Dr. Smith's ECG Blog

JULY 21, 2024

There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( Some residual ischemia in the infarct border might still be present. Both episodes are initiated by an "R-on-T" phenomenon.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

JULY 5, 2018

We admitted him for probable EP study and possible pacemaker. He underwent pacemaker placement and is doing fine. SSS is by far the most common reason for permanent pacemaker placement. These include rate-slowing medication recent ischemia/infarction hypothyroidism sleep apnea. Learning Points: 1.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Bradycardia Pacemaker 52

Dr. Smith's ECG Blog

JANUARY 22, 2020

There was no evidence of ischemia. She had a permanent pacemaker implanted. After pacer AND conversion to sinus rhythm: Computer diagnosis: IMPRESSION ELECTRONIC VENTRICULAR PACEMAKER ABNORMAL RHYTHM ECG What is missing from this interpretation? We are not told how ischemia has been ruled out in this case. Hyperkalemia.

Pulmonary 52

Pulmonary AFIB Atrial Fibrillation Pacemaker 52

Ken Grauer, MD

OCTOBER 27, 2023

My Immediate Impression — was that this elderly woman with a several week history of symptoms would most likely leave the hospital with a pacemaker. This suggests ischemia of uncertain duration. A permanent pacemaker was placed. PEARL # 2: Interpretation of the 12-lead ECG in Figure-1 is no easy task!

Blog 103

Blog Pacemaker Bradycardia Arrhythmia 103

Dr. Smith's ECG Blog

JANUARY 1, 2024

Again, see Ken's discussion below) Discussion continued The absence of pace spikes suggests this is not a pacemaker/ICD-related rhythm in this patient with an ICD. Are the apparent P-waves (which now we suspect might not be P-waves) actually part of the QRS, in which case the QRS is even wider than it appears? Where does the QRS begin?

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. EKG shown here: LAFB with no clear signs of OMI or ischemia. Sent by Pete McKenna M.D. Triage ECG: What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

Automatic activity refers to enhanced pacemaking function (typically from a non sinus node source), for example atrial tachycardia. Possible mechanisms of ventricular arrhythmias elicited by ischemia followed by reperfusion. The most common triggered arrhythmia is Torsades de Pointes. And is there new left bundle branch block (LBBB)?

Chest Pain 107

Chest Pain Arrhythmia Myocardial Infarction STEMI 107

Dr. Smith's ECG Blog

JANUARY 23, 2024

Isoprenalin was discontinued, and a temporary transveous pacemaker was implanted. The patient stabilized following pacemaker placement. Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc).

Tachycardia 107

Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death 107

Wellnest

DECEMBER 21, 2022

Poor blood supply Ischemia, or inadequate blood supply to the heart, is an abnormality that can be detected in an ECG test. ECG testing is also carried out to see how medicines work during treatment and the pacemaker's functioning. If the vital organs do not get their blood supply back quickly, it can lead to death.

Cardiac Arrest 52

Cardiac Arrest Heart Attack Heart attacks Atrial Fibrillation 52

Dr. Smith's ECG Blog

MAY 5, 2023

My thoughts were the following: ECGs #1 and #2 showed a completely unreliable sinus pacemaker, with presumed high-grade 2nd-degree AV block — and frequent resultant pauses of over 2 seconds ( that would have been even longer had it not been for intermittent relief from the atrial escape focus ). What Does this All Mean?

Bradycardia 52

Bradycardia Cardiac Arrest Arrhythmia Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

100% occluded RCA with TIMI 0 flow Post drug-eluting stent placement with TIMI 3 flow While in the cath lab, she transiently developed complete heart block and became hypotensive requiring transvenous pacemaker placement and transient pressors. The transvenous pacemaker was removed the following day and pressors were not required again.

Chest Pain 52

Chest Pain Critical Care Article Pacemaker 52

Dr. Sanjay Gupta

MARCH 6, 2022

Some patients with pacemakers and metal prosthesis can’t be exposed to such strong magnetic fields. These are therefore not looking for coronary disease but instead ischemia heart disease. Remember functional tests tell you about ischemia and anatomical tests tell you about coronary disease.

Heart Attack 52

Heart Attack Heart attacks Heart Rhythm Exercise 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

The medics recorded the following initial ECG at time 0: The computer read (see below) gives no further comment beyond ventricular pacemaker. There is no way the ST-T wave should change from lead V4-to-V5 as we see here given the similar all negative QRS appearance in these 2 leads, unless there is acute ischemia. What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI. If you can safely and easily increase the patient's heart rate, you can convert the patient to sinus and repeat the ECG to see if the atrial repolarization wave was the cause of the concern for ischemia.

