Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case presented in cardiogenic shock from proximal LAD occlusion, in conjunction with a subtotally stenosed LMCA. 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. (

Arrhythmia 112

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 112

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

APRIL 24, 2020

Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Subendocardial ischemia results in ST depression, but unfortunately, and rather mysteriously, it does not localize to the ischemic wall. Similarly, STD in aVL is usually reciprocal to inferior ST elevation, not "lateral ischemia."

Ischemia 52

Ischemia Chest Pain Stenosis Cardiogenic Shock 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). The patient arrived to the ED in cardiogenic shock but awake.

Cardiogenic Shock 52

Cardiogenic Shock Chest Pain Tachycardia Ischemia 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 Coronary Artery Disease 52

Dr. Smith's ECG Blog

AUGUST 28, 2020

Now appears to be in cardiogenic shock." This is ischemia until proven otherwise. However, cardiogenic shock usually takes some time to develop, so it is probably subacute." Cardiogenic shock and ACS is an indication for the cath lab, even if you don't think there is OMI. I was texted these ECGs.

Cardiogenic Shock 52

Cardiogenic Shock Chest Pain Ischemia Stenosis 52

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. The patient is started on epinephrine infusion for cardiogenic shock and cardiology took the patient to the cath lab. 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

OCTOBER 8, 2023

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. The patient died of cardiogenic shock within 24 hours despite mechanical circulatory support. There are also J-waves.

Ischemia 108

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 108

Dr. Smith's ECG Blog

OCTOBER 26, 2010

ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. Then ACS (STEMI) might be primary; this might be cardiogenic shock. Even if this ECG is the first thing one sees (as it was for me), one should stop and think: "This is an unusual STEMI." Are the lungs clear? Is the patient cool and pale?

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 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. But by this time the patient went into cardiogenic shock and passed away.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

DAIC

FEBRUARY 29, 2024

ET Main Tent (Hall B1) This session offers more insights from key clinical trials presented at ACC.24 24 and find out what it all means for your patients.

Aortic valve 103

Aortic valve Myocardial Infarction Aortic Blood Pressure 103

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

DISCUSSION: The 12-lead EKG EMS initially obtained for this patient showed severe ischemia, with profound "infero-lateral" ST depression and reciprocal ST elevation in lead aVR. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology.

Ischemia 52

Ischemia Cardiogenic Shock Aortic Stenosis 52

DAIC

MARCH 25, 2024

Session 510) To Treat or Not to Treat Anatomy and Ischemia? (Session 508) Battle of the Imagers - Jeopardy Edition! Session 509) Who Wants to Be a Millionaire in Eradicating Vascular Medicine Disparities?

Education 59

Education Cardiogenic Shock Heart Failure Plaque 59

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Why is the patient in shock? He was in profound cardiogenic shock. RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1.

Bradycardia 52

Bradycardia Cardiogenic Shock STEMI Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

There is normal R-wave progression in the precordial leads with no evidence of ischemia. Here the image quality is enhanced using the PM Cardio app. What do you think? The presenting ECG shows SR with narrow QRS complexes. In the limb leads there is T-wave inversion in lead aVL with a low amplitude QRS preceding the T-wave.

Pulmonary 96

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 96

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Assessment was severe sudden cardiogenic shock. Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury. Clinically — the patient was felt to be in cardiogenic shock. They recorded an EC G: New ST Elevation.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

MAY 3, 2024

When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI). Today's patient did make it to the hospital — but was in cardiogenic shock, and despite valiant attempt at treatment, succumbed soon after.

Cardiogenic Shock 113

Cardiogenic Shock Cardiac Arrest Hospital Ischemia 113

Dr. Smith's ECG Blog

OCTOBER 6, 2023

All of this appears to be consistent with "No Reflow", or small vessel occlusion with persistent ischemia in spite of an open artery. His included cardiogenic shock, V Tach, AV block. --There is persistent ST elevation in leads V1-V4, with a lot of STE in V4 (another bad sign). Such large infarcts have many complications.

Aneurysm 69

Aneurysm Chest Pain Cardiogenic Shock Blog 69

Dr. Smith's ECG Blog

MAY 8, 2023

Impella (cardiac output augmentation device) placed for cardiogenic shock Unfortunately, the patient progressed to multiorgan failure with worsening cardiac output despite being maxed on pressors and a balloon pump. EKG shown here: LAFB with no clear signs of OMI or ischemia. He expired 4 days later. No labs were performed.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

MARCH 30, 2014

Then the notes mention "cardiogenic shock" but without any reference to a cardiac echo or to a chest x-ray. This is the etiology of the syncope and hypotension and shock and elevated CVP. Furthermore, there are T-wave changes in V2 and V3 which are highly suggestive of ischemia, but difficult to localize: anterior?

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

The patient went into cardiogenic shock and ultimately died of this MI. Given our concern about possible subtle high-lateral OMI — this raises the question whether the upright T waves in leads V1 and V2 of this 1st ECG might be abnormal and reflect ischemia. Regional WMA: Lateral , large, hypokinetic.

Myocardial Infarction 52

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI 52