Dr. Smith's ECG Blog

JULY 14, 2023

Non-randomized trials show better outcomes (neurologic survival) using this device; see this article in Resuscitation: Head and Thorax Elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Finally, head-up CPR (which was not used here), makes for better resuscitation.

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The pain will resolve and you will think the ischemia is gone when it is only hidden ! Brief aside: "Early repolarization" is a frequently proclaimed and poorly understood electrocardiographic phenomenon which mostly serves to reassure clinicians that not all ST elevations are ischemic (something readers of this blog know well).

Chest Pain 130

Chest Pain Myocardial Infarction Blog Stents 130

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 82

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 82

Dr. Smith's ECG Blog

FEBRUARY 14, 2024

When the ischemia is resolved, if there is no infarction, the T-wave can normalize. When I see a case like this, I am skeptical that the ECG is manifesting acute ischemia or reperfused OMI. Outcome: All hs troponin I ﹤ 3 ng/L (undetectable). On occasion, unstable angina can present with reversible T-wave inversion during pain.

Chest Pain 110

Chest Pain Angina Ischemia Outcomes 110

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.

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

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. Outcome and Analysis: ECG 1 is diagnostic of inferior and right ventricular MI. The minute this medical student saw the first ECG, he knew the diagnosis without any further information. right ventricular?

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

JUNE 27, 2021

If this STD were due to LVH or to subendocardial ischemia, rather than posterior OMI, it would be maximal in V5 and V6. If I saw this without the STD V2-V4, I would not make anything of it, and even with that precordial STD, I am not convinced that it is a manifestation of ischemia. Alcohol intoxication? V5-V6), even if less than 0.1

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

Dr. Smith's ECG Blog

OCTOBER 18, 2023

1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes. Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Acad Emerg Med.

Chest Pain 119

Chest Pain STEMI Electrocardiogram Ischemia 119

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

AUGUST 26, 2024

What was the outcome?" There is akinesis of the distal septum, anterior, apex, and distal inferior wall consistent with LAD territory ischemia or infarction. This was sent to me without any info while I was out and about, and I looked at it on my phone. I responded: "That is a tough one. V2 is very worrisome. But no other leads are.

Myocardial Infarction 121

Myocardial Infarction Critical Care Echocardiogram Ischemia 121

Dr. Smith's ECG Blog

DECEMBER 26, 2020

We have also shown several cases in which atrial flutter hides true, active ischemia. Long-term outcome is unknown. First, there can simply be diffuse STD (which obligates reciprocal STE in aVR) associated with tachycardia, which are not even necessarily indicative of ischemia. Christmas Eve Special Gift!! Is this inferor STEMI?

Atrial Flutter 52

Atrial Flutter Ischemia STEMI Tachycardia 52

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.

Chest Pain 98

Chest Pain Cardiac Arrest STEMI Defibrillator 98

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?

Cardiac Arrest 52

Cardiac Arrest Ischemia Defibrillator Electrocardiogram 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

But ECGs interpretation is often conflated with clinical assessment, so if patients don’t present with chest pain the ischemic changes are not seen or are attributed to something other than ischemia. Instead, ECGs need to be interpreted in isolation and then applied to the patient.

Chest Pain 98

Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Most such rhythms in the setting of ischemia are VF and will not convert without defibrillation. Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia. Acute ischemia? Case continued The tachyarrhythmia terminated on its own. Use of QT-prolonging drugs?

Cardiac Arrest 122

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 122

Dr. Smith's ECG Blog

JANUARY 3, 2022

2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. The absence of STE in V7-V9 is often due to resolution of ischemia, as seen by resolution of ST depression in V7-V9. non-occlusive ischemia) JAHA 2021 3. -- Meyers HP, Bracey A, Lee D, et al.

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

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. I have seen cases of Wellens' syndrome that were ignored because of either negative troponins or normal echo or both and the patient did not get an angiogram and had a bad outcome. Wellen's syndrome is a Reperfusion syndrome.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Groups were categorized based on moderate to severe chest pain (numerical rating scale pain ≥ 5/10) or less than moderate severity to compare procedural and clinical outcomes. And as we have shown before, morphine leads to slower times to treatment and worse outcomes. 414 patients were included in the analysis.

Chest Pain 119

Chest Pain STEMI Myocardial Infarction Electrocardiogram 119

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Atrial fibrillation is also a predictor of worse outcomes in this case (Alborzi). 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.

Tachycardia 115

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

Dr. Smith's ECG Blog

JULY 14, 2024

Outcome of case 2? In addition — there is transmural ischemia of the septum , most often resulting from occlusion proximal to the 1st septal perforator branch of the LAD. This one, too, is a swirl pattern and diagnostic of LAD occlusion. Admitted for NSTEMI. Cath days later showed complete occlusion of the LAD, stented.

