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Acute Chest pain with LBBB. What is going on?
This history and ECG were texted to me from a far away ED on a Friday night:" Very elderly make with history of coronary disease on an angiogram 1 year prior presents with 2 hours of chest pain, sternal, pressure, and mild diaphoresis. "What do you think?There is sinus tachycardia with LBBB. There is concordant ST depression (STD) in lead V2, and excessively proportionally discordant STD in all of leads V3-V6. Thus, there is one lead (V2) that meets the Sgarbossa criteria and the Smith modified criteria, and 4 other leads (V3-V6) that meet the alternative Smith modified criteria (proportionally excessively disc...
Source: Dr. Smith's ECG Blog - June 23, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
LVH and Anterior ST Elevation: is it OMI and would you activate the cath lab?
Written by Jesse McLaren (@ECGCases), with comments by Smith and Grauer A 50 year old presented with chest pain radiating to the shoulder. They had a history of an LAD stent 10 years ago and alcohol use disorder, with repeated visits for chest pain and two code STEMIs two years ago that found no occlusive disease. What do you think? There ’s normal sinus rhythm, normal intervals, normal axis, and normal R wave progression. There’s LVH with repolarization abnormalities, including discordant ST depression and T wave inversion inferolaterally and discordant ST elevation and tall T wave in V2. Are there...
Source: Dr. Smith's ECG Blog - June 20, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
ST elevation after gunshot to the chest
Conclusion: The ECG in Figure-1 would not be typical for non-traumatic acute pericarditis. However, it could be consistent with traumatic pericarditis (because ECG findings are so variable in traumatic pericarditis).NOTE: The ECG features of acute myocarditis may differ substantially from those of a " pure " pericarditis. There may be a resemblance between these 2 entities — but ST segment deviations (elevation and depression) with myocarditis may not follow the timing seen with pericarditis. In addition, Q waves may develop — so at times it may...
Source: Dr. Smith's ECG Blog - June 8, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Thin Film Electrodes for Neuro Applications: Interview with Dave Rosa, CEO of NeuroOne
NeuroOne, a medtech company based in Minnesota, has developed the Evo Cortical Electrode and the sEEG electrode, both of which are thin film electrodes for neural recording and stimulation. The small profile and flexible nature of the electrodes allo...
Source: Medgadget - June 1, 2022 Category: Medical Devices Authors: Conn Hastings Tags: Exclusive Materials Neurology Neurosurgery epilepsy N1MTC seizures Source Type: blogs
Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?
Written by Jesse McLaren, with comments by Smith and Grauer Four patients presented with cardiorespiratory symptoms, with inferior ST elevation and reciprocal change on their ECG. Which patient had occlusion MI? Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. First let ’s start with each ECG without clinical context. What do you think of each ECG? ECG 1: ECG 2:ECG 3:ECG 4:Now let ’s introduce some clinical context. How would this change management? Patient 1: 30 year old previously healthy, presenting with syncope, now asymptomatic with n...
Source: Dr. Smith's ECG Blog - May 23, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Quiz post - which of these, if any, are OMI? What is the South African Flag Sign? Will you activate the cath lab? Can you tell the difference on ECG?
Written by Pendell Meyers, additions and edits by Grauer, Smith, McLarenBelow we have 5 cases of adults (ranging from 40-70 years old) who all presented to the ED with acute nontraumatic chest pain that sounded at least somewhat like potential ACS to the provider. You should look at each ECG and decide if it is OMI, not OMI, or something else.Our goal in this post is to compare and contrast OMIs with false positives that mimic them. In this post we will examine the anterolateral distribution that has been described as the " South African Flag Sign. " (SAFS)It is very hard to describe why an ECG expert can easily...
Source: Dr. Smith's ECG Blog - May 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?
Submitted and written byDestiny Folk MD, peer reviewed by Meyers, Smith, Grauer, McLarenA man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. EMS arrived and found him awake and alert. He complained of generalized weakness and left lower extremity numbness. He reported that 12 hours prior to arrival he used fentanyl and cocaine. He reported difficulty walking and felt as if his left leg was “asleep.” He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. On arrival in the ED, he wa...
Source: Dr. Smith's ECG Blog - May 5, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 40s who really needs you to understand his ECG
Written by Pendell MeyersA man in his 40s presented for " left sided chest pain sudden onset yesterday when sneezing and coughing that is worsened with inspiration. " He also complained of associated SOB, dizziness, jaw pain, and back pain, which he described as " muscle spasms. " He has also had rhinorrhea and cough for 1 week. Also, left hand numbness today. He went to urgent care for evaluation. An ECG was performed there (unavailable) which reportedly was abnormal, so EMS was called to urgent care to take him to the ED.On EMS arrival, they noted the patient vomited then became unresponsive. He was reportedly...
