Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. He later developed mild continuous chest pain, that he describes as the sensation of someone standing on his chest. They agreed ischemia was likely in the setting of demand given DKA and infection.

Chest Pain 117

Chest Pain Ischemia Echocardiogram Myocardial Infarction 117

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chest pain with diaphoresis. The ECG was incorrectly interpreted as no signs of ischemia. The Importance of the History: As noted above — the onset of chest pain in today's case was acute. His vitals were within normal limits.

Chest Pain 52

Chest Pain Physiology Blog Stents 52

Dr. Smith's ECG Blog

JUNE 11, 2011

Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion. Whenever you see tachycardia with bundle branch block, you should suspect that it is rate related BBB. After resolution, there was T-wave inversion in V1-V3, highly suggestive of ischemia. link] Shvilkin et al.

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

AUGUST 3, 2018

In the evening, a middle-aged man complained of chest pain at the nursing home. His chest pain was vague. He mentioned "cancer" and "chest". He mentioned "cancer" and "chest". There is a narrow complex tachycardia at a rate of 130. He was awake, with a pulse of 130 and BP of 50/30. Is is sinus?

Chest Pain 40

Chest Pain Tachycardia Atrial Flutter Ultrasound 40

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Sinus tachycardia has many potential causes. This is especially true for the elderly patient with sinus tachycardia. What is the cause of the sudden tachycardia? She had a very elevated troponin T at 12,335 ng/L at the time of presentation. The patient in today’s case suddenly became tachycardic while sleeping.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

MARCH 26, 2024

Here is his ECG: Original image, suboptimal quality Quality improved with PM Cardio digitization The ECG is highly suggestive of acute right heart strain, with sinus tachycardia, S1Q3T3, and T wave inversions in anterior and inferior with morphology consistent with acute right heart strain. Moreover, there is tachycardia.

Chest Pain 68

Chest Pain Embolism Pulmonary Ischemia 68

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

EMS 12-Lead

APRIL 9, 2024

There was no chest pain. V1 and V2 are probably placed too high on the chest given close morphological similarity to aVR. More detailed reviews of subendocardial ischemia, as well as acute ECG patterns that breach the typical presentation, can be found here: [link] [link] Imaging revealed no acute head, or spinal, injuries.

Ischemia 116

Ischemia Stenosis Chest Pain Coronary Artery Disease 116

Dr. Smith's ECG Blog

SEPTEMBER 17, 2021

40-something yo who is on flecainide and diltiazem had sudden onset chest pain, palpitations, shortness of breath and diaphoresis : Rate is 220. It is a regular narrow complex tachycardia. There is a lot of ST depression -- this is ischemia caused by the very fast rate and is an indication for emergent electrical cardioversion.

Atrial Flutter 52

Atrial Flutter Tachycardia Chest Pain Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 26, 2010

This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. He had this ECG recorded. Are the lungs clear?

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

AUGUST 14, 2023

Written by Pendell Meyers, with some edits by Smith A man in his 40s with many comorbidities presented to the ED with chest pain, hypotension, dyspnea, and hypoxemia. The flutter waves can conceal or mimic ischemic repolarization findings, but here I don't see any obvious findings of OMI or subendocardial ischemia.

Chest Pain 52

Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

DECEMBER 27, 2014

A male in his 60's called 911 for dizziness and chest pain, onset with exertion. Here is his initial rhythm strip (it is not a full 10 seconds): Wide complex tachycardia, rate 235 This is a very wide complex regular tachycardia at a rate of 235. It should be considered to be Ventricular Tachycardia and treated as such.

Atrial Flutter 52

Atrial Flutter Tachycardia Chest Pain Ischemia 52

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. Chest pain was resolved upon arrival in the ED. Is there ischemia? A repeat ECG had sinus rhythm at a rate of 54 and normal conduction (no LBBB), and was completely normal with no ischemia. What is it?

Chest Pain 52

Chest Pain Ischemia Dysrhythmia STEMI 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

The chest pain quickly subsided. The above ECGs show the initiation and continuation of a polymorphic ventricular tachycardia. Polymorphic ventricular tachycardia can be ischemic, catecholaminergic or related to QT prolongation. Are you worried about OMI in this case? His response was: "I would not call it OMI.

Cardiac Arrest 121

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 121

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast. The patient was given opiates which improved his chest pain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

Chest Pain 119

Chest Pain Blog Hospital Tachycardia 119

Dr. Smith's ECG Blog

JANUARY 1, 2024

Although the patient reported experiencing mild pressure-like chest pain, there was suspicion among clinicians that this might be indicative of an older change. While the initial impression might not immediately suggest ventricular tachycardia (VT), a closer examination raises suspicion. What is the rhythm?

Tachycardia 111

Tachycardia Blog Heart Failure Ischemia 111

Ken Grauer, MD

MAY 20, 2023

NOTE: It's important to correlate ongoing circumstances at the time that a prior tracing was done ( ie, Was the patient stable and asymptomatic — or were they having chest pain, an exacerbation of heart failure, or some other ongoing process at the time the prior ECG was recorded? ).

Blog 145

Blog Chest Pain Ischemia STEMI 145

Dr. Smith's ECG Blog

APRIL 15, 2019

Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. 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.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? ST depression. Myocardial Contusion?

