Dr. Smith's ECG Blog

JUNE 1, 2022

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. Figure-1: I've labeled the 1st, 2nd and 4th tracings in today's case ( See text ).

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity?

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Dr. Smith's ECG Blog

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1]

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 9, 2012

While undergoing a stress test as a part of the non-invasive approach, she developed chest pain and hypotension and had this ECG: There is sinus bradycardia with massive inferior ST elevation, as well as ST elevation in V1-V3, diagnostic of inferior and right ventricular (RV) STEMI.

Chest Pain 52

Chest Pain Bradycardia STEMI Hypertension 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria. The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI.

Hospital 84

Hospital STEMI Blog Chest Pain 84

Dr. Smith's ECG Blog

JUNE 19, 2024

Three months prior to this presentation, he received a pacemaker for severe bradycardia and syncope due to sinus node dysfunction. His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”.

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Chest Pain Pericarditis Pacemaker STEMI 60

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean. There was no OMI.

Strokes 69

Strokes Stroke Chest Pain Cardiomyopathy 69

EMS 12-Lead

MARCH 19, 2023

It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. But until its magic is available at bedside the clinician must train his/her eyes to spot the subtle features of OMI, and equally allow the bias of STEMI to fossilize. Is this OMI?

Myocardial Infarction 52

Myocardial Infarction STEMI Coronary Angiogram Coronary Artery Disease 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI. Why bradycardia? QTc is the computer measurement.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

EMS 12-Lead

JULY 21, 2022

We have borderline sinus bradycardia with 1 ° AVB and occasional PACs. ECG diagnosis: Borderline sinus bradycardia, 1st degree AVB, RBBB, and occasional PACs. Generally speaking, right bundle branch block does not mimic, or obscure, the ECG diagnosis of acute STEMI the way left bundle branch block does. What’s the rhythm?

Bradycardia 52

Bradycardia Tachycardia STEMI Chest Pain 52

Dr. Smith's ECG Blog

MARCH 30, 2014

Repeat ECG showing no STEMI, only non-specific ST-segment and T-wave abnormalities, unchanged from prior" Transferred to surgery for exploration but diagnostic studies were too indeterminate to be certain of intra-abdominal pathology. Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

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. Moreover, T-wave inversion in aVL was also found to be 100% sensitive and 86% specific for inferior STEMI. mm ST depression in aVL.

Pericarditis 52

Pericarditis Ischemia STEMI Chest Pain 52

Dr. Smith's ECG Blog

JULY 5, 2023

Any objective, rule-based analysis of this ECG would scream "STEMI" or "OMI". And I recognized this as a STEMI mimic. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. There are Q-waves in V4-V6, with what appear to be hyperacute T-waves.

Chest Pain 52

Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2017

The computer interpreted the ECG (GE Marquette 12 SL) as: "Sinus Bradycardia. Here it is: Computer interpretation: "Sinus bradycardia. This was sent to me by a former resident from a community hospital: A middle-aged woman complained of chest pain and was seen in triage. She had a ECG recorded. Normal ECG."

Chest Pain 52

Chest Pain Bradycardia Technology Electrocardiogram 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

JANUARY 5, 2024

The ECG shows sinus bradycardia but is otherwise normal. Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The documentation does not describe any additional details of the history. The following ECG was obtained. ECG 1 What do you think?

Angina 119

Angina Plaque Document Stents 119

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life. .: See these 3 other posts of sinoventricular rhythm The K came back at 6.2 The patient was treated.

Tachycardia 52

Tachycardia Document Blog Bradycardia 52

Dr. Smith's ECG Blog

MAY 19, 2020

There is sinus bradycardia with one PVC. This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI.

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Defibrillator Circulation Plaque Cardiac Arrest 52

Ken Grauer, MD

FEBRUARY 9, 2024

Whatever today's rhythm turns out to be — the "good news" is that the bradycardia and degree of AV block is likely to improve as soon as there is reperfusion of the "culprit" artery ( Therefore need for prompt cath with PCI ). ECG Blog #218 — Reviews HOW to define a T wave as being H yperacute ?

