Remove Dysrhythmia Remove Ischemia Remove Physiology
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Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

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.

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A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!

Dr. Smith's ECG Blog

We have also shown several cases in which atrial flutter hides true, active ischemia. Likewise, in some cases of ischemia concealed by flutter waves, the ischemia can be seen despite the flutter waves, whereas in other cases the dysrhythmia must be terminated before the ischemia can be clearly distinguished.

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A young woman with palpitations. What med is she on? With what medication is she non-compliant? What management?

Dr. Smith's ECG Blog

And superimposed subendocardial ischemia pattern, of course. Flecainide : This is a potentially dangerous Na channel blocker which can cause ventricular dysrhythmias including ventricular fibrillation. It simply does not make physiologic sense to suddenly see an all-negative QRS complex in this most lateral chest lead.

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A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

In terms of ischemia, there is both a signal of subendocardial ischemia (STD max in V5-V6 with reciprocal STE in aVR) AND a signal of transmural infarction of the inferior wall with Q wave and STE in lead III with reciprocal STD in I and aVL. The rhythm is atrial fibrillation. The QRS complex is within normal limits.

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Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Dr. Smith's ECG Blog

Evidence of acute ischemia (may be subtle) vii. Dysrhythmia, pacer), 4) valvular heart disease, 5) FHx sudden death, 6) volume depletion, 7) persistent abnormal vitals, 8) primary CNS event __ 3) Mendu ML et al. ST segment and T wave abnormalities consistent with or possibly related to myocardial ischemia. Left BBB vi.