Ken Grauer, MD

OCTOBER 13, 2023

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 ). Finally — If today's patient does not have significant underlying coronary disease — then her bradycardia with AV block may be the result of SSS ( S ick S inus S yndrome ).

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Blog Arrhythmia Bradycardia Download 158

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

Altered Mental Status, Bradycardia == MY Comment , by K EN G RAUER, MD ( 2/2 /2024 ): == Dr. Meyers began today’s case with the clinical challenge of asking you to identify the underlying cause of ECG #2. -- Read this ECG -- Osborn Waves and Hypothermia (this is the "Figure" above) What does LBBB look like in severe hypothermia?

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Blog Cardiac Arrest Atrial Fibrillation Bradycardia 137

Dr. Smith's ECG Blog

MARCH 22, 2024

I will leave more detailed rhythm discussion to the illustrious Dr. Ken Grauer below, but this use of calipers shows that the rhythm interpretation is: Sinus bradycardia with a competing (most likely junctional) rhythm. The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible.

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Chest Pain STEMI Bradycardia Ischemia 114

Dr. Smith's ECG Blog

OCTOBER 18, 2023

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. Most such rhythms in the setting of ischemia are VF and will not convert without defibrillation. Acute ischemia?

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Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 122

Dr. Smith's ECG Blog

JULY 30, 2023

The STD maximal in V1-V4 is diagnostic of acute transmural posterior wall ischemia, most likely due to posterior OMI. Subendocardial ischemia does not localize, and subendocardial ischemia presents with STD maximal in V5-6, II, and STE in aVR. Subendocardial ischemia does not localize.

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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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Blog Bradycardia Arrhythmia Tachycardia 78

Dr. Smith's ECG Blog

OCTOBER 26, 2015

Due to bradycardia, a 12-lead ECG was obtained: There is atrial fibrillation at a rate of 54. But because of bradycardia, a 12-lead was obtained, which gave the critical diagnosis. Slow atrial fibrillation implies an sick AV node, or one affected by electrolytes, ischemia, or medications/drugs. His breath alcohol was 0.259.

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Atrial Fibrillation Bradycardia Ischemia 52

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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Chest Pain Bradycardia Blog Electrocardiogram 116

Dr. Smith's ECG Blog

JULY 5, 2018

during which sinus bradycardia and arrhythmia are seen but not to a degree that produces symptoms. Thus, there is sinus bradycardia and arrhythmia sinus pauses ( which may be longlasting, ultimately leading to sinus arrest ) and SA nodal block. The indication for pacemaker placement with SSS is symptomatic bradycardia.

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Atrial Fibrillation AFIB Bradycardia Pacemaker 52

All About Cardiovascular System and Disorders

APRIL 17, 2024

Monomorphic ventricular tachycardia in the setting of acute myocardial ischemia can also be treated by intravenous lignocaine bolus followed by infusion. Predisposing causes for ventricular tachycardia like ischemia and electrolyte imbalance has to be treated simultaneously to prevent recurrence.

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Tachycardia Defibrillator Congenital Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ). Chest trauma was suspected on initial exam. Here is his initial ECG around 1330: What do you think?

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL ( featured in Audio Pearl #2 in this blog post ). The PR and QRS intervals are both normal. ECG Blog #230 — How to compare serial ECGs.

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Blog Chest Pain STEMI Ischemia 145

Dr. Smith's ECG Blog

JANUARY 22, 2020

There are 3 etiologies I always think of with bradycardia and AV block: 1. There was no evidence of ischemia. In addition to ruling out rate-slowing medication serum electrolyte disorders and/or ischemia/infarction as potential causes of bradyarrhythmias one should also rule out hypothyroidism + sleep apnea. Hyperkalemia.

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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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Pericarditis Ischemia STEMI Chest Pain 52

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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Blog Pacemaker Bradycardia Arrhythmia 100

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

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. 2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. What do you think? But it is still STEMI negative.

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Dr. Smith's ECG Blog

OCTOBER 13, 2022

2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia. 3] So a patient with WPW can have the pattern induced by ischemia, and there is also a report of a patient with pre-existing WPW which was “ablated” by myocardial infarction after an LAD occlusion.[4]

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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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Blog Bradycardia Exercise Ischemia 52

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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Sickle Cell Disease Ischemia Dysrhythmia Chest Pain 52

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. He had multiple episodes of bradycardia and nonsustained ventricular tachycardia. The patient had none of these conditions. Patient 1 remained in the hospital overnight.

