Dr. Smith's ECG Blog

OCTOBER 13, 2022

Written by Jesse McLaren, with edits from Smith and Grauer A 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. 2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia.

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Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. At this time he reported ongoing chest pain and was given aspirin and nitroglycerin. J Am Heart Assoc.

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Dr. Smith's ECG Blog

JUNE 19, 2023

The patient’s chest pain spontaneously resolved before he was evaluated and has a repeat ECG obtained at 22:12 obtained shown below. Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. It is unclear if he received aspirin at triage. This ECG is more difficult.

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Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. PEARL # 2: Applying PEARL #1 to today's case — the fact that this patient's symptoms began before ECG #1 was obtained, and that his chest pain had resolved by the time ECG #1 was recorded — strongly suggests that the "culprit" artery may have spontaneously opened.

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Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. 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." Chest pain in high risk patient. Is it STEMI?

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Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. Their apparently excessive length (QT interval) is due to bradycardia. This is a case I had quite a while back.

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Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. Here was my answer: "Not ischemia. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. This was texted to me in real time. What do you think? Maybe HOCM or another form of LVH. I would not activate cath lab.

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Dr. Smith's ECG Blog

DECEMBER 5, 2016

(This ECG could easily be seen in an ED chest pain patient, and I have seen many) What do you think? Description Sinus bradycardia. 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.

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Dr. Smith's ECG Blog

DECEMBER 18, 2019

A 40-something woman with h/o obesity, hyperlipidemia, smoking, as well as cocaine and alcohol abuse presented with intermittent chest pain for 2-3 weeks that became constant in the last day. There is also some generalized weakness. There is some associated SOB, but no nausea and vomiting. Here is the initial EKG: What do you think?

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Dr. Smith's ECG Blog

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. His wife contacted the ambulance service after the patient experienced an episode of loss of consciousness.

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Ken Grauer, MD

OCTOBER 13, 2023

She was hemodynamically stable — and did not have chest pain, lightheadedness or syncope. Even if we stopped here — We could conclude the following: There is marked bradycardia in today's rhythm ( ie, Heart rate in the low 30s ). QUESTIONS: HOW would you interpret the rhythm in Figure-1 ? Is this " high -grade" AV block?

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Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

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Dr. Smith's ECG Blog

OCTOBER 8, 2023

All of the patients presented with chest pain , and they are all in triage. 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. True Positive ECG#2 : Also sinus rhythm.

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Dr. Smith's ECG Blog

OCTOBER 18, 2023

The chest pain quickly subsided. During the night, while on telemetry, the patient became bradycardic, with periods of isorhythmic AV dissociation (nodal escape rhythm alternating with sinus bradycardia), and there were sporadic PVCs. Acute ischemia? Are you worried about OMI in this case? Use of QT-prolonging drugs?

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Ken Grauer, MD

JUNE 2, 2023

to 1828 msec. ) — which corresponds to a variation in the rate of sinus bradycardia from 36-to-33/minute. This makes sense given that the underlying rhythm in today's case appears to be marked sinus bradycardia and arrhythmia , with a ventricular escape rhythm appearing when the SA node rate drops below 33/minute.

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Dr. Smith's ECG Blog

OCTOBER 15, 2024

He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. The patient had none of these conditions.

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Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? ST depression. Myocardial Contusion?

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Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The computer called "Sinus Bradycardia" only (implying that everything else is normal. The overreading Cardiologist called it only "Sinus Bradycardia" with no other findings. There is zero ST Elevation.

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Dr. Smith's ECG Blog

JUNE 1, 2022

A 40-something male with no previous cardiac disease presented with chest pain. Here is his ECG: There is no clear evidence of OMI or ischemia. This is suspicious for inferior reciprocal At this point, with continued pain, cath lab activation is indicated. even in the absence of ECG findings.

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Dr. Smith's ECG Blog

NOVEMBER 3, 2017

This is the initial ED ECG of a 46 year old male with chest pain: The QTc was 420 ST Elevation at 60 ms after the J-point in lead V3 = 2.5 ng/ml) A 45 year old male called 911 for chest pain: The QTc was 400 ST Elevation at 60 ms after the J-point in lead V3 = 3.5 100% LAD occlusion. He underwent CABG. QRS V2 = 15.5

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Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. The patient was still in pain, with a third troponin of 500.