Source: Dr. Smith's ECG Blog - May 1, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 40s with RUQ abdominal pain
Conclusion:In hemodynamically stable patients with chest pain, sinus tachycardia aids in the identification of patients unlikely to have type I MI, especially in those with HR greater than 120 bpm.===================================MY Comment by KEN GRAUER, MD (4/28/2020):===================================Insightful case presented by Drs. Goss and Meyers highlighting the importance of recognizing the ECG signs of acute PE. I focus my comments on further dissecting some of these " tell-tale " ECG features.The " theme " of today ' s case was "pattern recognition". Like the ECG diagnos...
Source: Dr. Smith's ECG Blog - April 28, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, a ‘normal’ ECG, a ' normal trop ' , and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.
Written by Jesse McLaren, with comments from Smith and GrauerA 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. ECG was labeled ‘normal’ by the computer (confirmed by the overreading cardiologist) and the high-sensitivity Troponin I was normal at a value of 11 ng/L (Abbott Alinity assay, where normal is<26 in males,<16 in females; this assay is nearly identical to the Abbott Architect high sensitivity assay). So the patient was low risk according to HEART and EDACS scores. Should this patient be discharged home? How about a stress test? ...
Source: Dr. Smith's ECG Blog - April 22, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 50s with acute chest pain and history of prior MI
Written by Pendell MeyersA man in his 50s with prior history of anterior MI with LAD stent presented with acute chest pain similar but more intense than his last MI. He presented around midnight with pain that had started around 9pm the night before. He had taken NTG at home with no improvement, and immediately received morphine on arrival at the ED for severe chest pain (a very bad idea if your accuracy for finding OMI on ECG is low, since ongoing pain will be your last chance to identify those with ongoing untreated OMI).Here is his triage ECG at 0012:What do you think? What is the differential of this ECG?There is sinus...
Source: Dr. Smith's ECG Blog - April 13, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
RBBB with STE in I and aVL. Will the angiogram tell you if this ECG represents Occlusion MI or not?
A middle aged male with history of STEMI and stents presented with one hour of chest pain.Here is his ED ECG:What do you think?Analysis: There is sinus rhythm with RBBB. There is ST Elevation in I and aVL which is discordant to the wide S-wave (a wide S-wave in lateral leads is a feature of RBBB). There is also some ST depression in lead V3 (inferoposterior OMI is suggested). There is no R ' -wave in V2 and so one would not expect the typical discordant ST depression and TW inversion that one often sees in V2. However, V3 does have an R ' -wave, and STD, but the T-wave isconcordantly positive, which...
Source: Dr. Smith's ECG Blog - April 11, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?
Case written and submitted by Brandon Fetterolf MD, edits by MeyersA woman in her early 30s with multiple autoimmune disorders including vasculitis presented with 2-3 hours of mid-left side chest discomfort with radiation to neck and left arm and associated with nausea, diaphoresis and dizziness. Initial ECG on presentation at 1554 (no prior for comparison):What do you think is happening to his 30s woman? The ECG shows NSR with a normal QRS except for poor R wave progression and pathologic QS-waves in V2-3. There is STE and hyperacute T waves in V2, I, and aVL with reciprocal STD in II, III, and aVF. This is...
Source: Dr. Smith's ECG Blog - April 8, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
4 Approaches To Eliminate Bias In Healthcare A.I.
Historically, healthcare data has been focused on white men, and in the age of artificial intelligence (A.I.), this represents a challenge to train the algorithms to deliver results that are representative across the ethnic and gender spectrum. Given that existing data leans towards the white male subset of the population, this will inevitably lead to ‘algorithmic bias’ in healthcare. The latter term is what researchers define as the instances when the application of an algorithm does not account for inequities but may in fact exacerbate them in healthcare systems.
Indeed, researchers have found that inherent biases...
Source: The Medical Futurist - April 7, 2022 Category: Information Technology Authors: Pranavsingh Dhunnoo Tags: TMF Artificial Intelligence in Medicine E-Patients Future of Medicine Healthcare Policy Telemedicine & Smartphones AI algorithm digital health bias AI bias Source Type: blogs
Diffuse ST Depression, with ST Elevation in aVR. Do you see the diagnosis?
This was texted to me from 2000 miles away. It is from a 30-something male with chest pain. There was worry for ischemia.What do you think?Is there any evidence of ischemia?No. There is not. All of the ST-T abnormalities are secondary to the abnormal QRS that is produced by pre-excitation. This is WPW.Notice the very short PR interval. Notice the obvious delta waves. Most, but not all, of the ST elevation and ST depression are discordant to the abnormal QRS, and are not excessively discordant.In contrast, in the ECG below, the discordant ST elevation and ST depression are...
Source: Dr. Smith's ECG Blog - April 5, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
