Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

It shows sinus tachycardia with right bundle branch block. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). In patients with narrow QRS ( not this patient), this pattern is highly suggestive of acute pulmonary embolism. Both were wrong.

Cardiogenic Shock 128

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

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 69

Chest Pain Embolism Pulmonary Ischemia 69

Dr. Smith's ECG Blog

JANUARY 8, 2024

Smith interpretation: This is highly likely to be due to extreme right heart strain and is nearly diagnostic of pulmonary embolism. It is of course pulmonary embolism. KEY Findings in ECG #1 include the following: Sinus tachycardia at ~110/minute. Junctional tachycardia? ).

Chest Pain 71

Chest Pain Pulmonary Embolism STEMI 71

Dr. Smith's ECG Blog

NOVEMBER 17, 2023

Ken (below) is appropriately worried about pulmonary embolism from the ECG. A Closer LOOK at the ECG in Figure-1: The ECG in Figure-1 shows sinus tachycardia — with QRS widening due to complete RBBB. It is of an elderly woman who complained of shortness of breath and had a recent stent placed. What do you think?

Aneurysm 124

Aneurysm Stents Stent Chest Pain 124

EMS 12-Lead

APRIL 9, 2024

An increase in myocardial oxygen demand due to tachycardia, elevated ventricular afterload (BP or Aortic stenosis), increased wall stretch, or a decrease in oxygen supply due to hypotension, anemia, hypoxia, sepsis, or a combination of all of the above. This latter part has been implicated in embolic CVA. Type II ischemia.

Ischemia 116

Ischemia Stenosis Chest Pain Coronary Artery Disease 116

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Smith comment: before reading anything else, this case screamed pulmonary embolism to me. CT chest showed left sided pulmonary embolism and a pulmonary infarct that had previously been mistaken for pneumonia. Instead, he was diagnosed with pneumonia — that turned out to be a left-sided pulmonary embolism that was initially missed.

Chest Pain 73

Chest Pain STEMI Pulmonary Embolism 73

Dr. Smith's ECG Blog

MARCH 4, 2023

The ECG is rather classic for pulmonary embolism, and indeed this was a large acute PE. This one is far more specific, as it is combined with sinus tachycardia and some T-wave inversion in V1-V3. and tachycardia, 1.8. this is highly suggestive of pulmonary embolism. This is a classic S1Q3T3. Most S1Q3T3 is not due to PE.

Chest Pain 52

Chest Pain Embolism Tachycardia Pulmonary 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

The morphology of V2-V4 is very specific in my experience for acute right heart strain (which has many potential etiologies, but none more common and important in EM than acute pulmonary embolism). CT angiogram showed extensive saddle pulmonary embolism. He had multiple cardiac arrests with ROSC regained each time. This is a quiz.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Journal of the American Heart Association

MARCH 7, 2025

Genetic testing for hypertrophic cardiomyopathyassociated genes was performed in 72 patients.ResultsAmong the patients, 60 were classified as pureapical form, and 51 were classified as distaldominant form.

Cardiomyopathy 40

Cardiomyopathy Embolism Heart Failure Tachycardia 40

Dr. Smith's ECG Blog

MARCH 12, 2018

Notice I did not say "pulmonary embolism," because any form of severe acute right heart strain may produce this ECG. Differences of Pulmonary Embolism T-waves from Wellens' T-waves: 1. Acute coronary occlusion (especially during reperfusion) is very rarely accompanied by tachycardia. What is the answer?

Chest Pain 40

Chest Pain Pulmonary Embolism Tachycardia 40

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 prompted cath lab activation. On arrival to the ED, this ECG was recorded: What do you think?

Cardiac Arrest 110

Cardiac Arrest STEMI Ischemia SCAD 110

Dr. Smith's ECG Blog

JUNE 11, 2011

Whenever you see tachycardia with bundle branch block, you should suspect that it is rate related BBB. First, as I have pointed out in posts on pulmonary embolism (see links), T-wave inversion of anterior infarction (Wellens' syndrome) almost always has an upright T-wave in lead III. Moreover, and importantly, there was sinus tach.

