Ken Grauer, MD

MARCH 15, 2024

By the P s, Q s, 3 R Approach ( which I review in ECG Blog #185 ): Lots of P waves are present — being well seen in the long lead II rhythm strip. This slight variation in sinus P wave regularity tends to be greater when a 2nd- or 3rd-degree AV block is present ( called ventriculophasic sinus arrhythmia — as shown in ECG Blog #344 ).

Blog 160

Blog Arrhythmia STEMI Ischemia 160

Ken Grauer, MD

OCTOBER 13, 2023

To do this — I apply the P s, Q s, 3 R Approach ( See ECG Blog #185 — for review of my system ). As a result — IF no "fixable" cause is found ( ie, ischemia/infarction — electrolyte disturbance — rate-slowing medication ) — then because of the AV block and very slow heart rate, this patient will probably need a pacemaker.

Blog 159

Blog Arrhythmia Bradycardia Download 159

Ken Grauer, MD

MAY 20, 2023

Voltage for LVH is satisfied — at least by Peguero Criteria ( Sum of deepest S in any chest lead + S in V4 ≥23 mm in a woman — as discussed in ECG Blog #73 ). Smith's ECG Blog — Drs. Figure-3: Selected sets of V1,V2 leads from the examples of Precordial Swirl provided in the October 15, 2022 post in Dr. Smith's ECG Blog.

Blog 145

Blog Chest Pain Ischemia STEMI 145

Ken Grauer, MD

AUGUST 26, 2023

As discussed in many posts in this ECG Blog — despite not satisfying the millimeter-based definition of a STEMI — in this patient with new chest pain, the ECG findings in Figure-1 merit prompt cath lab activation without any need to wait for serum troponin to return elevated ( See ECG Blog #193 — regarding the new "OMI" paradigm ).

Blog 145

Blog Chest Pain STEMI Ischemia 145

Ken Grauer, MD

AUGUST 8, 2024

PEARL # 3: While not 100% predictive — seeing a significant negative component to the P wave in these leads ( as per the YELLOW arrows in Figure-2 ) — suggests that the V1,V2 electrodes may be placed 1 or 2 interspaces too high on the chest ( See ECG Blog #274 — for more on too high placement of the V1,V2 electrode leads ). Smith's ECG Blog.

Blog 126

Blog STEMI Ischemia 126

Ken Grauer, MD

APRIL 5, 2024

As a result, the ST elevation ( with especially tall, peaked T wave in lead V2) — is not indication of acute ischemia. As suggested by Figure-4 below in the ADDENDUM — assessment of the ST-T waves in leads V2,V3 and V5,V6 — is consistent with ischemia and / or LV "strain". ECG Blog #73 — Reviews "My Take" on the ECG Diagnosis of LVH.

Blog 94

Blog Ischemia Chest Pain Hypertension 94

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 ).

Blog 98

Blog Chest Pain Ischemia STEMI 98

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 ). A permanent pacemaker was placed.

Blog 101

Blog Pacemaker Bradycardia Arrhythmia 101

Ken Grauer, MD

SEPTEMBER 21, 2024

This is because clinicians ( including too many cardiologists ) have trouble accepting the fact that a young patient can have an acute MI ( See case discussion in the January 9, 2023 post in Dr. Smith's ECG Blog — with links at the bottom of this post to a series of more cases illustrating this phenomenon ).

Chest Pain 120

Chest Pain Blog Thrombosis Tachycardia 120

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

This confirms that the pain was ischemia and is now resovled. For more on MINOCA — See My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog ). The cardiology fellow agreed with plan for emergent cath and escorted the patient to the cath lab. The i nitial hs troponin I returned 75%.

Ischemia 123

Ischemia Plaque Stenosis Myocardial Infarction 123

Dr. Smith's ECG Blog

MAY 30, 2024

ischemia) or it can be secondary to abnormal depolarization (e.g Discussion: The ECG in today's case does not have typical ST depression vector of diffuse subendocardial ischemia. The ST vector in subendocardial ischemia (SEI) usually has the largest amount of ST depression in leads II and V5, towards the apex of the heart. (ST

Ischemia 89

Ischemia Coronary Angiogram Pulmonary STEMI 89

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.

