings that Dr. Smith or Meyers see while simply checking out “tracings on the system”.

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Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Bradycardia. But — one of the causes of Brugada Phenocopy is acute infarction — so I didn’t know how to distinguish between a preexisting Brugada-1 ECG pattern vs a Brugada ECG pattern developing as a result of acute ongoing anterior STEMI. Is it Brugada pattern?

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

JULY 30, 2023

It does not meet STEMI criteria. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). Learning Points: We can find OMI on ECG much sooner than STEMI criteria in many cases, and of course many OMIs never meet STEMI criteria at all. Easy for anyone.

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Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

MAY 19, 2020

There is sinus bradycardia with one PVC. This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI.

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Defibrillator Circulation Plaque Cardiac Arrest 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

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Tachycardia STEMI Chest Pain Ischemia 52

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. Recall that air is a poor conductor of electricity and will, therefore, generate smaller amplitudes on posterior leads (hence why STEMI criteria requires only >0.5

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI. Why bradycardia? QTc is the computer measurement.

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Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 9, 2012

While undergoing a stress test as a part of the non-invasive approach, she developed chest pain and hypotension and had this ECG: There is sinus bradycardia with massive inferior ST elevation, as well as ST elevation in V1-V3, diagnostic of inferior and right ventricular (RV) STEMI.

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Chest Pain Bradycardia STEMI Hypertension 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. There’s minimal concave ST elevation in III which does not meet STEMI criteria, so this ECG is "STEMI negative". Use STEMI criteria to identify acute coronary occlusion: the ECG was STEMI negative 2.

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Chest Pain STEMI Bradycardia Ischemia 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. Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI. There is a junctional bradycardia. And they teach me a lot. Now chest pain free. What was the diagnosis?

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Outcomes Cardiogenic Shock STEMI Chest Pain 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. Moreover, T-wave inversion in aVL was also found to be 100% sensitive and 86% specific for inferior STEMI. mm ST depression in aVL.

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Pericarditis Ischemia STEMI Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2017

The computer interpreted the ECG (GE Marquette 12 SL) as: "Sinus Bradycardia. Here it is: Computer interpretation: "Sinus bradycardia. This was sent to me by a former resident from a community hospital: A middle-aged woman complained of chest pain and was seen in triage. She had a ECG recorded. Normal ECG."

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Chest Pain Bradycardia Technology Electrocardiogram 52

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI.

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Pericarditis Chest Pain Pulmonary Embolism 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." Like other cases on this blog who died before cath was done, I cannot prove that this patient had OMI. The whole paradigm is literally called "STEMI" vs. "NSTEMI." Canto et al.

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Chest Pain STEMI Blog Tachycardia 52

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". 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.

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Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Is it STEMI? Syncope and Bradycardia Syncope in a 20-something woman Long QT: Do not trust the computerized QT interval when the QT is long An Alcoholic Patient with Syncope Cardiac Arrest. Chest pain in high risk patient. Are these Hyperacute T-waves? What is going on here?

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Ischemia Chest Pain Cardiac Arrest Blog 115

Dr. Smith's ECG Blog

JULY 5, 2023

Any objective, rule-based analysis of this ECG would scream "STEMI" or "OMI". And I recognized this as a STEMI mimic. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. There are Q-waves in V4-V6, with what appear to be hyperacute T-waves.

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Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia STEMI 52