Dr. Smith's ECG Blog

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. Formal Echocardiogram: Normal left ventricular size and wall thickness. The patient had ROSC and maintained it. A 12-lead ECG was obtained: What do you think?

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

A transthoracic echocardiogram showed an LV EF of less than 15%, critically severe aortic stenosis , severe LVH , and a small LV cavity. DISCUSSION: The 12-lead EKG EMS initially obtained for this patient showed severe ischemia, with profound "infero-lateral" ST depression and reciprocal ST elevation in lead aVR.

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Dr. Smith's ECG Blog

NOVEMBER 9, 2023

She underwent exercise echocardiogram in mid October where she exercised for nearly 7 minutes on the standard Bruce protocol and had typical anginal pain and shortness of breath. Baseline echocardiogram showed moderate LV systolic dysfunction with no wall motion abnormalities. There is inferoseptal hypokinesis. link] Shvilkin et al.

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Chest Pain Echocardiogram Blog Ischemia 78

Dr. Smith's ECG Blog

OCTOBER 12, 2024

or basilar ischemia. Echocardiogram was obtained and showed mild LVH without regional wall motion abnormality. For a list of lead reversal cases we've discussed in Dr. Smith's ECG Blog — GO TO the bottom of the page in My Comment from the January 6, 2024 post). EKG on arrival to the ED is shown below: What do you think?

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Dr. Smith's ECG Blog

AUGUST 26, 2024

There is akinesis of the distal septum, anterior, apex, and distal inferior wall consistent with LAD territory ischemia or infarction. Echocardiography: Normal left ventricular size with mild to moderately reduced LV systolic function; estimated LVEF is 44 %. How large is the infarct? Probably significant infarction.

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Myocardial Infarction Critical Care Echocardiogram Ischemia 122

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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Dr. Smith's ECG Blog

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.

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Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

DECEMBER 5, 2016

There is ST elevation in V2 and V3 There are inverted T-waves in V2 and V3 There are prominent U-waves in V2 and V3 Many responders were worried about ischemia or hypertrophic cardiomyopathy. This short QT at least makes ischemia all but impossible. This is a classic pattern and the QT is so short as to make ischemia very unlikely.

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Dr. Smith's ECG Blog

OCTOBER 15, 2024

Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls. Additionally, a bedside echocardiogram showed no wall motion abnormality and normal LV function. The patient had none of these conditions.

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Chest Pain STEMI Echocardiogram Stents 117

Dr. Smith's ECG Blog

APRIL 24, 2015

Again, it is common to have an ECG that shows apparent subendocardial ischemia after resuscitation from cardiac arrest, after defibrillation, and after cardioversion. and repeat the ECG, to see if the apparent ischemia persists. A third ECG was done about 25 minutes after the first: This shows resolution of all apparent ischemia.

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Cardiac Arrest Defibrillator Atrial Fibrillation Ischemia 52

Dr. Smith's ECG Blog

MARCH 13, 2024

Nossen also pointed out that with voltage this high in the limb leads, you would typically expect some degree of inferior/inferolateral ST depression (the so-called "LVH strain" pattern), and in fact this patient did have severe LVH on subsequent echocardiogram (which Dr. Nossen did not know at the time). The troponin peaked at 25749 ng/L.

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Chest Pain Angina Echocardiogram Myocardial Infarction 108

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Hopefully a repeat echocardiogram will be performed outpatient. 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. No cardiac MRI was done.

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 116

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. See this case: what do you think the echocardiogram shows in this case? Anything more on history? POCUS will be helpful.” J Electrocardiol 2013;46:240-8 2.

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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?

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Dr. Smith's ECG Blog

MARCH 9, 2013

For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering. In this case, the duration of ischemia was so brief that there was no such evolution, and there was near-normalization. Ischemia may be so brief that Wellens' waves do not evolve 3. The peak troponin I was 0.364 ng/ml.

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Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. I have warned in the past that one must think of other etiologies of ischemia when there is tachycardia. Whether it is subendocardial ischemia or posterior STEMI, if you cannot get it to resolve, you must activate the cath lab. There is no ST elevation.

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Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

Does this mean that the ST depression in V3 represents "anterior" subendocardial ischemia, and not posterior OMI? Echocardiogram: The estimated left ventricular ejection fraction is 34% Regional wall motion abnormality-lateral, akinetic. non-occlusive ischemia) 2. Thus, they have much less voltage. They have ZERO ST Elevation.

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Dr. Smith's ECG Blog

OCTOBER 26, 2010

One very useful adjunct is ultrasound: Echo of his heart can distinguish aneurysm from acute MI by presence of diastolic dyskinesis, but it cannot distinguish demand ischemia from ACS. These must raise suspicion of old MI with persistent ST elevation. Troponins peaked at 0.275 ng/ml. An angiogram showed no acute coronary lesions.

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Dr. Smith's ECG Blog

NOVEMBER 15, 2013

The ECG in the chart was read as "no obvious ST changes," (even though no previous ECG was available) and the formal read by the emergency physicians was: "ST deviation and moderated T-wave abnormality, consider lateral ischemia." When the ischemia is resolved, the wall motion may completely recover, or there may be persistent stunning.