Blog 78

Blog Ischemia STEMI Cardiac Arrest 78

Ken Grauer, MD

APRIL 14, 2023

The terminology favored to describe these ECG findings is diffuse subendocardial ischemia ( See ECG Blog #271 — for more on diffuse subendocardial ischemia ). Smith’s 8/9/2019 post in his ECG Blog. 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.

Blog 78

Blog Chest Pain Ischemia Tachycardia 78

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.

Blog 78

Blog Pulmonary Hypertension Aortic 78

Ken Grauer, MD

JULY 22, 2023

Although this " Imbalance " of precordial T waves is not see n very often — in the “right” clinical setting, it has been associated with recent OMI ( O cclusion-based MI ) , most often from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM — and ECG Blog #350 ).

Blog 78

Blog Chest Pain STEMI AFIB 78

Ken Grauer, MD

MARCH 29, 2023

M Y T houghts on the ECG in Figure-1: I have presented similar ECGs to the one in today's tracing on several occasions ( most recently in ECG Blog #284 ). Discussion of the pros and cons of these various agents extends beyond the scope of this ECG Blog. I have synthesized what I find the BEST from these programs in my ECG Blog #76.

Blog 78

Blog AFIB Arrhythmia Download 78

Ken Grauer, MD

MARCH 18, 2023

FOR O ther E xamples of Acute RV MI: Discussion of the 12-lead ECG in Blog #187 — See Figure-4 in ECG Blog #80 ( More on the "culprit" artery in this post ) — See ECG Blog #141 — Figure-5 ( together with Figure-6 ): Reviews the ECG Essentials of RV MI ( Excerpted from my ECG-2014-ePub ).

Blog 78

Blog Chest Pain STEMI Ischemia 78

Ken Grauer, MD

MARCH 7, 2023

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 #193 — illustrates use of the M irror T est to facilitate recognition of acute Posterior MI. ECG Blog #294 — How to tell IF the "culprit" artery has reperfused.

Blog 78

Blog Chest Pain STEMI Ischemia 78

Ken Grauer, MD

JULY 15, 2023

By the P s, Q s, 3 R Approach ( as reviewed in ECG Blog #185 ): The Q RS complex is obviously wide. ie, Severe subendocardial ischemia from sustained VT in a patient severe apical cardiomyopathy resulted in a peak troponin >31,000 ng/L in today's case ). . = I do not see P waves. The rhythm is R egular — at a R ate of ~230/minute.

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Ken Grauer, MD

APRIL 29, 2023

The overall ST-T wave appearance in this lead looks more like LV “strain” than ischemia. In a patient with new chest pain — this ST-T wave appearance in lead V2 of ECG #2 is consistent with a positive " Mirror " Test ( as described in ECG Blog #285 — as well as in other Related ECG Blog links provided below ).

Blog 78

Blog Chest Pain STEMI Ischemia 78

Ken Grauer, MD

MARCH 23, 2023

With experience, applying the P s, Q s, 3 R Approach ( See ECG Blog #185 ) — to formulate the above steps in our initial assessment of the rhythm in Figure-1 can ( should ) be completed in less than 30 seconds! These are reviewed in ECG Blog #343. I reviewed the concept of Echo beats in ECG Blog #239.

Blog 78

Blog Tachycardia Arrhythmia Atrial Flutter 78

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.

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78

ECG Cases

SEPTEMBER 12, 2023

In this ECG Cases blog Dr. Jesse MacLaren guides us through 10 cases of patients who present with generalized weakness or acute neurologic symptoms and discusses how to look for ECG signs of dysrhythmias, electrolyte emergencies, acute coronary occlusion, and demand ischemia in patients with generalized weakness and in patients with neurologic symptoms, (..)

Dysrhythmia 128

Dysrhythmia Atrial Fibrillation Embolism Blog 128

Ken Grauer, MD

JUNE 2, 2023

PEARL # 6: As I discuss in my review of SSS ( See ECG Blog #342 for details ) — establishing a diagnosis that sinus bradycardia indicates SSS — will depend on the following: Finding out the age of the patient ( ie, SSS is most common in older individuals ) — and learning whether the patient has been symptomatic?