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Dr. Smith's ECG Blog

MAY 5, 2022

He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. He complained of generalized weakness and left lower extremity numbness. What is it? Activate the Cath Lab?

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Wellnest

DECEMBER 21, 2022

If you experience any symptoms, such as chest pain, dizziness, unusual tiredness or fatigue, shortness of breath, or irregular heartbeat, your doctor would want you to go for an ECG test to find out the underlying cause. A fast heartbeat is called tachycardia, while a slow heartbeat is called bradycardia in medical terms.

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Dr. Smith's ECG Blog

JANUARY 28, 2018

Here is his previous ECG: This was my interpretation of the first ECG: Sinus bradycardia with less than 1mm ST elevation in V4-V6, elevated compared to the previous ECG, suggestive of lateral MI. This is his first ECG in the department, which I saw as it was being printed: What do you think? Notice how useful serial ECGs are!

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Ken Grauer, MD

OCTOBER 27, 2023

That said — obvious findings include: i ) Marked bradycardia! — This suggests ischemia of uncertain duration. MY " Q uick T houghts" on Today's CASE: The ECG in Figure-1 is highly concerning — so it is indeed fortunate that this elderly woman came to the ED when she did! be regular! —

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Dr. Smith's ECG Blog

FEBRUARY 8, 2022

Although in the context of chest pain such ST depression would be all but diagnostic of posterior OMI, one should make no conclusions in such an unusual case. In all leads, there is a 2nd wave after the initial QRS. This is an Osborn wave. I have not found any previous report of Osborn waves in RBBB.

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Dr. Smith's ECG Blog

FEBRUARY 15, 2018

Here are inferior leads, and aVL, magnified: A closer inspection of the inferior leads and aVL Sinus bradycardia. She went on to describe her chest pain as a "buffalo sitting on my chest" and a "weird" sensation in her jaw for 1 hour prior to arrival, associated with lightheadedness and diaphoresis. What do you think?

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Dr. Smith's ECG Blog

MARCH 2, 2019

Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? Ischemia b. ST depression: is it ischemia? In my experience, Ive seen U waves not only with low K+/low Mg++ but also in patients with bradycardia, LVH, and sometimes in normal subjects.

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Dr. Smith's ECG Blog

MARCH 30, 2014

Now chest pain free. There is a junctional bradycardia. Furthermore, there are T-wave changes in V2 and V3 which are highly suggestive of ischemia, but difficult to localize: anterior? ng/mL (not giving exact number, but significantly high) Now having frequent PVCs. Troponin was repeated and returned higher still.

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Dr. Smith's ECG Blog

JUNE 28, 2019

60-something with h/o MI and stents presented with chest pain radiating to the back and nausea/vomiting. For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%.

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Dr. Smith's ECG Blog

APRIL 15, 2019

If a patient presents with chest pain and a normal heart rate, or with shockable cardiac arrest, then ischemic appearing ST elevation is STEMI until proven otherwise. This, in turn, could produce platelet aggregation and vasospasm and result in an acute coronary syndrome." Clinical Context is everything !

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Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI.

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Dr. Smith's ECG Blog

JANUARY 23, 2024

There was no chest pain. Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc). For example — bradycardia and AV conduction disturbances are not uncommon with Hyperkalemia , with these conduction disturbances most often resolving once serum K+ is corrected.

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EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. Lead V2 shows RR’ QRS configuration, and although ST depression is otherwise expected here, the discordance is a bit excessive.

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Dr. Smith's ECG Blog

NOVEMBER 18, 2019

U waves may also be found in patients with LVH and/or bradycardia , or occasionally as a normal variant. This is often quite challenging to recognize — but the finding of negative U waves in a patient with chest pain is highly suggestive of ischemia ! N OTE # 2 — On rare occasions, the U wave may be negative.

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Dr. Smith's ECG Blog

APRIL 29, 2020

A recent similar case: A 40-something with chest pain. Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia. Acute ischemia? Is this inferior MI? Just as interesting is EKG 1, 24 minutes before the first: What do you think here?

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Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. There is also bradycardia. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. Torsades in acquired long QT is much more likely in bradycardia because the QT interval following a long pause is longer still.

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