Ken Grauer, MD

MARCH 23, 2023

What is the cardiac rhythm shown in the long lead II rhythm strip? Figure-1: The initial ECG in today’s case — obtained from an elderly woman following successful resuscitation from cardiac arrest. ( These are reviewed in ECG Blog #343. To improve visualization — I've digitized the original ECG using PMcardio ).

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Blog Tachycardia Arrhythmia Atrial Flutter 78

Dr. Smith's ECG Blog

JUNE 5, 2024

The ECG does not show any definite signs of ischemia. 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 ).

Chest Pain 109

Chest Pain Cardiac Arrest Blog Cardiomyopathy 109

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

See our other blog posts of hypothermia and Osborn waves -- Massive Osborn Waves of Severe Hypothermia (23.6 C), with Cardiac Echo -- A Pathognomonic ECG. His temperature was brought back to normal over time in the ICU. He was extubated and had normal neurologic function. He did well and was discharged.

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Cardiac Arrest Blog Atrial Fibrillation Bradycardia 134

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury. NOTE: For those interested — I review in detail determination of the artifact “culprit extremity” in My Comment in the September 27, 2019 post of Dr. Smith’s ECG Blog.

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Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. So, your next step is to Trace it down, and Copy it over".

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 87

Dr. Smith's ECG Blog

OCTOBER 24, 2013

Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. Ischemia on the ECG can be very subtle and is easily missed. Ischemia on the ECG can be very subtle and is easily missed. Lesson : 1.

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Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

JUNE 23, 2024

This was interpreted by the treating clinicians as not showing any evidence of ischemia. The electrophysiologist is a reader of Dr. Smith's ECG Blog. The above said — it may prove insightful to take another look at the Wellens' Syndrome case instantly recognized by Dr. Smith in the August 12, 2022 post in Dr. Smith’s ECG Blog.

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Chest Pain Cardiac Arrest Sudden Cardiac Death Stents 111

Dr. Smith's ECG Blog

JANUARY 4, 2021

This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with reciprocal ST depression in aVL, and some STE in V1. If there is also subendocardial ischemia, the ST depression vector remains leftward, with a reciprocal ST Elevation vector also to the right.

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Ischemia Pulmonary STEMI Chest Pain 52

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Edited by Bracey, Meyers, Grauer, and Smith A 50-something-year-old female with a history of an unknown personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return of spontaneous circulation. The described rhythm was an irregular, wide complex rhythm. What is ELECTRICAL ALTERNANS?

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Tachycardia Cardiac Arrest ICU Blood Pressure 123

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 116

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

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Chest Pain Cardiac Arrest STEMI Defibrillator 96

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

His response: “subendocardial ischemia. Smith : It should be noted that, in subendocardial ischemia, in contrast to OMI, absence of wall motion abnormality is common. With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. Anything more on history?

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Ischemia STEMI Stenosis Coronary Artery Disease 52

Ken Grauer, MD

OCTOBER 27, 2023

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 ). See ECG Blog #188 for review on how to read and/or draw Laddergrams ).

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Blog Pacemaker Bradycardia Arrhythmia 104

Ken Grauer, MD

JUNE 6, 2023

== P lease N OTE : After today — No new ECG Blog posts for 2- to -3 weeks. — I will also not be prompt in replying to emails. == All material on this ECG Blog site remains open! IF you scroll down a little on the right-hand column of this blog — You'll see a lot of icons. Figure-1: The initial ECG in today's case.

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Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

OCTOBER 4, 2010

There is profound LVH with anterolateral ST elevation and reciprocal ST depression in II, III, aVF, and ST depression in V5 and V6 that could all be secondary to LVH or could represent ischemia superimposed on the repolarization abnormalities of LVH: note that wherever there is ST depression, it is associated with a very high voltage R-wave.

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Cardiac Arrest Ischemia Stenosis STEMI 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

The differential is: Posterolateral OMI or subendocardial ischemia The distinction between posterior OMI and subendocardial ischemia can be important and sometimes difficult. Ischemic ST depression includes posterior OMI and subendocardial ischemia. Her prior ECG on file is shown below: What are your next steps?

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Chest Pain Ischemia Aortic Aortic valve 52

Dr. Smith's ECG Blog

JUNE 11, 2021

Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes. VF arrest is of course "electrical instability"! Learning points 1.

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Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 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. Smith: This bizarre ECG looks like a post cardiac arrest ECG with probable acidosis or hyperkalemia in addition to OMI.

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Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 112

Dr. Smith's ECG Blog

JANUARY 21, 2023

Occurrence of “J Waves” in 12-Lead ECG as a Marker of Acute Ischemia and Their Cellular Basis. Occurrence of "J waves" in 12-lead ECG as a marker of acute ischemia and their cellular basis. The final letter in the SLOWED mnemonic is " D " for "Dead" ( resulting from VT/VF or asystolic cardiac arrest ).