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Blog Arrhythmia STEMI Bradycardia 105

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI.

Pericarditis 52

Pericarditis Chest Pain Pulmonary STEMI 52

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 Ischemia Exercise 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

JULY 26, 2023

My Thoughts on the Initial ECG: Systematic interpretation of ECG #1 shows: Sinus bradycardia at ~55-60/minute — normal intervals ( PR-QRS-QTc ) — normal frontal plane axis ( about +20 degrees ) — no chamber enlargement. At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010.

Aneurysm 52

Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

JULY 30, 2023

It does not meet STEMI criteria. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). Learning Points: We can find OMI on ECG much sooner than STEMI criteria in many cases, and of course many OMIs never meet STEMI criteria at all. Easy for anyone.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 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. 3) STEMI criteria failed to identify this acute coronary occlusion, like many others. I had no history on the case and no prior ECG for comparison. What do you think?

Chest Pain 52

Chest Pain Critical Care Article Pacemaker 52

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. Recall that air is a poor conductor of electricity and will, therefore, generate smaller amplitudes on posterior leads (hence why STEMI criteria requires only >0.5

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 2, 2019

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. B OTTOM L INE : I was not certain about the diagnosis of electrolyte disturbance ( low K+ and/or low Mg++ ) when I saw ECG #1.

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Sickle Cell Disease Ischemia Dysrhythmia Chest Pain 52

Dr. Smith's ECG Blog

JUNE 8, 2023

There’s sinus bradycardia, normal conduction, normal axis, delayed R wave progression, and normal voltages. The patient has a history of CABG so some of these changes could be old, but with ongoing chest pain and bradycardia in a high risk patient this is still acute OMI until proven otherwise. Sinus bradycardia.”

Chest Pain 86

Chest Pain STEMI Bradycardia Myocardial Infarction 86

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. EKG is pictured below: What do you think?

Bradycardia 40

Bradycardia STEMI Cardiogenic Shock Ischemia 40

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

See our other countless hyperkalemia cases below: General hyperkalemia cases: A 50s year old man with lightheadedness and bradycardia Patient with Dyspnea. A woman with near-syncope, bradycardia, and hypotension What happens if you do not recognize this ECG instantly? Also: How did this happen? Is this just right bundle branch block?

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Cardiac Arrest Bradycardia Tachycardia Chest Pain 140

Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? There is also bradycardia. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. Learning Points: 1.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later.

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STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MARCH 24, 2023

There’s sinus bradycardia, first degree AV block, normal axis, delayed R wave progression, and normal voltages. There’s minimal concave ST elevation in III which does not meet STEMI criteria, so this ECG is "STEMI negative". Use STEMI criteria to identify acute coronary occlusion: the ECG was STEMI negative 2.

Chest Pain 52

Chest Pain STEMI Bradycardia Ischemia 52

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI? About one hour later his high sensitivity troponin I resulted at 3,000 ng/L (reference 3-54 ng/L). The patient continued having chest pain. Fortunately the patient was then taken for angiography. Do not treat AIVR.

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Chest Pain Arrhythmia Myocardial Infarction STEMI 106

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There was no evidence bradycardia leading up to the runs of PMVT ( as tends to occur with Torsades ). With longterm use there may be — bradycardia, AV conduction defects and risk of Torsades de Pointes ( especially in patients also on Digoxin ).

Arrhythmia 130

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 130

Dr. Smith's ECG Blog

DECEMBER 15, 2015

In any case, there is bradycardia. Although most cardiac arrest from MI is due to ventricular fibrillation, some is due to high grade AV block, and so this could indeed be due to large acute STEMI. LV anterior STEMI does not give maximal ST elevation in V1. So this ECG is typical of right ventricular (RV) STEMI.

STEMI 40

STEMI Embolism Pulmonary Ultrasound 40