Embolism, Ischemia and Pulmonary - Cardiovascular Update

A man in his 50s with shortness of breath

Dr. Smith's ECG Blog

MARCH 26, 2024

There is also STE in lead III with reciprocal depression in aVL and I, as well as some subendocardial ischemia pattern with STD in V5-V6 and STE in aVR. Aslanger's is a combination of acute inferior OMI plus subendocardial ischemia, and due to the ischemia vectors , it has STE only in lead III. Moreover, there is tachycardia.

Chest Pain

Chest Pain Embolism Pulmonary Ischemia

Elder Male with Syncope

EMS 12-Lead

APRIL 9, 2024

Many of the changes seen are reminiscent of LVH with “strain,” and downstream Echo may very well corroborate such a suspicion, but since the ECG isn’t the best tool for definitively establishing the presence of LVH, we must favor a subendocardial ischemia pattern, instead. The CXR demonstrated no pulmonary edema. Type I ischemia.

Ischemia

Ischemia Stenosis Chest Pain Coronary Artery Disease

ECG Cases 43 – ECG Interpretation in Shortness of Breath

ECG Cases

JUNE 6, 2023

We discover that for STEMI/OMI vs subendocardial ischemia, we should look for STEMI(-)OMI, subacute OMI, and OMI in the presence of LBBB and RBBB, and consider the differential for diffuse ST depression with reciprocal ST elevation in aVR.

STEMI

STEMI Pulmonary Blog Ischemia

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

Dr. Smith's ECG Blog

OCTOBER 10, 2022

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.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

Syncope, Shock, AV block, Large RV, "Anterior" ST Elevation.

Dr. Smith's ECG Blog

DECEMBER 15, 2015

There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. It makes pulmonary embolism (PE) very likely. The small LV implies very low LV filling pressures, which implies low pulmonary venous pressure. Possible, but huge pulmonary embolism is more likely.

STEMI

STEMI Embolism Pulmonary Ultrasound

50 yo with V fib has ROSC, then these 2 successive ECGs: what is the infarct artery?

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This usually represents posterior OMI, but in tachycardia and especially after cardiac arrest, this could simply be demand ischemia, residual subendocardial ischemia due to the low flow state of the cardiac arrest. This rules out subendocardial ischemia and is diagnostic of posterior OMI. V4-5 continue to show STD.

Cardiac Arrest

Cardiac Arrest STEMI Ischemia SCAD

RBBB with dynamic T-waves

Dr. Smith's ECG Blog

APRIL 27, 2012

He had a history of pulmonary embolism but was no longer on coumadin and states the pain is different. Here are V1-V3 from the last 3 ECGs: It is now clear that there is cardiac ischemia. 56 y/o male who presented with 12/10 severe chest pain starting at 3AM, radiating to his upper back. Wraparound? It was negative.

Chest Pain

Chest Pain Embolism Ischemia Pulmonary

Chest pain and LBBB. LBBB resolves and there is V1-V3 T-wave inversion.

Dr. Smith's ECG Blog

JUNE 11, 2011

After resolution, there was T-wave inversion in V1-V3, highly suggestive of ischemia. There are features of the T-wave inversion, however, which argue against ischemia. Also, anterior ischemia is unlikely to spare lead V4 as in this case. This phenomenon is poorly understood, but involves "transient electrical remodeling."

Chest Pain

Chest Pain Ischemia STEMI Tachycardia

Are there hyperacute T-waves? And how can we know?

Dr. Smith's ECG Blog

DECEMBER 6, 2024

Watch what happends as the heart recovers from its episode of ischemia. The ECG shows inferior ischemia. By itself seeing this ECG pattern does not necessarily mean that the patient has a pulmonary embolism. Are the T-waves in leads I and II hyperacute? Hard to tell. How can we know? By the evolution of the ECG!

Coronary Artery Bypass Graft

Coronary Artery Bypass Graft Ischemia Stenosis Chest Pain

What can you find with continuous ST monitoring in the ED?

Dr. Smith's ECG Blog

DECEMBER 3, 2024

His initial high sensitivity troponin I returned at 1300 ng/L and given that his cardiac workup was otherwise unremarkable, a CT was obtained to evaluate for pulmonary embolism and aortic aneurysm or dissection but this too was unrevealing. Also: electrical instability, pulmonary edema, or hypotension.

Catheterization Laboratory

Catheterization Laboratory STEMI Blog Ischemia

What does the ECG show in this patient with chest pain, hypotension, dyspnea, and hypoxemia?

Dr. Smith's ECG Blog

AUGUST 14, 2023

The bedside echo showed a large RV (Does this mean there is a pulmonary embolism as the etiology?) The flutter waves can conceal or mimic ischemic repolarization findings, but here I don't see any obvious findings of OMI or subendocardial ischemia. Obviously he has multiple reasons to have pulmonary hypertension.

