Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. The patient had a history of ‘NSTEMI’ a decade prior, with an RCA stent. Does this change your interpretation?

Chest Pain 116

Chest Pain STEMI Aneurysm Stent 116

Dr. Smith's ECG Blog

AUGUST 6, 2024

This led to immediate cath lab activation — which revealed total occlusion of a large 1st diagonal branch that was stented. == Below is the ECG of Patient #3 — recorded from a 35-year old man with sudden, new-onset CP. NOTE #1: Sinus tachycardia is not usually seen in an uncomplicated acute MI.

Chest Pain 103

Chest Pain Ischemia Pericarditis Tachycardia 103

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

This is ischemic ST depression, and could be due to increasing tachycardia, with a heart rate over 130, but that is unlikely given that the patient is now complaining of crushing chest pain and that there was tachycardia all along. There is widespread ST depression. Figure-1: Comparison of the first 2 ECGs in today's case.

Chest Pain 117

Chest Pain Ischemia Echocardiogram Myocardial Infarction 117

Dr. Smith's ECG Blog

JANUARY 1, 2013

Notice there is tachycardia. I have warned in the past that one must think of other etiologies of ischemia when there is tachycardia. In this case, the patient had failed to take his atenolol in the AM and was having reflex tachycardia in addition to ACS. The OM-1 was opened and stented, then the LAD was stented 3 days later.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

An EKG was repeated around midnight: By itself, this ECG is not diagnostic of anything besides sinus tachycardia, and could be called normal (although there is ST segment straightening in the anterior leads, which should always prompt suspicion). The conventional computer algorithm called “ sinus tachycardia, otherwise normal EKG ”.

Chest Pain 119

Chest Pain Blog Hospital Tachycardia 119

Dr. Smith's ECG Blog

JUNE 17, 2017

There is sinus tachycardia. It was stented. I saw this as I was reading a large a stack of ECGs: What do you think? The T-waves are slightly peaked, suggesting hyperkalemia. But what is atypical is that the T-wave in V3 towers over the R-wave. The QTc is 462 ms. The possibility of anterior STEMI was not noticed during patient care.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Stent 52

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. He had multiple episodes of bradycardia and nonsustained ventricular tachycardia. It was stented. He wrote most of it and I (Smith) edited.

Chest Pain 115

Chest Pain STEMI Echocardiogram Stent 115

Dr. Smith's ECG Blog

JANUARY 28, 2023

Prior ECG available on file from 2 months before: We do not know the clinical events happening during this ECG, but there is borderline tachycardia, PVCs, and likely some evidence of subendocardial ischemia with small STDs maximal in V5-6/II, slight reciprocal STE in aVR. Culprit lesion was reduced to 0% and stented.

STEMI 52

STEMI Chest Pain Stent Stents 52

EMS 12-Lead

MARCH 19, 2023

He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myocardial infarction, or any prior PCI/stent. No appreciable skin pallor. He reported to be a social drinker, but used tobacco products daily. Here is the time-zero 12 Lead ECG.

Myocardial Infarction 52

Myocardial Infarction STEMI Coronary Angiogram Coronary Artery Disease 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. It was opened and stented with a door to balloon time of about 120 minutes (this is long for STEMI, but very short for a high risk Non STEMI). If it is MI, is it type 1 or type 2?

Chest Pain 52

Chest Pain STEMI Aortic Pulmonary 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Cath done around 4pm next afternoon: Acute culprit lesion: LCX 99%, TIMI 1 flow, stented Also LAD 50%, TIMI 3 flow, which was also stented And chronic RCA occlusion with collaterals (no information is in the cath report regarding where the collateral flow is from, for example if collateral flow was from the LAD or LCX).

Chest Pain 52

Chest Pain Physiology Blog Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. I find AV dissociation in VT to be very difficult to differentiate from artifact, as there are always random blips on tachycardia tracings. Read this post: Idiopathic Ventricular Tachycardias for the EM Physician 2. Initial ED ECG: What do you think?

Tachycardia 138

Tachycardia Cardiogenic Shock Angina Coronary Angiogram 138

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent. C linically — the rhythm we see in the long lead II of ECG #3 behaves similar to MAT, even though there is no tachycardia. In the available view, the RCA appears fully occluded. To our knowledge, the patient did well.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

MAY 10, 2023

INTERVENTION * Successful angioplasty and stenting (drug eluting) of the mid LAD * Successful angioplasty of the ostial 1st diagonal Learning points: 1. 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 26, 2018

2) Tachycardia to this degree can cause ST segment changes in several ways. First , there can simply be diffuse ST depressions (which obligates reciprocal STE in aVR) associated with tachycardia which are not indicative of ischemia. Serial troponin T measurements rose from zero to 2.80 ng/mL over the next 10 hours.

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

The patient was referred immediately for cath which revealed RCA occlusion that was stented. I completely agree with Dr. Nossen that in this patient with new CP and sinus tachycardia with LAHB — that the T waves in each of the inferior leads are hyperacute ( ie, clearly disproportionately "bulky" given size of the QRS in these leads ).

