Dr. Smith's ECG Blog

OCTOBER 23, 2023

Alternation in ST segment appearance ( or in the amount of ST elevation or depression ) — is often linked to ischemia. Repolarization Alternans — entails beat-to-beat variation in the ST segment and/or T wave. Conduction and Refractoriness Alternans — entails variance of impulse propagation along some par t of the conduction system.

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All About Cardiovascular System and Disorders

APRIL 23, 2024

ECG is recorded periodically during the test in addition to documenting any specific events like arrhythmias. The recording in early phase of recovery at 1 minute, shows very little ST segment depression, making us suspect further whether the earlier recording was really due to myocardial ischemia.

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Stroke Journal

JANUARY 30, 2025

Collateral status is a well-documented marker of reperfusion and mortality in patients with large vessel occlusion (LVO) anterior circulation strokes, which account for approximately one-third of AIS. Modified Treatment in Cerebral Ischemia (mTICI) score was used to determine reperfusion status, with mTICI > 2b considered successful.

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Dr. Smith's ECG Blog

MARCH 22, 2024

The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible. Back to the assessment of ischemia: Returning to the ECG, the leads that catch my eye first are -- I, II, V4, V5, V6. Ischemia can be disguised by a wide escape rhythm, which decreases the sensitivity of ECG.

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Dr. Smith's ECG Blog

NOVEMBER 15, 2013

The ECG in the chart was read as "no obvious ST changes," (even though no previous ECG was available) and the formal read by the emergency physicians was: "ST deviation and moderated T-wave abnormality, consider lateral ischemia." It is well documented with continuous 12-lead monitoring that acute re-occlusion is frequently asymptomatic.

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Dr. Smith's ECG Blog

MARCH 27, 2025

But it was interpreted as no acute ischemia and the patient was referred to cardiology as Non-STEMI. But clearly this 'Non-STEMI' patient with OMI would have benefited from immediate cath lab activation on arrival, when their first troponin was 11ng/L, rather than after after it rose to 12,000ng/L after 12 hours of refractory ischemia.

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All About Cardiovascular System and Disorders

APRIL 13, 2024

ST segment elevation in aVR in proximal LAD occlusion before first septal is thought to be due to transmural ischemia of the basal part of the septum. In a case reported by Shinde RS et al, coronary angiography documented total occlusion of left coronary artery and the patient underwent emergency coronary artery bypass surgery.

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All About Cardiovascular System and Disorders

MARCH 25, 2024

Pediatric exercise testing may be used for evaluation of various disorders of cardiac rhythm rather than for inducible ischemia as in adults. Ventricular arrhythmias during exercise can be documented in congenital long QT syndromes as well as in catecholaminergic polymorphic ventricular tachycardia.

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Circulation

NOVEMBER 11, 2024

Stress echocardiogram ruled out myocardial ischemia. Cases of concurrent atrial CS involvement and bi-atrial fibrosis with Left ventricular hyperenhancement are documented, but this is the first known report of isolated bi-atrial hyperenhancement on FDG-PET CT for CS.

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Dr. Smith's ECG Blog

DECEMBER 14, 2018

This was my interpretation: although most ischemic T-wave inversion is post -ischemic like Wellens, sometime active ischemia results in isolated T-wave inversion. In such cases, if there is no infarction (necrosis), when the ischemia resolves, the T-wave may normalize (in contrast to Pseudo-normalize).

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Dr. Smith's ECG Blog

OCTOBER 18, 2023

A majority (62.5%) of those presenting with ‘normal’ ECGs had the cath lab activated without any ECG being labeled ‘STEMI’ by automated interpretation – based on signs of Occlusion MI including ECG changes, regional wall motion abnormality on bedside ultrasound, or refractory ischemia. Hughes KE , Lewis SM , Katz L , Jones J. Acad Emerg Med.

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Circulation

NOVEMBER 11, 2024

The anti-angiogenic impact of neutrophil elastase clouded the understanding of the role of neutrophils in promoting neovascularization (NV) and fibrinolysis in patients with chronic limb-threatening ischemia (CLTI).

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Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." Smith : the profound persistent STE suggests either persistent occlusion or " no reflow " with persistent downstream ischemia. It makes you think you have done something for the ischemia when you have not!

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STEMI Myocardial Infarction Ischemia Academic 77

Dr. S. Venkatesan MD

DECEMBER 29, 2023

This can be simply a equivalent of HT, with no true supply side ischemia with LVF with global ST depression ) Management *More or less similar to STEMI with aggressive opening of culprit lesions with few differences. A search for the word NSTEMI in both these document drew a blank. Nothing, yes it is true. Are you surprised ?

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Dr. Smith's ECG Blog

MARCH 8, 2021

Perhaps they indicate an open artery with minimal flow and severe subendocardial ischemia, but not total subepicardial ischemia. This is the longest lasting I have ever documented a hyperacute T wave without going "up" or "down." Of course, the ECG after the cath was very much changed.

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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. SUMMARY Normal left ventricular cavity size. Normal estimated left ventricular ejection fraction.

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Dr. Smith's ECG Blog

JULY 11, 2018

His astute observation is worthy of brief discussion: Rituparna et al document a case study report, in which J waves appeared to be induced by ischemia ( Pacing Clin Electrophysiol 30(6):817-819, 2007 ). See P.S. below ) == P.S. : I believe I found another example of ischemia-induced J waves ( See Oct.

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Dr. Smith's ECG Blog

APRIL 4, 2023

Acute Q waves are a marker of severe ischemia and a predictor for delayed reperfusion. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. As cardiology documented, “possible STEMI. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion.

