Dr. Smith's ECG Blog

OCTOBER 28, 2013

STE limited to aVR is due to diffuse subendocardial ischemia, but what of STE in both aVR and V1? The additional ST Elevation in V1 is not usually seen with diffuse subendocardial ischemia, and suggests that something else, like STEMI from LAD occlusion, could be present. Was this: 1) ACS with ischemia and spontaneous reperfusion?

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Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

He was admitted to the hospital for evaluation of these symptoms — but no ECG was done at that time. The patient’s angiogram should have been expedited, but the EKG change was not recognized as recurrence of transmural ischemia. RAO Caudal View Post PCI This is the RAO Caudal view after thrombectomy and stent placement.

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Ken Grauer, MD

AUGUST 26, 2023

About 20 minutes later ( on the way to the hospital ) — the patient's CP resolved, and ECG #1 was recorded. That the "culprit" artery spontaneously opened ~20 minutes later while the EMS unit was en route to the hospital ( at which time the patient's CP had resolved — and ECG #1 was obtained ).

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Dr. Smith's ECG Blog

JUNE 11, 2021

Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes. So the RCA was stented.

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Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

IntroductionDelirium is an acute cognitive or perceptual disturbance that is associated with prolonged hospital and ICU length of stay, therefore, extending recovery time. This is secondary to delayed postoperative cerebral ischemia and infarction caused by vasospasm.7

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Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. It was opened and stented. Data from stress testing proves that the ST depression of ischemia does not localize.

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Dr. Smith's ECG Blog

AUGUST 11, 2024

Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. Cath lab was activated, and found a 95% proximal LAD occlusion which was stented. Figure-1: I've put together the 2 pre-hospital ECGs in today's case — which focus on the initial rhythm. (

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Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls. It was stented.

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EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital.

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Dr. Smith's ECG Blog

JULY 11, 2018

He did, found the true culprit, and went back in to stent it. Figure-1: Initial ECG, obtained pre-hospital from this 40-ish year old woman with new-onset chest pain ( See text ). Figure-2: TOP — Initial ECG obtained pre-hospital. See P.S. below ) == P.S. : I believe I found another example of ischemia-induced J waves ( See Oct.

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EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. Upon hospital arrival, the patient verbalized slight attenuation of pain. He was rushed to the Cath Lab where an LAD culprit lesion was stented.

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Dr. Smith's ECG Blog

JULY 31, 2018

Post by Smith, with short article by Angie Lobo ( [link] ), a third year intermal medicine resident at Abbott Northwestern Hospital Case A 30-something woman with no past history, who is very fit and athletic, presented with 1.5 It was late evening and the patient will be in the hospital overnight with a potentially very unstable LAD lesion.

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Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

Troponin profile The patient underwent angiography and had a 90% thrombotic proximal LAD lesion that was stented. This patient's ischemia was so brief that it did not cause any myocardial stunning. This patient's ischemia was so brief that it did not cause any myocardial stunning.

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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. Interestingly, in further review of the chart it seems the patient was admitted to the hospital floor 3 weeks prior for an unrelated surgical procedure. The T-waves here are not upright or particularly large.

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Dr. Smith's ECG Blog

FEBRUARY 6, 2023

The ECG was incorrectly interpreted as no signs of ischemia. Admitted to the hospital service for further evaluation and management." Artificial intelligence can be trained to recognize subtle OMI = My Comment by K EN G RAUER, MD ( 2/6 /2023 ): = The initial ECG in today's case was incorrectly interpreted as, "No signs of ischemia".

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EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. He requested transport to the hospital out of an abundance of caution, and all subsequent serial ECG’s showed no changes from Figure 1-2, shown above. Attached is the first ECG.

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Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. His initial cTnI at the receiving hospital was 27 ng/mL, and no further troponins were measured thereafter. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent.

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Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Case 4 Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04 After many hours, the decided that it was appropriate to do an angiogram and they found a distal LAD occlusion which was opened and stented. This makes it almost certain that the ST elevation on the first one is due to ischemia.

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Dr. Paddy Barrett

DECEMBER 5, 2023

The logic of stenting obstructed coronary arteries is simple. A stent unblocks the artery. Subscribe now Stenting stable coronary artery disease has not been convincingly proven to reduce the risk of future heart attacks or death 1. But coronary stenting is not the only way to reduce symptoms of angina. All is fixed.

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DAIC

APRIL 11, 2024

PCI is commonly used to open blocked arteries to treat significant myocardial ischemia , which occurs when the heart muscle does not get enough oxygenated blood. During PCI, an operator inserts a stent into a blocked artery through a catheter in the groin or arm.