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Dr. Smith's ECG Blog

JULY 16, 2022

If you put the inferior and posterior findings together, it is diagnostic of OMI This was read as "inferior ischemia" without any other information by Dr. Richard Gray and as probable reperfused inferior-posterior OMI much later by both me and Pendell Meyers, also without any clinical information.

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Dr. Smith's ECG Blog

JUNE 18, 2011

When flow is restored, wall motion may completely recover so that echocardiogram does not detect the previous ischemia. Even when the serial troponins are negative, the ECG is critical to the diagnosis of ACS. This is not pericarditis because: a. Pain was typical for MI (substernal, not postional or sharp, resolved with NTG) b.

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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. Echocardiogram the following day showed a left ventricular ejection fraction of 52% (+/- 5%) with hypokinesis of the basal-mid inferior and inferoseptal myocardium. Two stents were placed with resultant TIMI 3 flow.

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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. There is also a Q-wave in III. There is also subtle STD in V3-V5. ng/ml (99th %-ile URL = 0.04

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Dr. Smith's ECG Blog

JULY 22, 2023

Formal echocardiogram showed normal EF, no wall motion abnormalities, no pericardial effusion. The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. No more troponins were done. He was found to be influenza positive. 1849 after cath: Brugada pattern is gone!

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 91

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Next day echocardiogram showed inferolateral hypokinesia with an EF of %45-50. On echocardiogram you will not see a "posterior" hypokinesia (will see "inferolateral") and, as in this case, LCx may not give the blood supply of basal inferior segment (formerly called "posterior"). The patient recovered well. J Am Heart Assoc. 121.022866.

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Myocardial Infarction Chest Pain Blog Echocardiogram 40

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. SUMMARY Normal left ventricular cavity size. Normal estimated left ventricular ejection fraction.

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Tachycardia Ischemia Cardiac Arrest Echocardiogram 52

Dr. Sanjay Gupta

MARCH 6, 2022

So today i wanted to talk to you about what each heart test tells us about these different aspects of heart disease Tests that tell you about the heart as a pump The most commonly used test to assess the heart as a pump is an echocardiogram. Overall though a normal cardiac MRI is even more reassuring than a normal echocardiogram.

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Dr. Smith's ECG Blog

OCTOBER 25, 2022

We see a regular tachycardia with a narrow QRS complex and no evidence of OMI or subendocardial ischemia. She had an echocardiogram which was normal. For more on the concept of retrograde conduction during a regular SVT rhythm — Please see My Comment at the bottom of the page in the March 6, 2020 post of Dr. Smith’s ECG Blog.

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Dr. Smith's ECG Blog

JANUARY 28, 2023

Prior ECG available on file from 2 months before: We do not know the clinical events happening during this ECG, but there is borderline tachycardia, PVCs, and likely some evidence of subendocardial ischemia with small STDs maximal in V5-6/II, slight reciprocal STE in aVR. Notice the normal precordial T waves.

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Dr. Smith's ECG Blog

FEBRUARY 6, 2020

Next day, a stress echo was done: The exercise stress echocardiogram is normal. This ST-T wave appearance in the lateral chest leads of ECG #2 is consistent with L V “ S train” vs ischemia. Normal estimated left ventricular ejection fraction improved with stress. No wall motion abnormality at rest.

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Chest Pain Ischemia Angina Electrocardiogram 40

Dr. Smith's ECG Blog

JULY 31, 2018

Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. These are reperfusion T-waves (the same thing as Wellens' waves) Echocardiogram Regional wall motion abnormality-distal septum and apex. It they are static, then they are not due to ischemia.

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Dr. Smith's ECG Blog

NOVEMBER 25, 2022

An echocardiogram was done. As we've discussed on numerous other posts in Dr. Smith's ECG Blog ( See My Comment at the bottom of the page in the May 5, 2022 post) — a growing number of conditions other than Brugada Syndrome have been found to temporarily produce a Brugada-1 ECG pattern. Is there also Brugada?

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Dr. Smith's ECG Blog

NOVEMBER 1, 2022

2 days later This is a typical LVH pattern, without ischemia Patient underwent 4 vessel CABG. After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time."

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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 ). I think a good start would be a posterior EKG and a high quality contrast echocardiogram read by an expert. In there ECG evidence of possible ongoing ischemia? (ie,

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Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! He underwent formal echocardiogram several days later, which confirmed the findings of anterior, and apical wall motion abnormalities. Smith comment: this patient might have been sent home because of the poor sensitivity of this Point of Care (POC) assay.

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Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. Unfortunately there is no echocardiogram accessible because the patient checked himself out of the hospital in order to get back to his home state before it could be completed. No significant changes, ongoing pain.

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Dr. Smith's ECG Blog

JANUARY 30, 2019

A formal echocardiogram was completed the next day and again showed a normal ejection fraction without any focal wall motion abnormalities to suggest CAD. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab.

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