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Tachycardia (or nearly) 2. And some similar ECGs from Pulmonary Embolism: A young woman with altered mental status and hypotension An elderly woman transferred to you for chest pain, shortness of breath, and positive troponin - does she need the cath lab now? Tachycardia, = 1.8. Poor R-wave progression 4. Kosuge et al.

Chest Pain 52

Chest Pain Pulmonary Tachycardia Embolism 52

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?) When you suspect pulmonary embolism due to large RV on POCUS, always look for right axis deviation and a large R-wave in V1 because the large RV may be entirely due to chronic RVH, not acute PE. Here is his triage ECG: What do you think?

Chest Pain 52

Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

JANUARY 15, 2024

We can see enough to make out that the rhythm is sinus tachycardia. Tachycardia is unusual for OMI, unless the patient is in cardiogenic shock (or getting close). A bedside ultrasound should be done to assess volume and other etiologies of tachycardia, but if no cause of type 2 MI is found, the cath lab should be activated NOW.

Chest Pain 64

Chest Pain Blog Arrhythmia Critical Care 64

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. These are the conditions which have to be considered or excluded as they can sometimes manifest Brugada pattern on ECG.

Sudden Cardiac Death 52

Sudden Cardiac Death Atrial Fibrillation Electrophysiology Arrhythmia 52

Dr. Smith's ECG Blog

DECEMBER 14, 2016

The patient had no hypertension, no tachycardia, a normal hemoglobin, no drug use, no hypotension/shock, no murmur of aortic stenosis. The patient had been on a long drive, suggesting possible pulmonary embolism (this was unlikely given absence of tachyardia, hypoxia, or any other feature of PE), so we sent a d dimer.

Chest Pain 52

Chest Pain STEMI Aortic Pulmonary 52

Dr. Smith's ECG Blog

MAY 10, 2023

If there are T-wave inversions and elevated trops in the context of persistent pain, think of other pathologies such as pulmonary embolism. That said, against acute PE — is the inconstancy of this patient's symptoms — the lack of tachycardia — and the lack of any other ECG signs of acute RV strain.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Clinically — despite an initial 2-fold increased troponin, the normal bedside Echo was reassuring against OMI or pulmonary embolism. This sinus tachycardia ( at ~130/minute ) — is consistent with the patient’s worsening clinical condition, with development of cardiogenic shock.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Patients with pulmonary embolism or aortic dissection who have normal variant ST elevation are at high risk of being diagnosed with pericarditis when what they have is far more serious!! The vast majority of cases with chest pain diffuse ST Elevation are due to Normal Variant ST Elevation, NOT to pericarditis.

Pericarditis 52

Pericarditis Chest Pain Aortic Blog 52

Dr. Smith's ECG Blog

APRIL 8, 2015

If the patient has Abnormal Vital Signs (fever, hypotension, tachycardia, or tachypnea, or hypoxemia), then these are the primary issue to address, as there is ongoing pathology which must be identified. Serious outcomes included death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage.

Arrhythmia 52

Arrhythmia Outcomes Risk Factors Chest Pain 52

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. See our other acute right heart strain / pulmonary embolism cases: A man in his 50s with shortness of breath Another deadly triage ECG missed, and the waiting patient leaves before being seen.

Chest Pain 113

Chest Pain Embolism Pulmonary Tachycardia 113

Dr. Smith's ECG Blog

MARCH 8, 2025

Third, a slow motion segment showing delayed, brisk filling of the PDA due to dislodgment of a thrombus from contrast injection and distal embolization. A distal RCA lesion ( blue arrow ), Delayed brisk filling of an initially occluded PDA due to a thrombus dislodged during injection which embolized distally.

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75