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Dr. Smith's ECG Blog

JUNE 23, 2024

He was intubated in the field and sedated upon arrival at the hospital. This was interpreted by the treating clinicians as not showing any evidence of ischemia. Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. Two subsequent troponins were down trending.

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DAIC

MAY 14, 2024

The benefits of QFR guidance are supported in a recent study that showed that a QFR-guided strategy of lesion selection for PCI improved two-year clinical outcomes, including reduction in myocardial infraction and ischemia-driven revascularization, when compared with standard angiography guidance alone.2

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Stroke Journal

JANUARY 30, 2025

Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We

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Frontiers in Cardiovascular Medicine

FEBRUARY 29, 2024

In this study, we collected case data of patients who underwent cardiac major vascular surgery at our hospital to analyze the effectiveness of reoperation treatment options for type A aortic dissection and to summarize our treatment experience.

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Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

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Dr. Smith's ECG Blog

APRIL 8, 2016

This was stented. If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. I have read articles that say that patients without ischemia are at low risk of complications from hypokalemia, But it is not entirely without risk.

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Dr. Smith's ECG Blog

MARCH 9, 2017

As above, it is unclear from the history whether the patient was experiencing chest pain at the time of this ECG, but these right precordial t-wave findings were appreciated and the patient was treated with medical therapy and admitted to the hospital.

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Dr. Smith's ECG Blog

OCTOBER 2, 2021

He had been seen several weeks ago at an outside hospital for a similar issue and had been discharged home, presumably after unremarkable workup. This proves that the first one was, surprisingly, due to ischemia!! He was successfully treated with one drug eluting stent. Occurred while driving to a doctor’s appointment.

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Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Written by Pendell Meyers, edits by Steve Smith A man in his 60s with history of hypertension and MI 10 years ago, with PCI, presented to an outside hospital complaining of chest pain that started while mowing the lawn. The LAD lesion was acute and required 3 stents to restore flow. Here is his ECG on arrival: What do you think?

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Dr. Smith's ECG Blog

MARCH 11, 2016

It was treated with and dual "kissing balloons" and drug eluting stents. Here is the post stent ECG: There is greater than 50% resolution of ST elevation (all but diagnostic of successful reperfusion) and Terminal T-wave inversion (also highly suggestive of successful reperfusion). TIMI flow is 0. Door to balloon time was 51 minutes.

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EMS 12-Lead

AUGUST 14, 2022

However, upon entry into the respective hospital campus, the patient experienced restoration of pain and displayed an uncomfortable grimace. One stent was deployed with restorative TIMI-0 flow. The patient’s vital signs remained stable, and he was equally comfortable, even verbalizing that his pain had mostly resolved.

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Dr. Smith's ECG Blog

OCTOBER 7, 2019

RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. He was successfully stented. The patient never arrested during his time at the hospital and his prognosis is good. His troponin I peaked at 6.107 ng/mL. He was discharged neurologically intact and did very well.

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Dr. Anish Koka

MAY 16, 2023

There may be no better study to symbolize the dysfunction that has invaded cardiology than the VIRGO trial, a study examining the outcomes of young patients (18-55) presenting to the hospital with a heart attack. In the modern era patients who survive a cardiac event to present to the hospital generally do well. This happens.

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Dr. Smith's ECG Blog

FEBRUARY 5, 2019

distal stent patent. Setting Secondary and tertiary care hospitals in the United Kingdom and United States. Given our concern about possible subtle high-lateral OMI — this raises the question whether the upright T waves in leads V1 and V2 of this 1st ECG might be abnormal and reflect ischemia. The cath lab was activated.

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Dr. Smith's ECG Blog

OCTOBER 31, 2024

He works in a small hospital in Northern Michigan. The patient was transferred to a hospital with PCI capability. Here is the circumflex after stenting: Wide open The cardiologist called Dr. Lufkin back and said "Great call!!" This case was sent by an old residency friend, Kirk Lufkin. Case A 61 year old female.

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Dr. Smith's ECG Blog

MARCH 25, 2025

There is low voltage in the precordium which always makes reading ischemia harder. In ACS, chest pain is the warning sign of ongoing ischemia. Smith : As Willy says, and as we've said many times before, morphine will resolve pain without resolving ischemia. ECG 1 What do you think? To me, this ECG is not diagnostic.

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Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. He had a 100% RCA occlusion which was stented.

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