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Dr. Smith's ECG Blog

JUNE 30, 2023

And ECGs can change and evolve even when there is no ischemia. Smith and Meyers containing thousands of tracings with documentation of cardiac catheterization results. LEARNING POINT : 1. Morphology matters. Pattern recognition is essential. AI does a great job at this but most humans do not. This is where morphology is most critical!

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Dr. Smith's ECG Blog

JUNE 28, 2019

For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%. More likely, these T waves probably reflect ischemia of uncertain age. It was stented. Troponin I peaked at 12.1

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Dr. Smith's ECG Blog

DECEMBER 27, 2023

The pain will resolve and you will think the ischemia is gone when it is only hidden ! Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present." Smith comment: this troponin alone should be enough data to activate the cath lab, regardless of the ECG.

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Dr. Smith's ECG Blog

JUNE 4, 2019

T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH. Resolution of pain, by itself, is not reliable enough to be certain of resolution of ischemia. the ischemia has truly resolved. Circ Arrhythm Electrophysiol. 2013;6(1):76-83. One must record another ECG.

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Dr. Smith's ECG Blog

APRIL 17, 2023

His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Chest pain is documented as ongoing. Cardiologist interpretation: "Technically does not meet STEMI criteria but concerning for ischemia." QOH: "OMI High confidence". Physician interpretation: "No STEMI."

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Dr. Smith's ECG Blog

APRIL 15, 2019

But when the clinical presentation is sepsis, one must entertain the possibility that the ST elevation is due to demand ischemia, or some other process, and exacerbated by tachycardia. CLICK HERE — for the ESC/ACC/AHA/WHF 2018 Consensus Document on the 4th Universal Definition of MI, in which these concepts are discussed and illustrated.

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Dr. Smith's ECG Blog

NOVEMBER 26, 2015

Ischemic Hyperacute T waves (Tall, round, symmetric, vs the “pointy” peaked-T’s of HyperK), are often a clue to ischemia. What are some clues to help us differentiate between the two in this scenario? In STEMI, they are generally upright and large in proportion to the QRS. The T-waves here are not upright or particularly large.

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Dr. Smith's ECG Blog

FEBRUARY 16, 2019

There is no ST depression in V6, II, III, or aVF, and no significant ST elevation in aVR, all confirming that the ST vector is not consistent with diffuse subendocardial ischemia, but rather a focal ST vector pointed at the posterior wall. There is sinus rhythm with normal QRS complex and ST depression in V2-V5, maximal in V3-V4.

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Dr. Smith's ECG Blog

NOVEMBER 28, 2022

This patient was reported to have distant heart sounds but was not hypotensive and did not have JVD according to documentation. Alternation in ST segment appearance ( or in the amount of ST elevation or depression ) — is often linked to ischemia. Beck’s triad only happens all 3 together in approximately 1/3rd of patients.

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Dr. Smith's ECG Blog

JUNE 20, 2018

The medicine note documents that the patient had worsening pain with lying flat and relief with leaning forward. I know from reading your blog that you "diagnose pericarditis at your own peril", but are there any signs on that initial ECG that would make you think ischemia? There was no history of preceding viral symptoms.

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Dr. Smith's ECG Blog

MARCH 19, 2023

To realize — Assessment of ECG #1 is complicated by knowing: i ) That today’s patient has a history of documented CAD ; and , ii ) The lack o f a prior tracing for comparison at the time the initial ECG was interpreted. To EMPHASIZE: We are not told the circumstances under which ECG #2 was obtained.

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Dr. Smith's ECG Blog

JUNE 23, 2023

This likelihood of VT increases to at least 90% if the patient has documented underlying heart disease. Statistics: It's important to appreciate that statistical odds that in an unselected population of adults of a certain age — at least 80% of regular WCT rhythms without clear sign of atrial activity will turn out to be VT.

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Dr. Smith's ECG Blog

AUGUST 8, 2020

Weren't you taught that "new tall T wave in V1" is concerning for ischemia, and so this is the opposite? Weren't you taught that concave morphology favors pericarditis? There is also new flattening of the T wave in V1 compared to prior.

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Dr. Smith's ECG Blog

OCTOBER 6, 2018

If the patient had been "lucky," his symptoms from the prior day might have been due to ischemia prolonged and intense enough to result in small troponin increase. Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel: limitations of ST-segment elevation in standard and extended ECG leads.

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Journal of the American Heart Association

FEBRUARY 29, 2024

BackgroundDelayed cerebral ischemia represents a significant contributor to death and disability following aneurysmal subarachnoid hemorrhage. Journal of the American Heart Association, Ahead of Print. Our analysis included 102 eligible studies. Vasospastic events were mainly assessed through microscopy of large cerebral arteries.

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Dr. Smith's ECG Blog

JUNE 13, 2024

Her first set of vitals were documented: BP 116/57 Pulse 94bpm Respiratory rate 24/min O2 sat 90% on room air Temp 97F She had been cleaning a Jeep in the sun, and was sunburned. V1 sits over both the RV and the septum, so transmural ischemia of either one with give OMI pattern in V1 and reciprocal STD in V5 and V6. CK MB was 1.9

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Dr. Smith's ECG Blog

JULY 21, 2024

There is no definite evidence of acute ischemia. (ie, In both tracings — an exceedingly fast PMVT is documented. Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( Some residual ischemia in the infarct border might still be present.

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Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

I therefore feel it relevant to document ( in your dictation/on the medical chart ) when significant artifact potentially impairs the accuracy of your interpretation. Regarding my Systematic assessment of ECG #1: There is significant baseline artifact , as well as baseline wander.

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Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

IntroductionAcute spinal cord ischemia syndrome (ASCIS) is a rare disease that is thought to comprise roughly only 1.2% Stroke: Vascular and Interventional Neurology, Volume 3, Issue S2 , November 1, 2023. of all strokes [1, 2]. Due to the scarcity of these events, the patient outcomes are unclear.

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