Chest Pain

Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter

Understanding an Enlarged Heart (Cardiomegaly): Causes, Symptoms, and Treatment

MIBHS

OCTOBER 31, 2024

This may result in ischemia (lack of oxygen to the heart muscle), causing parts of the heart to weaken and enlarge. Chronic Pulmonary Disease Lung diseases like chronic obstructive pulmonary disease (COPD) can lead to pulmonary hypertension, which in turn can cause the right side of the heart to enlarge, a condition known as cor pulmonale.

Blood Pressure

Blood Pressure Blood Clot Heart Valves Heart Rhythm

A 60-something with Syncope, LVH, and convex ST Elevation

Dr. Smith's ECG Blog

APRIL 26, 2017

Low LV filling pressures are due to several etiologies, most commonly due to volume depletion (dehydration or hemorrhage), but also due to other etiologies including, but not limited to: mitral stenosis, pulmonary hypertension (chronic, or due to pulmonary embolism), or poor RV performance.

Chest Pain

Chest Pain STEMI Ultrasound Pulmonary

Off and on chest pain for 24 hours in a 50s year old man

Dr. Smith's ECG Blog

APRIL 9, 2023

remain hypo- or akinetic for some time even if not infarcted, just due to the profound ischemia incurred during the occlusive phase. Thus, an acute wall motion abnormality is not a sign of active or persistent ischemia, and thus is not necessarily an indication for emergent cath. Even many NOMI have wall motion abnormalities.

Chest Pain

Chest Pain Ischemia Stenosis Pulmonary

Brugada Syndrome: Diagnosis and Risk Stratification

All About Cardiovascular System and Disorders

OCTOBER 26, 2023

They include myocardial ischemia, acute pericarditis, pulmonary embolism, external compression due to mass over the right ventricular outflow tract region, and metabolic disorders like hyper or hypokalemia and hypercalcemia. According to a recent systematic review and meta-analysis, spontaneous type 1 ECG had 2.4%

Sudden Cardiac Death

Sudden Cardiac Death Atrial Fibrillation Electrophysiology Arrhythmia

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Dr. Smith's ECG Blog

JANUARY 9, 2023

CT angiogram chest: no aortic dissection or pulmonary embolism. Serial chest xrays: progressive bilateral pulmonary edema. He spent several days in the PICU, undergoing workup including: Serial troponins: rising from 5,700 ng/L (unknown if I or T) to greater than 25,000 ng/L (greater than the lab's upper limit of reporting).

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

and the patient was converted to veno-venous (V-V) ECMO due to persistent pulmonary insufficiency. Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury. He remained supported on an intraaortic balloon pump.

Cardiac Arrest

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock

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

Dr. Smith's ECG Blog

APRIL 8, 2015

Evidence of acute ischemia (may be subtle) vii. Of the 67 patients who underwent targeted tests, suspected diagnoses were confirmed in 49 (73%) patients: aortic stenosis (n = 8, 1%), pulmonary embolism (n = 8, 1%), seizures/stroke (n = 30, 5%), and other diseases (n = 3). Left BBB vi. Pathologic Q-waves viii. LVH or RV d.

Arrhythmia

Arrhythmia Outcomes Risk Factors Chest Pain

A woman in her 40s with acute chest pain and shortness of breath

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

Smith : This is classic for pulmonary embolism (PE). Acute pulmonary embolism was confirmed on CT angiogram: The patient did well. Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis Answer: pulmonary embolism. Vitals were within normal limits. Now another, with ultrasound.

Chest Pain

Chest Pain Embolism Pulmonary Tachycardia

A man in his 50s with shortness of breath

Elder Male with Syncope

ECG Cases 43 – ECG Interpretation in Shortness of Breath

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

Syncope, Shock, AV block, Large RV, "Anterior" ST Elevation.

50 yo with V fib has ROSC, then these 2 successive ECGs: what is the infarct artery?

RBBB with dynamic T-waves

Chest pain and LBBB. LBBB resolves and there is V1-V3 T-wave inversion.

Are there hyperacute T-waves? And how can we know?

What can you find with continuous ST monitoring in the ED?

What does the ECG show in this patient with chest pain, hypotension, dyspnea, and hypoxemia?

Understanding an Enlarged Heart (Cardiomegaly): Causes, Symptoms, and Treatment

A 60-something with Syncope, LVH, and convex ST Elevation

Off and on chest pain for 24 hours in a 50s year old man

Brugada Syndrome: Diagnosis and Risk Stratification

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Extreme shock and cardiac arrest in COVID patient

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

A woman in her 40s with acute chest pain and shortness of breath

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