Dr. Smith's ECG Blog

OCTOBER 4, 2010

There is profound LVH with anterolateral ST elevation and reciprocal ST depression in II, III, aVF, and ST depression in V5 and V6 that could all be secondary to LVH or could represent ischemia superimposed on the repolarization abnormalities of LVH: note that wherever there is ST depression, it is associated with a very high voltage R-wave.

Cardiac Arrest 52

Cardiac Arrest Ischemia Stenosis STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

Although one may have all kinds of ischemic findings as a result of cardiac arrest (rather than cause of cardiac arrest), this degree of ST elevation and HATW is all but diagnostic of acute proximal LAD occlusion. This rules out subendocardial ischemia and is diagnostic of posterior OMI. V4-5 continue to show STD.

Cardiac Arrest 109

Cardiac Arrest STEMI Ischemia SCAD 109

Ken Grauer, MD

DECEMBER 29, 2023

The H ISTORY in T oday's C ASE: The patient in today's case is a teenager who presented to the ED ( E mergency D epartment ) in cardiac arrest after electrocution. Shark Fin" ST segment elevation is most often a sign of severe transmural ischemia that results from acute coronary occlusion.

Blog 173

Blog Cardiac Arrest Ischemia Hospital 173

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation.

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

JUNE 5, 2024

The ECG does not show any definite signs of ischemia. Uncontrolled coronary spasm may be associated with serious arrhythmias , including cardiac arrest ( Looi et al — Postgrad Med, 2012 ; Tan et al — Eur Heart J Case Rep, 2018 ; Chevalier et al — JACC, 1998 ; Rodriguez-Manero — EP Europace, 2018 ). The below ECG was recorded.

Chest Pain 121

Chest Pain Blog Cardiac Arrest Cardiomyopathy 121

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

FEBRUARY 2, 2024

We periodically review this intriguing ECG finding that is best known for its association with hypothermia — but which may also be seen in association with a number of other entities, including acute infarction and cardiac arrest. My Comment addresses a few additional aspects of this phenomenon.

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Blog Cardiac Arrest Bradycardia AFIB 137

Dr. Smith's ECG Blog

JANUARY 4, 2021

This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with reciprocal ST depression in aVL, and some STE in V1. If there is also subendocardial ischemia, the ST depression vector remains leftward, with a reciprocal ST Elevation vector also to the right.

Ischemia 40

Ischemia Pulmonary STEMI Chest Pain 40

Circulation

NOVEMBER 11, 2024

Background:The incidence of cardiac arrest (CA) increases with age, leading to poorer neurological outcomes after the return of spontaneous circulation (ROSC) in the elderly.

Ischemia 40

Ischemia Cardiac Arrest Circulation Outcomes 40

Dr. Smith's ECG Blog

JANUARY 2, 2025

See this post: How a pause can cause cardiac arrest 2. 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. The plan: 1. Place temporary pacemaker 3.

Tachycardia 115

Tachycardia Cardiomyopathy Blog Bradycardia 115

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Edited by Bracey, Meyers, Grauer, and Smith A 50-something-year-old female with a history of an unknown personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return of spontaneous circulation. The described rhythm was an irregular, wide complex rhythm.

Tachycardia 130

Tachycardia Cardiac Arrest Blog ICU 130

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

Blog 98

Blog Chest Pain Ischemia STEMI 98

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. The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Ischemia comes and goes. He was defibrillated. Anterolateral STEMI.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 52

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

JUNE 11, 2021

Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes. VF arrest is of course "electrical instability"! Learning points 1.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

EMS 12-Lead

JULY 24, 2023

It should be known that each category can easily manifest the generic subendocardial ischemia pattern. In general, subendocardial ischemia is a consequence of global supply-demand mismatch that usually ameliorates upon addressing, and mitigating, the underlying cause. What’s interesting is that the ECG can only detect ischemia.

Angina 52

Angina Ischemia Coronary Angiogram Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

The differential is: Posterolateral OMI or subendocardial ischemia The distinction between posterior OMI and subendocardial ischemia can be important and sometimes difficult. Ischemic ST depression includes posterior OMI and subendocardial ischemia. Her prior ECG on file is shown below: What are your next steps?

Chest Pain 40

Chest Pain Ischemia Aortic Aortic valve 40

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

He had a previous MI with cardiac arrest 2 years prior. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. This ECG is diagnostic of ischemia.

Ischemia 40

Ischemia Chest Pain STEMI Stenosis 40

Dr. Smith's ECG Blog

AUGUST 1, 2020

He has done a lot of great work on cardiac arrest, including as co-author of our study on esmolol in refractory cardiac arrest, and much more with Keith Lurie. The Queen was not able to see this one: Of course we do not know for certain that the inferior findings represent ischemia. It was not.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JULY 27, 2023

hours ECG: Not much change hs troponin I peaks at 500 ng/L 8 hours Next morning Urine drug screen: Amphetamine, Methamphetamine, Fentanyl, Fentanyl metabolite Formal Bubble Contrast Echocardiogram: Indications for Study: Silent Ischemia. Conclusion: Type II MI probable due to hypoxia and tachycardia from resp arrest and amphetamine use.