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Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

MARCH 30, 2014

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? Troponin was repeated and returned higher still. She was taken to the cath lab. What was the diagnosis? and right ventricular echo findings. right ventricular?

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Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Patient presentation is important This was a 60-something with acute chest pain: There is sinus bradycardia at a rate of 44. To me, this makes the ECG nearly diagnostic of ischemia, though if it is LAD occlusion, there should be ST depression in III and aVL, so it is a bit confusing. Why bradycardia? 100% distal LAD occlusion.

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Dr. Smith's ECG Blog

JULY 5, 2023

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. The patient has acute chest pain. 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

APRIL 15, 2019

But when the clinical presentation is sepsis, one must entertain the possibility that the ST elevation is due to demand ischemia, or some other process, and exacerbated by tachycardia. It is prudent to treat the other conditions, get the heart rate controlled, and repeat the ECG.

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Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

APRIL 29, 2020

Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia. Acute ischemia? ECG #5 — This is the 4th ECG done on the patient in this case ( obtained ~6 hours after arrival in the ED ). Use of QT-prolonging drugs?

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Dr. Smith's ECG Blog

JUNE 28, 2019

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%. This is sinus bradycardia. More likely, these T waves probably reflect ischemia of uncertain age.

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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 # 1 — U waves are not specific for hypokalemia!

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Chest Pain Cardiac Arrest Bradycardia Ischemia 52

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. I had no history on the case and no prior ECG for comparison. What do you think? The T-wave in lead III is slightly tall and broad (increased area under the curve) compared to its QRS complex.

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Chest Pain Critical Care Article Pacemaker 52

Dr. Smith's ECG Blog

JUNE 1, 2022

Here is his ECG: There is no clear evidence of OMI or ischemia. The Initial ECG in Today's Case: ECG #1 showed sinus bradycardia at a rate slightly under 60/minute — normal intervals — slight left axis ( about -15 degrees ) — and no chamber enlargement. A 40-something male with no previous cardiac disease presented with chest pain.

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Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

DECEMBER 18, 2019

Dr. Smith and I both ( independently ) used lead III but selection of lead aVF by the computer ( considering the bradycardia ) would yield a corrected QTc value close to the 450 msec reported. I suspect the computer in this case used lead III, or possibly lead aVF for its calculation of the QTc.

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Dr. Smith's ECG Blog

JANUARY 23, 2023

Triage physician interpretation: -sinus bradycardia -lateral ST depressions While there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). 121.022866.

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Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

These include ( among others ) — acute febrile illness — variations in autonomic tone — hypothermia — ischemia-infarction — malignant arrhythmias — cardiac arrest — and especially Hyperkalemia. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ).

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Arrhythmia Blog Chest Pain Cardiac Arrest 52

Dr. Smith's ECG Blog

MARCH 15, 2023

Baseline bradycardia in endurance athletes limits the use of ß-blockers. These include: i ) Use of rate-slowing medication ( ie, ß-blockers, digoxin, verapamil/diltiazem, etc. ) ; ii ) Acute or recent infarction or ischemia; iii ) Hypothyroidism; iv ) Neurologic injury; v ) Electrolyte disturbance; and , vi ) Sleep apnea.

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Atrial Fibrillation AFIB Arrhythmia Exercise 52

Dr. Smith's ECG Blog

JUNE 23, 2023

The patient later settled into sinus bradycardia. He was started on amiodarone and had no more events. Next day, the cardiologists were convinced (I think correctly) that this was SVT with aberrancy that was triggered by DKA.

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Tachycardia Cardiomyopathy Arrhythmia Diabetes 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Both of these features make inferior + RV MI by far the most likely ( Pseudoanteroseptal MI is another name for this ) There is also sinus bradycardia and t he patient is in shock with hypotension. A narrow complex bradycardia without any P-waves is also likely to respond to atropine, as it may be a junctional rhythm.

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Dr. Smith's ECG Blog

JANUARY 26, 2020

Her vital signs were within normal limits except for bradycardia at 55 bpm. It is probably sinus bradycardia with very small/depressed P-waves and prolonged PR interval. P EARL # 4 In my opinion, it is not worth wasting time trying to figure out the specific rhythm diagnosis of a bradycardia when there is hyperkalemia.

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