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Blog Cardiac Arrest Ischemia 
Ken Grauer, MD
JUNE 27, 2024
He developed cardiac arrest shortly after the ECG in Figure-1 was recorded. As discussed in ECG Blog #231 — Bidirectional VT is a special form of VT, in which there is beat-to-beat alternation of the QRS axis. Acute myocardial ischemia. Cardiac Sarcoidosis. Primary Cardiac Tumors and/or Cardiac Metastasis.
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Ken Grauer, MD
DECEMBER 29, 2023
The H ISTORY in T oday's C ASE: The patient in today's case is a teenager who presented to the ED ( E mergency D epartment ) in cardiac arrest after electrocution. As discussed in ECG Blog #364 and ECG Blog #265 — We are looking at " Shark Fin " ST elevation! Figure-1: The initial ECG in today's case. (
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Dr. Smith's ECG Blog
OCTOBER 18, 2023
Cardiac arrest was called and advanced life support was undertaken for this patient. The patient was given chest compressions while waiting for the cardiac arrest team to arrive. Most such rhythms in the setting of ischemia are VF and will not convert without defibrillation. Calcium level was normal.
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Dr. Smith's ECG Blog
JULY 25, 2024
The ECG shows severe ischemia, possibly posterior OMI. But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. It takes time for that ischemia to resolve. After cardiac arrest, I ALWAYS wait 15 minutes after an ECG like this and record another.
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Ken Grauer, MD
OCTOBER 21, 2023
PEARL # 1: Although seeing an elevated Troponin would provide additional support for immediate cardiac catheterization — the clinical reality is that the initial Troponin reading will not always be elevated in patients with acute coronary occlusion ( See March 24, 2023 post in Dr. Smith's ECG Blog ).
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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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Ken Grauer, MD
MAY 26, 2023
This ST depression appears to be maximal in leads V3-to-V5 — which could reflect acute posterior OMI ( O cclusion-based M yocardial I nfarction ) — most probably with multi -vessel disease ( ie, diffuse subendocardial ischemia suggested by the ST depression with ST elevation in aVR>V1 ). ECG Blog #316 — The patient died.
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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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Dr. Smith's ECG Blog
JANUARY 2, 2025
See this post: How a pause can cause cardiac arrest 2. It should be kept in mind that on occasions, beta-one agonist can result in increased ventricular ectopy e.g., in severe myocardial ischemia (by increasing myocardial demand), or sometimes with congenital long-QT syndrome. The plan: 1. Place temporary pacemaker 3.
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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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Ken Grauer, MD
APRIL 9, 2023
The Long Lead II Rhythm Strip: As always — I favor a systematic approach to rhythm interpretation, using the P s, Q s, 3 R memory aid ( See ECG Blog #185 ). The other main consideration — is to take another look at the 12-lead ECG, and assess this for recent ischemia or infarction.
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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 ).
124 
Dr. Smith's ECG Blog
APRIL 24, 2015
ST depression is common BOTH after resuscitation from cardiac arrest and during atrial fib with RVR. Again, it is common to have an ECG that shows apparent subendocardial ischemia after resuscitation from cardiac arrest, after defibrillation, and after cardioversion. The patient was cardioverted. This was done.
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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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.
Dr. Smith's ECG Blog
OCTOBER 20, 2013
This ECG is diagnostic of diffuse subendocardial ischemia. What is the utility of a head CT in cardiac arrest? We found intracranial hemorrhage in 2% of non-traumatic cardiac arrest patients, and in 4 others the presence of cerebral edema changed management. We studied this and published the abstract below in 2010.
Dr. Smith's ECG Blog
OCTOBER 28, 2013
STE limited to aVR is due to diffuse subendocardial ischemia, but what of STE in both aVR and V1? The additional ST Elevation in V1 is not usually seen with diffuse subendocardial ischemia, and suggests that something else, like STEMI from LAD occlusion, could be present. Was this: 1) ACS with ischemia and spontaneous reperfusion?
Dr. Smith's ECG Blog
SEPTEMBER 29, 2024
Although one may have all kinds of ischemic findings as a result of cardiac arrest (rather than cause of cardiac arrest), this degree of ST elevation and HATW is all but diagnostic of acute proximal LAD occlusion. This rules out subendocardial ischemia and is diagnostic of posterior OMI. V4-5 continue to show STD.
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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.
125 
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.
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.
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".
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.
120 
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.
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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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?
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.
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.
132 
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.
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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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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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.
124 
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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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?
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.
98 
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.
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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Dr. Smith's ECG Blog
APRIL 8, 2016
If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. If cardiac arrest from hypokalemia is imminent (i.e., As I indicated above, in our cardiac arrest case, after pushing 40 mEq, the K only went up to 4.2
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.
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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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?
40 
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.
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.
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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