Dr. Smith's ECG Blog

OCTOBER 24, 2013

Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. Ischemia on the ECG can be very subtle and is easily missed. Ischemia on the ECG can be very subtle and is easily missed. Lesson : 1.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

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.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 89

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. His response: “subendocardial ischemia. Anything more on history? POCUS will be helpful.”

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 25, 2017

911 was called and the medics recorded this ECG (unfortunately, leads V4-V6 are missing) Due to marked ST Elevation, the computer read was STEMI What do you think? See this post and associated case reports: Cardiac arrest, severe acidosis, and a bizarre ECG The patient was admitted and ruled out for acute MI by serial troponins.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

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." Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest.

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Ischemia Chest Pain Cardiac Arrest Blog 112

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 ).

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Blog Chest Pain Ischemia STEMI 99

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

DAIC

APRIL 8, 2024

The new trial, called DanGer Shock , is the first trial powered to examine whether the use of micro-axial flow pumps can improve survival in ST-elevation myocardial infarctions (STEMI, the most serious type of heart attack) that are complicated by cardiogenic shock. Overall, we have more complications, but we also save lives.”

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Heart Attack Heart attacks Cardiogenic Shock Catheterization Laboratory 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. On arrival, GCS was 13 and the patient complained of ongoing chest pain.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

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Chest Pain STEMI Myocardial Infarction Blog 86

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( The below ECG was recorded.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 113

Ken Grauer, MD

MAY 26, 2023

This ST depression appears to be maximal in leads V3-to-V5 — which could reflect acute posterior OMI ( O cclusion-based M yocardial I nfarction ) — most probably with multi -vessel disease ( ie, diffuse subendocardial ischemia suggested by the ST depression with ST elevation in aVR>V1 ). This patient has new CP — and — he is hypotensive.

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Blog Ischemia STEMI Cardiac Arrest 78

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. Anterolateral STEMI. Ischemia comes and goes.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 52

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

DECEMBER 15, 2015

There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. It was a PEA or bradyasystolic arrest , not a shockable rhythm. LV anterior STEMI does not give maximal ST elevation in V1. So this ECG is typical of right ventricular (RV) STEMI. Summary: 1.

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STEMI Embolism Pulmonary Ultrasound 52

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think? The ECG is consistent with high lateral STEMI. Called 911.

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STEMI Chest Pain Cardiac Arrest Stent 52

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. Therefore it is not a STEMI.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern). Code STEMI was activated. This is "shark fin" morphology.

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Cardiogenic Shock Chest Pain Tachycardia Ischemia 52

Ken Grauer, MD

JUNE 6, 2023

Part of the ST depression with deep T wave inversion in the lateral chest leads clearly reflects LV "strain" from the marked LVH — but despite the very large QRS amplitudes, this ST-T wave appearance looks disproportionate, suggesting at least a component of ischemia. Then there is the significant ST elevation we see in lead V1.

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Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia mimics STEMI and OMI in many distributions, but probably the most common is the Brugada morphology in V1-V2 which mimics anterior OMI for those who cannot recognize the Brugada pattern. HyperKalemia with Cardiac Arrest.

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 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.

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Tachycardia STEMI Chest Pain Ischemia 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. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

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Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). In there ECG evidence of possible ongoing ischemia? (ie, IMPRESSION: I’d interpret this tracing as consistent with LVH and/or “strain” and/or ischemia. ie , Is it more than 50-60% likely? ).

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

A repeat ECG was done: Obvious anterolateral wall STEMI. 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). This rhythm reportedly produced no palpable pulse, and CPR was continued.

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Chest Pain STEMI Defibrillator Stent 52

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. BOTTOM Line: It can at times be extremely challenging to distinguish between anterior ST elevation from a benign Brugada Phenocopy pattern vs an acute anteroseptal STEMI.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 70

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. Bicarb 20, Lactate 4.2,

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Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52