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STEMI Bradycardia Arrhythmia Cardiac Arrest 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern). Plus recommendations from a 5-member panel on cardiac arrest.

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Cardiogenic Shock Chest Pain Tachycardia Ischemia 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

They had had twice the rate of cardiac arrest and twice the in-hospital mortality[1] In another study of patients diagnosed with STEMI, those on dialysis experienced delayed reperfusion and double the mortality.[2] They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

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Chest Pain STEMI Myocardial Infarction Blog 85

Dr. Smith's ECG Blog

DECEMBER 23, 2014

None of these findings are diagnostic of ischemia, but they should give you a high index of suspicion and prompt serial ECGs at a minimum. The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Ischemia comes and goes. He was defibrillated. Anterolateral STEMI.

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Chest Pain Cardiac Arrest Ischemia STEMI 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

In terms of ischemia, there is both a signal of subendocardial ischemia (STD max in V5-V6 with reciprocal STE in aVR) AND a signal of transmural infarction of the inferior wall with Q wave and STE in lead III with reciprocal STD in I and aVL. He had multiple cardiac arrests with ROSC regained each time.

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Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

JANUARY 25, 2017

See this post and associated case reports: Cardiac arrest, severe acidosis, and a bizarre ECG The patient was admitted and ruled out for acute MI by serial troponins. Cocaine not only has effects on dopamine neurotransmission, but is also a sodium channel blocker, as are all "-caine" local anesthetics.

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Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

APRIL 29, 2020

A 60-something woman presented after a witnessed cardiac arrest. This is commonly found after epinephrine for cardiac arrest, but could have been pre-existing and a possible contributing factor to cardiac arrest. Final Diagnosis: Cardiac Arrest due to Torsades from long QT of unknown etiology.

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Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Dr. Smith's ECG Blog

JULY 27, 2023

hours ECG: Not much change hs troponin I peaks at 500 ng/L 8 hours Next morning Urine drug screen: Amphetamine, Methamphetamine, Fentanyl, Fentanyl metabolite Formal Bubble Contrast Echocardiogram: Indications for Study: Silent Ischemia. Conclusion: Type II MI probable due to hypoxia and tachycardia from resp arrest and amphetamine use.

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Tachycardia Ischemia Cardiac Arrest Echocardiogram 52

Dr. Smith's ECG Blog

AUGUST 1, 2020

He has done a lot of great work on cardiac arrest, including as co-author of our study on esmolol in refractory cardiac arrest, and much more with Keith Lurie. The Queen was not able to see this one: Of course we do not know for certain that the inferior findings represent ischemia. It was not.

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Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

He had a previous MI with cardiac arrest 2 years prior. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. This ECG is diagnostic of ischemia.

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Ischemia Chest Pain Stenosis STEMI 52

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.

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Bradycardia Cardiac Arrest Arrhythmia Pacemaker 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." Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest.

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Ischemia Chest Pain Cardiac Arrest Blog 115

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

LOW VOLTAGE on ECG: We have reviewed many of the causes of low voltage on ECG in previous posts of Dr. Smith's ECG Blog. Figure-2: Causes of Low Voltage on ECG ( Figure reproduced from My Comment at the bottom of the page in the November 12, 2020 post in Dr. Smith's ECG Blog ). What is ELECTRICAL ALTERNANS?

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Tachycardia Pericarditis Ultrasound Blood Pressure 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. Acute febrile illness. Hypothermia.

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). In there ECG evidence of possible ongoing ischemia? (ie, IMPRESSION: I’d interpret this tracing as consistent with LVH and/or “strain” and/or ischemia. ie , Is it more than 50-60% likely? ).

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Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

Is there likely to be fixed coronary stenosis that led to demand ischemia during pneumonia? --Was Was the ST elevation due to transient demand ischemia, or is it false positive? Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died.

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STEMI Chest Pain Cardiac Arrest Stents 52

Dr. Smith's ECG Blog

DECEMBER 15, 2015

There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. First, what kind of arrest was this? It was a PEA or bradyasystolic arrest , not a shockable rhythm. There is either RBBB (see rSR' in V1) or there is a left sided escape rhythm that gives RBBB morphology.

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STEMI Embolism Pulmonary Ultrasound 52

Dr. Smith's ECG Blog

MAY 3, 2024

When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI). Suffice it to say that, "The heart does whatever it will do when a patient is about to arrest". There is STE in aVR.

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Cardiogenic Shock Cardiac Arrest Hospital Ischemia 117

Dr. Smith's ECG Blog

OCTOBER 26, 2020

Case submitted by Magnus Nossen MD from Norway, written by Pendell Meyers A man in his 50s with no pertinent medical history suffered a witnessed cardiac arrest. 12 minutes later, the patient went back into VFib arrest and underwent another 15 minutes of resuscitation followed by successful defibrillation and sustained ROSC.

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Ischemia Arrhythmia Defibrillator Chest Pain 52