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A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith.  Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 50-something with Regular Wide Complex Tachycardiaa: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith.  Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

50 year-old in remote rural community with chest pain and ‘normal’ ECG
Submitted by anonymous, edited by Jesse McLarenThe first person " I " and " me " is this anonymous sender. A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you manage the patient?There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages. There’s clear T wave inversion in III/aVF, which is reciprocal to subtle ST elevation and h...
Source: Dr. Smith's ECG Blog - September 8, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

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

75 year old dialysis patient with nausea, vomiting and lightheadedness
Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. RR18 sat 99% HR 90 BP 90/60, afebrile. Below is the 15 lead ECG. What do you think? There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages. There’s subtle inferior ST elevation with straightening of the ST segment, reciprocal ST depression and T wave inversion in aVL, and ST depression in V2. This is diagnostic of infero-posterior OMI, but it is falsely n...
Source: Dr. Smith's ECG Blog - August 19, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

Chest pain and T wave inversion, NSTEMI?
Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLarenA 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. The nurse alerted the MD because the patient was still symptomatic, diaphoretic and “looking unwell”. What do you think?      ECG interpretation: sinus rhythm, normal conduction (PR, QRS, and QTc), normal axis, delayed R-wave progression, and normal voltages. There ’s primary TWI inferiorly (aVF and III) and V6, with reciprocal tall T-wave in lead I/aVL, and a Q wave in III. The...
Source: Dr. Smith's ECG Blog - August 10, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

OMI Pocket Guide
  📕OMI Pocket Guide TheOMI Pocket Guide (https://omiguide.org) is a user-friendly online resource designed to help healthcare professionals learn how to recognize subtle signs of acute coronary occlusion on the ECG which represent occlusion myocardial infarctions (OMI). Learning to recognize OMIs is an important clinical skill because it helps identify the subpopulation of " NSTEMIs " who are likely to be found with total thrombotic occlusion at the time of cardiac catherization.Although there are more criteria to consider when looking for OMIs compared to STEMIs, anyone can learn them, and this guid...
Source: Dr. Smith's ECG Blog - August 3, 2023 Category: Cardiology Authors: Mark Hellerman Source Type: blogs

Outpatient Vascular Care: Good, bad or ugly?
BY ANISH KOKA Filling in the holes of recent stories in the New York Times, and Propublica on the outpatient care of patients with peripheral arterial disease Most have gotten used to egregiously bad coverage of current events that fills the pages of today’s New York Times, but even by their now very low standards a recent telling of a story about peripheral artery disease was very bad. The scintillating allegation by Katie Thomas, Jessica Silver-Greenberg and Robert Gebeloff is that “medical device makers are bankrolling doctors to perform artery clearing procedures that can lead to amputations�...
Source: The Health Care Blog - July 24, 2023 Category: Consumer Health News Authors: Ryan Bose-Roy Tags: Medical Practice Anish Koka Medical Devices Outpatient vascular care Source Type: blogs

63 year old with " good story for ACS " but negative troponins.....
 This was texted to me from a former resident, while working at a small rural hospital, with the statement:" I can ’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS. "  (Chest pain or discomfort)What do you think?Here was my response:" Suspicious for inferior posterior OMI.  Get serial ECGs "He then sent a previous from 4 years prior:" This is totally normal, which confirms that the first EKG does indeed represent OMI "Then the patient ' s chest pain resolved and he recorded another:The ST depression in aVL is gone and the T-waves are less hyperacu...
Source: Dr. Smith's ECG Blog - July 2, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

Ultrahigh-Resolution Photon-counting CT Useful Prior to Transcatheter Aortic Valve Replacement
Assessment of coronary anatomy prior to Transcatheter Aortic Valve Replacement has great prognostic significance. Invasive coronary angiography is done prior to TAVR though CT coronary angiography has a role in ruling out coronary artery disease in those with low or intermediate pretest probabilities. Accurate interpretation of coronary arteries in those planned for TAVR has challenges because of high occurrence of abnormal heart rhythm, contraindications for beta blockers and nitroglycerine administraton. Still important is the blooming artifacts on CT coronary angiography in those with coronary stents or severe calcific...
Source: Cardiophile MD - June 21, 2023 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs

A man in his 50s with acute chest pain who is lucky to still be alive.
 Sent by Magnus Nossen MD, written by Pendell MeyersA man in his 50s, previously healthy, developed acute chest pain. EMS was called, and they recorded the following ECG on scene at 13:16:What do you think?Below is the version standardized by PM Cardio appMeyers interpretation:Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). There is a relatively normal QRS yet there is STD maximal in V2-V4, which resolves from V4 to V6. The inferior leads may have a slightly full T wave (possibly hyperacute if compared to baseline which...
Source: Dr. Smith's ECG Blog - June 21, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

A man with chest pain off and on for two days, and " No STEMI " at triage.
 Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen SmithA 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.What do you think?This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 mm STE in III, and possibly 0.5 mm in aVF), but there is clear evidence of OMI findings on this ECG. Leads II, III, and aVF hav...
Source: Dr. Smith's ECG Blog - June 19, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

When ” Cath lab viability ” competes with myocardial viablity … Just carry on !
Pure science Whenever possible ,before doing a coronary revascularisation procedure , check twice the segments you try to perfuse is really short of blood supply and truly needs the procedure. Don’t ever waste your resources and try to blood-feed the dead myocardium. It’ can never be awakened ! Pragmatic science I was conversing with my colleague recently , who has grown into  suave , Interventional cardiologist with a huge academic & societal repute .He owns a personal cathlab and planning to get one more. I learnt a non-academic reality lesson from him . When planning myocardial revasascularisation, ...
Source: Dr.S.Venkatesan MD - June 8, 2023 Category: Cardiology Authors: dr s venkatesan Tags: bio ethics cardiology wisdom cardiology-ethics Cardiology-Statistics cath lab tips and tricks Medical education Medical ethics medical quotes medical satistics Two line sermons in cardiology wisdom in cardiology cath lab viablity vs Source Type: blogs

75 year old with 24 hours of chest pain, STEMI negative
Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. HR 40, BP 135/70, RR16, O2 100%. Here ’s the paramedic ECG (digitized by PMcardio). What do you think? There ’s sinus bradycardia, normal conduction, normal axis, delayed R wave progression, and normal voltages. There are inferior Q waves and lead III has mild concave ST elevation, with subtle reciprocal ST depression in I/aVL. This is diagnostic of inferior OMI, likely from the RCA. The patient has a hi story of CABG so some of these changes could be old, but with ongoing chest pain and bradycardia in a hig...
Source: Dr. Smith's ECG Blog - June 8, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

A 40-something male with resolving chest pain and a " Normal ECG " by computer and cardiology overread
A 40-something male presented by ambulance with one hour of chest pain that was improving after sublingual nitroglycerine and 325 mg of aspirin, chewed.  Here is his initial ED ECG:What do you think?I read this ECG without any history as reperfusing inferior and posterior OMI due to the Q-wave in lead III with minimal STE and reciprocal ST depression in V2-V4 (which should never be there).  The large upright T-wave in V2 is consistent with reperfusion.Any ST Depression Maximal in V1-V4 is OMI until proven otherwiseI sent this ECG with no information to Pendell.  We send each other EKG by the dozens...
Source: Dr. Smith's ECG Blog - June 5, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

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