AFIB 105

AFIB Stents Stent Chest Pain 105

Dr. Smith's ECG Blog

MAY 31, 2023

There is probably a trickle of flow which is why there is both subendocardial ischemia (ST depression) and early subepicardial ischemia (hyperacute T-waves). Opiates are associated with worse outcomes in Myocardial Infarction. It is one of the few OMI patterns that is really well described: de Winter’s T-waves. Am Heart J.

STEMI 96

STEMI Chest Pain Myocardial Infarction Ischemia 96

Dr. Smith's ECG Blog

APRIL 2, 2014

There is about 1 mm of STE in aVR I con sidered but rejected subendocardial ischemia. Is it subendocardial ischemia, or inferior MI? Outcome : Was it RCA or LCX with inferior MI? The ST elevation vector is posterior, inferior, and right , to the right of lead III and also posterior.

STEMI 52

STEMI Ischemia Chest Pain Angioplasty 52

Dr. Smith's ECG Blog

JUNE 12, 2016

Answer : There is very abnormal T-wave inversion in aVL which is typical of subtle transmural/subepicardial (due to occlusion) ischemia to the inferior wall. Similarly, the precordial T-wave inversions in V2-V4 are reciprocal to posterior wall transmural/subepicardial (due to occlusion) ischemia. This is reciprocal T-wave inversion.

Chest Pain 52

Chest Pain Ischemia STEMI Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Smith : the profound persistent STE suggests either persistent occlusion or " no reflow " with persistent downstream ischemia. Long term outcome unknown but obviously bleak. It makes you think you have done something for the ischemia when you have not! In the first year since discharge, he has been hospitalized 3 times with CHF.

STEMI 78

STEMI Myocardial Infarction Ischemia Academic 78

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Jason asked me if I thought it is due to occlusion (without either of us knowing the outcome), and this was my answer: This is a posterolateral MI. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This ECG is diagnostic of ischemia. Is this due to coronary occlusion?

Ischemia 40

Ischemia Chest Pain STEMI Stenosis 40

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. He underwent PCI and had a good outcome. Ischemia comes and goes. mm of STE at 60 ms after the J-point in lead V3, 400 ms QTc, and 6 mm of R-wave amplitude in V4. Learning Points: 1.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease. Detailed coronary artery evaluation not performed. Exam was interpreted and discussed with Dr. Simegn of cardiology, who reviewed the cardiac portion.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

AUGUST 3, 2017

Computer read: "Non-specific ST abnormality, consider anterior subendocardial ischemia" There are very poor R-waves in V1-V4 suggesting old anterior MI. Firstly, subendocardial ischemia does not localize on 12-Lead ECG. But the real question at hand is: Are these precordial ST-depressions a result of subendocardial ischemia?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

JUNE 30, 2023

Outcome: Patient ruled out for MI by troponins. And ECGs can change and evolve even when there is no ischemia. Wang and Smith as suggestive of BTWI ( These criteria were cited by Dr. Meyers in the March 22, 2022 post of Dr. Smith's ECG Blog ). Here is a great case of pseudonormalization. Here are multiple cases. in ECG #1 ).

Chest Pain 52

Chest Pain Blog Ischemia Document 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Abstract 556.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

NOVEMBER 17, 2014

Here is a link to a blog post with the formula , which we have recently validated and will publish. After the hyperacute phase, the ST segments rise and only fall with either 1) reperfusion or 2) prolonged ischemia leading to irreversible infarction. As for thrombolytics, that is a bit riskier. 3.0 = 0.50 The height of the ST segments.

Aneurysm 52

Aneurysm STEMI Chest Pain Risk Factors 52

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.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Here is PM Cardio's Queen of Hearts interpretation (AI ECG interpretation trained by Meyers, Smith, and PM Cardio team using thousands of cases and their outcomes): The output number ranges from 0 to 1, with numbers closer to zero meaning likely NOT OMI, and numbers closer to 1 meaning OMI.

Blog 52

Blog Bradycardia Exercise Ischemia 52

Dr. Smith's ECG Blog

JANUARY 3, 2024

The patient survived with unknown long term outcome. Instead — QRS widening is almost certainly related to acute ischemia from extensive infarction, thereby suggesting another adverse prognostic factor. No further ECGs were recorded. She was very lucky to have spontaneous reperfusion.

STEMI 102

STEMI Chest Pain Ischemia Outcomes 102

Dr. Smith's ECG Blog

JUNE 1, 2020

When PMVT is associated with a long QT interval — the rhythm is then defined as Torsades de Pointes ( Please SEE My Comment at the bottom of the April 29, 2020 post in Dr. Smith’s ECG Blog ). Figure-3: Comparison of ECG #1 with an example of PMVT, that I took from the October 12, 2013 post from Dr. Smith’s ECG Blog ( See text ).

Tachycardia 52

Tachycardia AFIB Blog Heart Disease 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. Thus, this ECG predicts poor myocardial perfusion and poor outcome. Small vessel occlusion is measured by "blush" on the angiogram, and codified by TIMI Myocardial Perfusion (TMP) Grading.

Aneurysm 66

Aneurysm Chest Pain Cardiogenic Shock Blog 66

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 116

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 116