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A middle-aged man with acute chest pain.
A 50-something male had onset of chest pain 1 hour prior to ED arrival.  It is constant, 9/10, left-sided CP that radiates into left arm and jaw. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. Has never had this before. Takes metoprolol for HTN. Here is the triage ECG:What do you think?This was not identified as OMI by either the conventional algorithm nor the triage faculty physician.Smith: I think leads V3 and V4 are highly concerning, and all but diagnostic, for acute LAD occlusion.  I would activate the cath lab, or at least look f...
Source: Dr. Smith's ECG Blog - September 1, 2023 Category: Cardiology Authors: Steve Smith 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

Wide Complex Tachycardia with Huge ST Elevation. What is going on?
This 70-something woman with no significant past history (no previous ECGs or cardiac history) presented by EMS with fairly acute chest pressure and shortness of breath, with nausea and diaphoresis.  " Like an elephant sitting on my chest. "  She had no history of atrial fibrillation and was not on any anticoagulants.She stated that she had had a similar episode a couple weeks earlier, lasting 24 hours, with rapid heart beat but without chest pain, that spontaneously resolved.  She thought she was having a panic attack.  Since then she has had " little spurts " of the same thing lasting 1-2 hours.E...
Source: Dr. Smith's ECG Blog - January 12, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

Important aspects in the management of neurocardiogenic syncope
Neurocardiogenic syncope is the most common cause of syncope. Initial measures in management include lifestyle modifications, increasing the fluid and salt intake and education about physical counterpressure methods. Pharmacological measures may be tried next. Pacemaker implantation has been tried in those with predominantly cardioinhibitory syncope [1]. Physical counterpressure measures are movements like leg crossing and hand gripping which may prevent loss of consciousness in those who feel the presyncopal symptoms. These measures increase the systemic vascular resistance and blood pressure to counter the vasodepressiv...
Source: Cardiophile MD - November 20, 2021 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: General Cardiology Source Type: blogs

A woman in her 60s with syncope and vomiting. Does she need a pacemaker?
 Written by Pendell Meyers with some edits by Steve SmithA woman in her 60s on chemotherapy presented to the Emergency Department for a syncopal episode just prior to arrival. She was walking to the bathroom when she suddenly felt nauseous and passed out. EMS was called by the patient ' s daughter, and en route to the ED she vomited twice. On arrival to the ED, she adamantly denies chest pain but says she ' s " just still not feeling well. " She had no prior known cardiac disease.Triage at 0755:The rhythm is most either atrial fibrillation with complete heart block and resulting junctional escape, or atrial flutter wi...
Source: Dr. Smith's ECG Blog - November 19, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 60s with misdiagnosed palpitations, part 2: Case follow up!
 Written by Pendell MeyersThis post will be follow up information on the patient from this recent case linked below. Make sure to read that one first, then see what happened to this patient in this post below!A woman in her 60s with palpitations, chest discomfort, and multiple misdiagnoses by both EM and Cardiology!!Here is the ECG:Here is the explanation:We see a regular, narrow, monomorphic tachycardia, for which the full differential would include sinus tachycardia, SVT (an umbrella term including many different rhythms), and atrial flutter. This ECG has a large negative atrial wave just before the QRS complex...
Source: Dr. Smith's ECG Blog - October 4, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 60s with palpitations, chest discomfort, and multiple misdiagnoses by both EM and Cardiology!!
 Written by Pendell MeyersA woman in her 60s was shopping when she suddenly experienced palpitations and chest " discomfort. " She denied outright chest pain or dyspnea. She walked across to the street to my Emergency Department. She had no known prior history of dysrhythmias or heart disease, but had known hypertension, breast cancer, diabetes, and obesity. She has had episodes of palpitations in the past, followed by holter monitor workups which did not reveal any cause of palpitations. However, her symptoms today feel worse than prior episodes, and she has never felt the " chest discomfort " with prior palpitations...
Source: Dr. Smith's ECG Blog - September 21, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

Paroxysmal Atrial Fibrillation with RVR, hypotension, volume depletion, good EF, AND pulmonary edema. Strange. Why? What to do?
A 30-something woman presented with a few days of feeling ill.  She had a history of paroxysmal atrial fibrillation, bio-prosthetic mitral valve, and tricuspid valvuloplasty, and was on Coumadin.Records showed she is usually in sinus rhythm and has normal LV function.She presented hypotensive (systolic pressure 80), with diffuse B lines, flat IVC, good LV function, and an irregular, fast heart beat.Here is here ECG:Atrial fib with RVR and some probable ischemic ST depression in V3-V6Here is her POCUS:What do you think?  There is asmall LV with good function and alarge left atrium, andmoderately large RV.Ther...
Source: Dr. Smith's ECG Blog - April 4, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs

Antiarrhythmic drug classification
The popular Vaughan Williams classification was published in 1975 [1]. It is still being used by most of us. The Sicilian Gambit published in 1991 [2] has not been so popular because of its complexity. Vaughan Williams classification is approximately as follows:  Class I: Sodium channel blockers ◦a: Moderate Na channel block. e.g. Quinidine, Disopyramide ◦b: Weak Na channel block. e.g. Lignocaine, Mexiletine ◦c: Marked Na channel block. e.g. Flecainide, Propafenone  Class II: Beta blockers  Class III: Potassium channel blockers: Amiodarone, Sotalol, Ibutilide  Class IV: Calcium channel blockers In 2018, an exten...
Source: Cardiophile MD - October 13, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: ECG / Electrophysiology Source Type: blogs

Cardiac arrest with anterior-inferior STEMI: Guess the value of the initial ED high sensitivity Abbott troponin I
A ~40 year old woman started having chest discomfort.  She called 911 after an uncertain amount of time.  EMS arrived and recorded thisprehospital ECG:Obvious Anterior and Inferior STEMI, consistent with LAD occlusionAfter recording this ECG, the patient went intoventricular fibrillation.She was rapidly defibrillated.The cath lab was activated by the paramedics.She arrived complaining of chest pain, with a BP of 110/70.An ED ECG was recorded:It looks worse stillAside: Should the patient receive antidysrhythmics to prevent recurrent VT/VF?  See discussion below on both beta blockers and other anti-dysrhythmic...
Source: Dr. Smith's ECG Blog - September 18, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 31 year old with Diabetes and HTN complains of bilateral arm tingling and headache
This ECG was texted to me with the message " A 31 year old with Diabetes and HTN complains of bilateral arm tingling and headache. "There is high lateral ST Elevation and inferior reciprocal ST depression.There is also STE in V2.The computer calls it a STEMI.What do you think?STE in I, aVL and V2 is a pattern associated with "Mid-anterolateral OMI, " which is seen with OMI of the first Diagonal.  See more of Mid-anterolateral OMII wrote back: " I think this is a false positive due to LVH.  PseudoSTEMI.  I can ' t tell you exactly why.  It just looks like it.  ECGs are often like faces to me.&n...
Source: Dr. Smith's ECG Blog - August 29, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Pre-existing Left Bundle Branch Block and Atrial Fib: what is alarming on this routine pre-procedure ECG?
An elderly patient had a pre-procedure ECG (ECG-1).  She was asymptomatic.  The patient had known Left Bundle Branch Block (LBBB) and atrial fibrillation (see ECG-2 below), and was rate controlled on metoprolol. ECG-1What is the problem?ECG-2 (previous for comparison):There are enormous U-waves, best seen in V1-V3, but also in V4 and V5.  This was seen by the overreading cardiologist.  The cardiologist called the The K was checked and it was 1.9 mEq/L.The patient was sent to the ED for hypokalemia.While being assessed and having potassium orally and IV, her heart rate dropped to 30 beats per minute...
Source: Dr. Smith's ECG Blog - January 20, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Anterior STEMI and multiform PVCs with Narrow Coupling Interval. When to give beta blockers in acute MI?
Conclusion of first report:In patients with anterior Killip class II or less ST-segment –elevation myocardial infarction undergoing primary percutaneous coronary intervention, early intravenous metoprolol before reperfusion reduced infarct size and increased left ventricular ejection fraction with no excess of adverse events during the first 24 hours after STEMI.Conclusion of 2nd report: In patients with anterior Killip class  ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer h...
Source: Dr. Smith's ECG Blog - October 19, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs

Propranolol found superior to Metoprolol for electrical storm
Propranolol found superior to Metoprolol for electrical storm: Use of propranolol has gone down with the availability of newer beta blockers. Here is one study which suggests that we may have to go back to propranolol in certain situations. The study by Chatzidou S et al [1] has found that propranolol is superior to metoprolol in the treatment of electrical storm along with intravenous amiodarone. Propranolol has a membrane stabilizing effect (local anaesthetic effect), which is not there for metoprolol. Of course metoprolol is beta one specific and has other advantages which propranolol does not have, being a non select...
Source: Cardiophile MD - April 30, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: ECG / Electrophysiology Source Type: blogs

Beta blocker in HOCM – Cardiology MCQ
Which of the following beta blockers is not an ideal choice in the treatment of hypertrophic obstructive cardiomyopathy? a) Metoprolol b) Propranolol c) Sotalol d) Carvedilol Post your answer as a comment below. Correct answer will be published on: Apr 24, 2018 @ 19:32 The post Beta blocker in HOCM – Cardiology MCQ appeared first on Cardiophile MD.
Source: Cardiophile MD - April 23, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

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