Blog 52

Blog Bradycardia Ischemia Exercise 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. It is also not a wandering pacemaker — because change in atrial pacing site is gradual with that disorder. The morphology in V2 is also concerning and it appears that the ST segment is being pushed down, as in ST depression.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

EMS 12-Lead

JUNE 20, 2022

I initially suspected V2 as being placed too high on the chest, but there is no accompanying inverted P wave here, so the positioning is sound. It’s important to stress the presence of a normal QRS (i.e.,

STEMI 52

STEMI Stents Stent Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 29, 2020

Therefore, she underwent temporary pacemaker placement and overdrive pacing at a rate of 90 bpm to keep the heart rate up in order to prevent these PVCs triggering ventricular arrhythmia. Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia. Acute ischemia?

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

DAIC

MARCH 25, 2024

Rapid Fire Challenging Structural Heart Imaging Cases with Heart Team Panel; Follow-up of Pacemakers and ICDS for the Non-electrophysiologist; The Real Reasons Your Patient with Heart Failure was Readmitted: Noncardiac Comorbidities, Geriatric Syndromes and Social Determinants of Health; and Death by a Thousand Cuts!

Education 59

Education Cardiogenic Shock Heart Failure Plaque 59

EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. He received a permanent pacemaker during the subsequent inpatient stay. Hospital transport was unremarkable.

Heart Failure 52

Heart Failure Myocardial Infarction Bradycardia Chest Pain 52

Ken Grauer, MD

JUNE 2, 2023

Ruling out other potential causes of bradycardia ( ie, recent ischemia-infarction; hypothyroidism ). I would bet that this patient will soon receive a permanent pacemaker. = Follow-Up: Our interpretation of this Holter was passed on to the patient's primary physician.

Blog 78

Blog Bradycardia Arrhythmia Tachycardia 78

Dr. Smith's ECG Blog

MARCH 15, 2023

These include: i ) Use of rate-slowing medication ( ie, ß-blockers, digoxin, verapamil/diltiazem, etc. ) ; ii ) Acute or recent infarction or ischemia; iii ) Hypothyroidism; iv ) Neurologic injury; v ) Electrolyte disturbance; and , vi ) Sleep apnea. I therefore thought the significance of this finding in today’s case was uncertain.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 52

Ken Grauer, MD

OCTOBER 4, 2024

No evidence of ischemia. Many favored pacemaker implantation at this time. Ultimately ( with completely informed patient consent ) — the decision was made to implant a pacemaker. CASE Disposition: Opinions of consulting cardiologists on this case were divided.

Blog 103

Blog Bradycardia Arrhythmia Pacemaker 103

Dr. Smith's ECG Blog

APRIL 8, 2015

Evidence of acute ischemia (may be subtle) vii. Negative predictors of adverse outcome: Pacemaker Pre-syncope or "near-syncope," but there is still some small risk (5, 18) These last two are identified in studies, but I consider them dangerous signs and symptoms in their own right, as above: 10. Left BBB vi. Pathologic Q-waves viii.

Arrhythmia 52

Arrhythmia Outcomes Risk Factors Chest Pain 52

Dr. Smith's ECG Blog

DECEMBER 20, 2024

No evidence for ischemia jumps out. How does a pacemaker accomplish RBBB morphology? Quick aside on device terminology (feel free to skip): A "single chamber" pacemaker is a device with only one lead. A "dual chamber" pacemaker is a device with an atrial lead and a ventricular lead. ECG 1 What do you think?

Chest Pain 102

Chest Pain Tachycardia Pacemaker Defibrillator 102

Ken Grauer, MD

DECEMBER 28, 2024

Unless a potentially fixable cause of this rhythm can be found ( ie, acute ischemia from recent infarction; electrolyte disturbance, use of rate-slowing medication ) the patient will need a pacemaker. This strongly suggests ischemia which could be recent and a contributing ( or precipitating) cause of todays abnormal rhythm.

Blog 169

Blog Ischemia Pacemaker 169

Ken Grauer, MD

FEBRUARY 21, 2025

PEARL # 2: Despite the challenge of assessing a ventricular rhythm for underlying ischemia and/or infarction there are primary ST-T wave changes that are seen in Figure-3 that suggest an ongoing acute event. The above said Today's patient had other ideas. He remained remarkably stable despite the above conduction disorder.

Blog 127

Blog STEMI Hospital Pacemaker 127

Dr. Smith's ECG Blog

MARCH 8, 2025

It is possible there is microvascular dysfunction producing residual transmural ischemia. But this is most common when there is prolonged ischemia, and this patient had the fastest reperfusion imaginable! Here is the final angiogram following placement of a stent in the ostial RCA. In the midst of this, she went into VF.

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75