Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The baseline ECG is basically normal with no ischemia. You can see in the lead-specific analysis that she "sees" the STD in V5, V5, and II, with STE in aVR as signs of "Not OMI", because subendocardial ischemia pattern is not the same as OMI. In my opinion, I think it looks more like subendocardial ischemia.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished.

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

Dr. Smith's ECG Blog

OCTOBER 26, 2010

ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. Then ACS (STEMI) might be primary; this might be cardiogenic shock. Even if this ECG is the first thing one sees (as it was for me), one should stop and think: "This is an unusual STEMI." Are the lungs clear? Is the patient cool and pale?

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 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 patient died of cardiogenic shock within 24 hours despite mechanical circulatory support. There are also J-waves.

Ischemia 123

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 123

Dr. Smith's ECG Blog

APRIL 24, 2020

Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Subendocardial ischemia results in ST depression, but unfortunately, and rather mysteriously, it does not localize to the ischemic wall. Similarly, STD in aVL is usually reciprocal to inferior ST elevation, not "lateral ischemia."

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

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?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 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). The patient arrived to the ED in cardiogenic shock but awake.

Chest Pain 52

Chest Pain Cardiogenic Shock Tachycardia Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

There is normal R-wave progression in the precordial leads with no evidence of ischemia. Here the image quality is enhanced using the PM Cardio app. What do you think? The presenting ECG shows SR with narrow QRS complexes. In the limb leads there is T-wave inversion in lead aVL with a low amplitude QRS preceding the T-wave.

Pulmonary 117

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 117

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 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. But by this time the patient went into cardiogenic shock and passed away.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 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. Then the notes mention "cardiogenic shock" but without any reference to a cardiac echo or to a chest x-ray. This is the etiology of the syncope and hypotension and shock and elevated CVP.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. The patient is started on epinephrine infusion for cardiogenic shock and cardiology took the patient to the cath lab. The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

OCTOBER 6, 2023

All of this appears to be consistent with "No Reflow", or small vessel occlusion with persistent ischemia in spite of an open artery. His included cardiogenic shock, V Tach, AV block. --There is persistent ST elevation in leads V1-V4, with a lot of STE in V4 (another bad sign). Such large infarcts have many complications.

Aneurysm 67

Aneurysm Chest Pain Cardiogenic Shock Blog 67

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Assessment was severe sudden cardiogenic shock. Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury. Clinically — the patient was felt to be in cardiogenic shock. They recorded an EC G: New ST Elevation.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Why is the patient in shock? He was in profound cardiogenic shock. RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1.

Bradycardia 40

Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. were pretty sick, with mostly LM/pLAD lesions and high rates of cardiogenic shock. Lobo et al.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

MAY 8, 2023

Impella (cardiac output augmentation device) placed for cardiogenic shock Unfortunately, the patient progressed to multiorgan failure with worsening cardiac output despite being maxed on pressors and a balloon pump. EKG shown here: LAFB with no clear signs of OMI or ischemia. He expired 4 days later. No labs were performed.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

The patient went into cardiogenic shock and ultimately died of this MI. Given our concern about possible subtle high-lateral OMI — this raises the question whether the upright T waves in leads V1 and V2 of this 1st ECG might be abnormal and reflect ischemia. Regional WMA: Lateral , large, hypokinetic.

Myocardial Infarction 52

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI 52

Dr. Smith's ECG Blog

JANUARY 11, 2025

The ECG shows sinus tachycardia, RBBB+LAFB, and signs of anterolateral acute transmural ischemia (most likely due to acute coronary occlusion), with concordant STE in I and aVL, inappropriate STE in V4-6 (though limited a bit by motion, still definite). Near 100% mortality without rapid reperfusion." The ST Elevation is NOT typical.

Cardiogenic Shock 137

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137

Dr. Smith's ECG Blog

MARCH 3, 2025

Whenever there is tachycardia, I am skeptical of OMI unless it has led to severely compromised ejection fracction with cardiogenic shock. The patient was started on heparin for possible NSTEMI vs demand ischemia. increasing stenosis, ischemia, volume changes, increased blood pressure, atrial fibrillation, etc.)

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73