Ischemia 121

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 121

Dr. Smith's ECG Blog

AUGUST 10, 2023

After the episode of VT and the troponin results the patient was taken to the cath lab: complete occlusion of the RCA with TIMI 0 flow, which was stented. So now there was ACS + electrical instability, another indication for emergent angiogram. He also had 70% lesion of his LAD. Peak troponin was 16,500 ng/L.

Chest Pain 98

Chest Pain STEMI Ischemia Nursing 98

Dr. Smith's ECG Blog

APRIL 8, 2016

This was stented. See here for management of Polymorphic Ventricular Tachycardia , which includes Torsades. In multivariate analysis, serum potassium level was negatively and age positively related to ventricular tachycardia. After pacing, there was no recurrence of Torsades. The patient stabilized. mEq/L: The STE is resolved.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

EMS 12-Lead

APRIL 21, 2022

pre-existing, stable atherosclerosis) amidst any state of global duress – to include hypertension, hypoxia, tachycardia, hypotension, sepsis, and GI bleed, for example. Advanced multi-vessel disease was found with stents deployed to the mid-LCx (80% stenosis), D1 (90% stensosis), and the pLAD (95% stenosis).

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Although the shock is no doubt partly a result of poor pump function, with low stroke volume, especially of the RV, it should be compensated for by tachycardia. He was successfully stented. Cardiac output is stroke volume x rate, so this patient needs a higher heart rate. This is a perfect indication for atropine.

Bradycardia 40

Bradycardia STEMI Cardiogenic Shock Ischemia 40

Dr. Smith's ECG Blog

AUGUST 9, 2019

Here is another proven left main occlusion in a young woman who presented with sudden pulmonary edema, had this ECG recorded, then arrested and was resuscitated after 30 minutes of CPR: This has sinus tachycardia with RBBB and LAFB, and STE in V2-V6 as well as I, aVL This pattern could just as easily be seen in LAD occlusion.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

DECEMBER 27, 2024

Submitted anonymously, written by Willy Frick A man in his 70s with a history of remote MI (details unavailable) and prior stent placement presented to cardiology clinic for routine follow up. This proves AV dissociation, and by extension ventricular tachycardia. The current ECG shows sinus tachycardia with old inferior infarct.

Tachycardia 120

Tachycardia Stent Stents Arrhythmia 120

Wellnest

JULY 19, 2023

The abnormal heart rhythms can further lead to death because of ventricular tachycardia and ventricular fibrillation. A completely blocked artery is located, a wire is inserted through it, the clot is sucked, the narrowing is widened with a balloon, and then a stent (stainless steel wire mesh) is placed to maintain consistent flow.

Heart Attack 52

Heart Attack Heart attacks Blood Pressure Myocardial Infarction 52

Cardiometabolic Health Congress

JANUARY 2, 2025

August 2024 Approvals Minima Stent System (P240003) (Approval Date: August 28, 2024) The Minima Stent System is an expandable cobalt-chromium metal mesh tube to reopen blood vessels in neonates, infants, and children with Coarctation of the Aorta and Pulmonary Artery Stenosis, specifically designed to expand as younger patients grow.

Coronary Artery Disease 52

Coronary Artery Disease Stent Stents Innovation 52

Dr. Smith's ECG Blog

NOVEMBER 8, 2024

The CAG showed a 99% thrombotic lesion of the proximal RCA, which was stented. The patient in today's case was lucky to re-perfuse. He remained chest pain free and underwent coronary angiography the following day. Due to rapid spontaneous reperfusion, high sensitivity troponin I peaked at just under 5000 ng/L.

Chest Pain 100

Chest Pain Myocardial Infarction Hypertension Hospital 100

Dr. Smith's ECG Blog

JANUARY 28, 2025

The thrombus was aspirated and the distal RCA was stented. The patient waited another three hours in the ED until the cath lab was ready to accept him. 6 hours after his initial presentation, he went to the cath lab: There is a filling defect consistent with thrombus in the distal RCA. There was TIMI 2 flow distal to the thrombotic occlusion.

Chest Pain 104

Chest Pain STEMI Hospital Blood Pressure 104

Dr. Smith's ECG Blog

JANUARY 11, 2025

He had undergone stenting of the LAD several weeks ago (unclear whether elective for stable symptoms, or in response to acute coronary syndrome). It is a wide complex regular tachycardia at a rate of 120. Is it ventricular tachycardia? It is a wide complex regular tachycardia at a rate of 120. He appeared critically ill.

Cardiogenic Shock 136

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 136

Dr. Smith's ECG Blog

MARCH 8, 2025

After stent deployment, we often see improvement in the ST-T within seconds or minutes. Here is the final angiogram following placement of a stent in the ostial RCA. 2:04 PM, post stent deployment You can see that even after complete restoration of flow, the ECG still looks terrible, V most of all.

Cardiomyopathy 74

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 74