Tachycardia 114

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 114

Dr. Smith's ECG Blog

OCTOBER 15, 2024

He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. The patient had none of these conditions. It was stented.

Chest Pain 115

Chest Pain STEMI Echocardiogram Stents 115

Dr. Smith's ECG Blog

JULY 16, 2024

This is the prehospital ECG from an 81 year old man with acute chest pain. The problem is, that the PR interval of the upright deflection in lead II ( under the RED arrows ) is relatively long ( clearly more than 1 large box in duration ) — and if anything, the PR interval should shorten when there is tachycardia. Arrhythmia?

Atrial Flutter 59

Atrial Flutter Chest Pain Tachycardia Arrhythmia 59

Circulation

NOVEMBER 11, 2024

Advanced cardiac imaging especially in atypical presentations, can aid in early diagnosis.Case:A 59 year-old man with history of biopsy-proven pulmonary sarcoidosis presented with non exertional chest pain for 2 months. Stress echocardiogram ruled out myocardial ischemia.

Chest Pain 40

Chest Pain Echocardiogram Document Ischemia 40

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Ken Grauer, MD

FEBRUARY 18, 2023

The presenting complaint was chest pain — and the patient collapsed soon after arrival in the ED. The finding of a fairly regular, wide tachycardia without clear sign of atrial activity ( especially when seen in an acutely symptomatic patient ) — should immediately prompt a diagnosis of VT until proven otherwise.

Blog 78

Blog AFIB Chest Pain STEMI 78

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia. Anything more on history? J Electrocardiol 2013;46:240-8 2.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

MARCH 11, 2019

The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." Here is the patient's troponin I profile: These were interpreted as due to demand ischemia, or type II MI. ng/mL is seldom a result of demand ischemia (type 2 MI). First was 2.9

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

EMS 12-Lead

JULY 24, 2023

But the symptoms returned with similar pattern – provoked by exertion, and alleviated with rest; except that on each occasion the chest pain was a little more intense, and the needed recovery period was longer in duration. It should be known that each category can easily manifest the generic subendocardial ischemia pattern.

Angina 52

Angina Ischemia Coronary Angiogram Stenosis 52

Dr. Smith's ECG Blog

JULY 1, 2019

Although as a general rule, there should be no ST elevation in RBBB in the absence of ischemia, there sometimes is ST elevation that looks like this. If the ECG findings are truly new compared to a baseline (unavailable), this could suggest persistent ECG findings of ischemia, meaning poor downstream perfusion ("no reflow" phenomenon).

Chest Pain 52

Chest Pain Ischemia STEMI Blog 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? In addition to sinus tachycardia, the only abnormalities listed by the computer were "low voltage, precordial leads" and "anteroseptal infarct, old.Q Physician: "No STEMI."

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

Dr. Smith's ECG Blog

JANUARY 28, 2023

Case 1 A middle aged woman presented with acute chest pain and shortness of breath, unclear time since onset, and likely with episodic symptoms off and on throughout the day. That first ECG (the one at the top) was interpreted as "no evidence of ischemia." Submitted by anonymous, written by Pendell Meyers.

STEMI 52

STEMI Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

OCTOBER 25, 2022

She reports that she is now unable to vagal out of her palpitations and is having shortness of breath and dull chest pain. We see a regular tachycardia with a narrow QRS complex and no evidence of OMI or subendocardial ischemia. Now the patient is in sinus tachycardia. Her initial EKG is below. Same as initial ECG.

Tachycardia 52

Tachycardia Atrial Flutter Dysrhythmia Ablation 52

Ken Grauer, MD

APRIL 9, 2023

No chest pain. Figure-1: The initial ECG in today's case — obtained from an 86-year old man with presyncope, but no chest pain. ( The other main consideration — is to take another look at the 12-lead ECG, and assess this for recent ischemia or infarction. How would YOU interpret the ECG in Figure-1 ?

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78

Ken Grauer, MD

JULY 15, 2023

Given the rapid rate of the tachycardia and the amorphous shape of the QRS — the decision was made to sedate the patient and cardiovert. This phenomenon may sometimes be seen following an episode of a sustained tachycardia — in which marked ST-T wave abnormalities not due to infarction may be seen for a period of hours, or even days!

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

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? It was a baseline finding in 62% of patients, usually due to LVH. Reference: Knotts RJ , Wilson JM, Kim E, Huang HD, Birnbaum Y. Hypokalemia c.

Sickle Cell Disease 52

Sickle Cell Disease Ischemia Dysrhythmia Chest Pain 52

Dr. Smith's ECG Blog

APRIL 29, 2020

A recent similar case: A 40-something with chest pain. A useful classification of WCT ( W ide- C omplex T achycardia ) rhythms — separates them into those that are mono morphic ( with similar QRS morphology during the tachycardia ) vs those that are poly morphic ( in which QRS morphology varies ). Acute ischemia?

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Ken Grauer, MD

JUNE 2, 2023

ie, with syncope-presyncope, fatigue, dyspnea, chest pain? ). Ruling out other potential causes of bradycardia ( ie, recent ischemia-infarction; hypothyroidism ). 2 short runs of SVT ( presumably atrial tachycardia ). 2 short runs of SVT ( presumably atrial tachycardia ). No pause beyond 2.0 No pause beyond 2.0

Blog 78

Blog Bradycardia Arrhythmia Tachycardia 78