Tachycardia 52

Tachycardia Ischemia Cardiac Arrest Echocardiogram 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

They had had twice the rate of cardiac arrest and twice the in-hospital mortality[1] In another study of patients diagnosed with STEMI, those on dialysis experienced delayed reperfusion and double the mortality.[2] They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

Chest Pain 98

Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

MAY 5, 2023

Common explanations for unusual rhythms such as this one include: i ) Hyperkalemia ( or other severe electrolyte disorder ); ii ) Recent infarction/ischemia; iii ) Sleep apnea; iv ) Severe hypothyroidism; v ) Acute neurologic catastrophe (ie, stroke, bleed, trauma, tumor ); vi ) Some other toxicity.

Bradycardia 52

Bradycardia Cardiac Arrest Arrhythmia Pacemaker 52

Ken Grauer, MD

APRIL 9, 2023

As discussed in ECG Blog #108 — AIVR generally occurs in one of the following C linical S ettings : i ) As a rhythm during cardiac arrest; ii ) In the monitoring phase of acute MI ( especially with inferior MI ) ; or , iii ) As a reperfusion arrhythmia ( ie, following thrombolysis, acute angioplasty, or spontaneous reperfusion ).

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This means that they occur shortly after onset of occlusion, but also may be the last remaining sign of ischemia after ST elevation resolves (after reperfusion). Smith likes to say: "Hyperacute T-waves occur 'on the way up,' and 'on the way down.'"

Chest Pain 52

Chest Pain STEMI Defibrillator Blog 52

Ken Grauer, MD

OCTOBER 27, 2023

This suggests ischemia of uncertain duration. Unfortunately, before this could be accomplished — the patient went into cardiac arrest. She was successfully resuscitated — with a post-arrest rhythm similar to that seen in Figure-1. Cardiac cath did not reveal significant coronary disease!

Blog 101

Blog Pacemaker Bradycardia Arrhythmia 101

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. It is prudent to treat the other conditions, get the heart rate controlled, and repeat the ECG.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

NOVEMBER 18, 2019

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. Figure-2: Sequential development of ST-T wave changes with hypokalemia. Note increasing U wave amplitude ( See text ).

Chest Pain 52

Chest Pain Cardiac Arrest Bradycardia Ischemia 52

Cardiology Update

MARCH 5, 2024

In the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, researchers examined the risk of ischemic events in patients with stable coronary artery disease. years, with 57.1% occurring within 30 days after CABG. Original article: Redfors B et al.

Coronary Artery Disease 116

Coronary Artery Disease Ischemia Coronary Artery Bypass Graft Myocardial Infarction 116

Ken Grauer, MD

MARCH 23, 2023

What is the cardiac rhythm shown in the long lead II rhythm strip? Figure-1: The initial ECG in today’s case — obtained from an elderly woman following successful resuscitation from cardiac arrest. ( To improve visualization — I've digitized the original ECG using PMcardio ). What about the 1 2- L ead E CG ?

Blog 78

Blog Tachycardia Arrhythmia Atrial Flutter 78

Dr. Smith's ECG Blog

OCTOBER 26, 2020

Case submitted by Magnus Nossen MD from Norway, written by Pendell Meyers A man in his 50s with no pertinent medical history suffered a witnessed cardiac arrest. 12 minutes later, the patient went back into VFib arrest and underwent another 15 minutes of resuscitation followed by successful defibrillation and sustained ROSC.

Ischemia 40

Ischemia Arrhythmia Defibrillator Chest Pain 40

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Alternation in ST segment appearance ( or in the amount of ST elevation or depression ) — is often linked to ischemia. The above said — Electrical alternans is a nonspecific ECG sign that may also indicate myocardial ischemia, LV dysfunction and/or possibility of any of a number of other precipitating factors.

Pericarditis 40

Pericarditis Tachycardia Ultrasound Blood Pressure 40

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

NOTE #3: In the context of a long QTc or ischemia — the finding of ST segment and/or T wave alternans may predict the occurrence of malignant ventricular arrhythmias.

Tachycardia 52

Tachycardia Heart Disease Dysrhythmia Ablation 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. Patients with such conditions that may transiently mimic the ECG findings of a Brugada-1 pattern are said to have Brugada Phenocopy.

Arrhythmia 52

Arrhythmia Blog Chest Pain Cardiac Arrest 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

It is apparently fortunate that she had a cardiac arrest; otherwise, her ECG would have been ignored. Then they did an MRI: Patient underwent cardiac MRI on 10/4 that showed mildly reduced BiV systolic function. She was defibrillated and resuscitated. Smith: this ECG and clinical presentation is diagnostic of LAD Occlusion.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury. Any of these entities may result in myocardial “ stunning ” ( ie, transient marked reduction in cardiac contractility, that occurs in response to a major acute insult ).

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Ken Grauer, MD

JUNE 27, 2024

He developed cardiac arrest shortly after the ECG in Figure-1 was recorded. Acute myocardial ischemia. Cardiac Sarcoidosis. Primary Cardiac Tumors and/or Cardiac Metastasis. C ASE C onclusion: As noted above — today's patient developed cardiac arrest shortly after arrival in the ED.

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Blog Cardiac Arrest Sudden Cardiac Death Tachycardia 160

Dr. Smith's ECG Blog

OCTOBER 20, 2013

This ECG is diagnostic of diffuse subendocardial ischemia. What is the utility of a head CT in cardiac arrest? We found intracranial hemorrhage in 2% of non-traumatic cardiac arrest patients, and in 4 others the presence of cerebral edema changed management. We studied this and published the abstract below in 2010.

Cardiac Arrest 52

Cardiac Arrest STEMI Hemorrhage Hospital 52