Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. A transthoracic echocardiogram showed an LV EF of less than 15%, critically severe aortic stenosis , severe LVH , and a small LV cavity. Look at the aortic outflow tract. What do you see?

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Ischemia Cardiogenic Shock Aortic Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." No prior echocardiogram was available for comparison. Can you diagnose an ACO (STEMI) when you also have LVH?

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STEMI Myocardial Infarction Chest Pain Aneurysm 52

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

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STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. But it could be anterior STEMI. 40% of anterior STEMI has upward concavity in all of leads V2-V6. is likely anterior STEMI).

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STEMI Pericarditis Hospital Aneurysm 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.

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Chest Pain Ischemia Pericarditis Tachycardia 85

Dr. Smith's ECG Blog

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. Formal Echocardiogram: Normal left ventricular size and wall thickness. The patient had ROSC and maintained it. A 12-lead ECG was obtained: What do you think?

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 89

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. I have warned in the past that one must think of other etiologies of ischemia when there is tachycardia.

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STEMI Ischemia Chest Pain Myocardial Infarction 52

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.

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Cardiac Arrest Ischemia Stenosis STEMI 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

A rapid echocardiogram was performed, revealing an ejection fraction of 20% with thinning of the anterior-apical walls. Learning Point: Concordant ST segment elevation can arise from profound ischemia triggered by ventricular tachycardia (VT), or it may represent an exaggerated basal ST change accompanying tachycardia.

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Tachycardia Blog Ischemia Heart Failure 97

Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio greater than 0.36, then it is STEMI, not LV aneurysm. Is this a transient STEMI? Is it normal ST elevation?

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STEMI Ischemia Chest Pain Aneurysm 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

Does this mean that the ST depression in V3 represents "anterior" subendocardial ischemia, and not posterior OMI? Echocardiogram: The estimated left ventricular ejection fraction is 34% Regional wall motion abnormality-lateral, akinetic. non-occlusive ischemia) 2. Thus, they have much less voltage. They have ZERO ST Elevation.

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Chest Pain Blog Ischemia STEMI 52

Dr. Smith's ECG Blog

MARCH 9, 2013

Here is the prehospital ECG, with pain:  Hyperacute anterolateral STEMI  The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering. A stent was placed. Lessons: 1.

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Myocardial Infarction Chest Pain Ischemia Angina 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

EKG initially negative but repeat shows a few T wave abnormalities… There is a chance this could be non-cardiac pain” At 1518, an echocardiogram showed normal LV size and systolic function with hypokinesis of the mid and distal anterior wall and the mid and distal septum. At 1605, another repeat troponin resulted at 5.271 ng/mL.

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Chest Pain Blog Hospital Tachycardia 108

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! He underwent formal echocardiogram several days later, which confirmed the findings of anterior, and apical wall motion abnormalities. Smith comment: this patient might have been sent home because of the poor sensitivity of this Point of Care (POC) assay. Chapman, A.

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Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Here is the cath report: Echocardiogram: There is severe hypokinesis of entire LV apex and apical segment of all the walls. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. From Gue at al.

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Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. A recent study found that SCAD causes almost 20% of STEMI in young women. Lobo et al.

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Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. These are reperfusion T-waves (the same thing as Wellens' waves) Echocardiogram Regional wall motion abnormality-distal septum and apex. Again, cath lab was not activated.

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SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Next day echocardiogram showed inferolateral hypokinesia with an EF of %45-50. On echocardiogram you will not see a "posterior" hypokinesia (will see "inferolateral") and, as in this case, LCx may not give the blood supply of basal inferior segment (formerly called "posterior"). The patient recovered well. J Am Heart Assoc. 121.022866.

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Myocardial Infarction Chest Pain Blog Echocardiogram 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

They recorded a prehospital ECG and diagnosed STEMI and activated the cath lab prehospital. Next day, a stress echo was done: The exercise stress echocardiogram is normal. This ST-T wave appearance in the lateral chest leads of ECG #2 is consistent with L V “ S train” vs ischemia. No wall motion abnormality at rest.

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Chest Pain Ischemia Angina Electrocardiogram 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. Formal echocardiogram showed normal EF, no wall motion abnormalities, no pericardial effusion. So maybe she is better than I am. No more troponins were done.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 70

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 ). I think a good start would be a posterior EKG and a high quality contrast echocardiogram read by an expert. In there ECG evidence of possible ongoing ischemia? (ie,

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Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

2 days later This is a typical LVH pattern, without ischemia Patient underwent 4 vessel CABG. After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time."

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. Unfortunately there is no echocardiogram accessible because the patient checked himself out of the hospital in order to get back to his home state before it could be completed. No significant changes, ongoing pain.

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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