Blog 78

Blog Bradycardia Arrhythmia Tachycardia 78

Ken Grauer, MD

FEBRUARY 18, 2023

"Shark Fin" ST segment elevation is most often a sign of severe transmural ischemia that results from acute coronary occlusion. Additional Relevant ECG Blog Posts to Today’s Case: ECG Blog #185 — Reviews my System for Rhythm Interpretation , us ing the P s, Q s & 3 R Approach.

Blog 78

Blog AFIB Chest Pain STEMI 78

ECG Cases

SEPTEMBER 23, 2019

In EM Cases' first ECG Cases blog we review 7 examples of ECGs of patients presenting to the ED with chest pain, who's ECG were read as normal by the computer. And guess what.they all show acute ischemia!

Ischemia 52

Ischemia Chest Pain Blog STEMI 52

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. The patient was brought to the ED and had this ECG recorded: What do you think? And what do you want to do?

Cardiac Arrest 126

Cardiac Arrest Ischemia Tachycardia Defibrillator 126

Dr. Smith's ECG Blog

JANUARY 2, 2025

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. Smith, this can be accomplished by either using beta-one agonists or temporary transvenous pacing.

Tachycardia 117

Tachycardia Cardiomyopathy Blog Bradycardia 117

Ken Grauer, MD

JUNE 7, 2024

Looking Systematically ( as per ECG Blog #205 ): The rhythm is sinus. I thought this finding consistent with the finding of ST depression in lateral leads I; V4,V5,V6 — and possibly indicative of multivessel disease ( ie, Diffuse Subendocardial Ischemia — as discussed in ECG Blog #400 ).

Blog 135

Blog Chest Pain STEMI Ischemia 135

Dr. Smith's ECG Blog

MAY 23, 2014

This case shows a CT image of subendocardial ischemia. The post cath ECG was not recorded until the next morning: The ischemia is almost entirely resolved. The inferior and posterior walls are also at chronic risk of subendocardial ischemia because of this tenuous blood supply. No evidence for watershed ischemia.

Ischemia 52

Ischemia Chest Pain STEMI Outpatient 52

ECG Cases

JUNE 6, 2023

In this ECG Cases blog we look at 10 patients with shortness of breath, and discuss how the ECG can be used to help diagnose cardiac, respiratory and metabolic emergencies.

STEMI 103

STEMI Pulmonary Blog Ischemia 103

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. This EKG is diagnostic of transmural ischemia of the inferior wall. Edited by Smith He also sent me this great case.

Chest Pain 127

Chest Pain Blood Pressure Ischemia STEMI 127

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. It was recorded at 0530: What do you think?

EKG Technician 126

EKG Technician Chest Pain Blog STEMI 126

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 124

Chest Pain Blog Cardiac Arrest Cardiomyopathy 124

Dr. Smith's ECG Blog

APRIL 14, 2024

No ischemia. This is a conundrum, because it is clear that the patient is having an acute MI, the ECG is dynamic, but the pain is very mild and there is no ECG evidence of active transmural ischemia. We already know that the ischemia is ongoing, though mild (because of the persistent pain). Q-waves are even more pronounced.

Chest Pain 120

Chest Pain Ischemia Myocardial Infarction Ultrasound 120

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 We've discussed Osborn Waves ( both ischemic and hypothermic ) — on a number of occasions in Dr. Smith's ECG Blog ( Please check out My Comment at the bottom of the page in the February 8, 2022 post ).

Blog 139

Blog Cardiac Arrest Atrial Fibrillation Bradycardia 139

Dr. Smith's ECG Blog

JANUARY 2, 2016

There may be ischemia present, but it is not evident on the ECG. In this paper, Dr. Birnbaum writes: "In patients with ACS without LVH, ST depression with negative T waves in the lateral leads is a sign of sub-endocardial ischemia and is an independent predictor of adverse outcome [11 – 13].

Ischemia 52

Ischemia Chest Pain STEMI Myocardial Infarction 52