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31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!
This was submitted by a fantastic medical student who wished to remain anonymous: A 31 year old male with a history of viral pericarditis one year ago presented with right upper quadrant pain. Here is his initial ED ECG:The R-wave in V4 extends to 33 mm, the computerized QTc is 372 msThe only available previous ECG is from one year ago, during the admission when he was diagnosed with pericarditis:1 year ago ECG, with clinician and computer interpretatioin of pericarditis What do you think? What do these EKGs show? What is your plan for this patient?Here was the story from my perspective, prospectively:I was shown this ECG ...
Source: Dr. Smith's ECG Blog - December 20, 2013 Category: Cardiology Authors: Steve Smith Source Type: blogs

Diffuse ST Elevation and Chest Pain, What is it?
A male in his 40s presented by EMS with 24 hours of chest pain.  The pain was central, anterior, dull and squeezing, and 5/10, not worsened with activity but associated with mild shortness of breath.No prehospital 12-lead could be found.Here is the initial ECG at time zero:QTc is 386 ms.  There is scary ST elevation especially in V2 and aVL, with some reciprocal ST depression in III. However, the ST elevation in V2 has a saddleback appearance.  I have seen Anterior saddleback ST elevation as a finding in anterior MI only once ever, in all the ECGs and MIs I have reviewed.If you apply the early repol vs. LAD ...
Source: Dr. Smith's ECG Blog - July 6, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs

This ECG is NOT Pathognomonic of Brugada
This was contributed by a friend and colleague from a Yale affiliated hospital, Brooks Walsh.Here is Brooks' caseI had a great opportunity to co-manage a patient with one of my partners, Dr. Charles Mize. He is not only an avid resuscitationist, but also a devoted reader of Dr Smith’s ECG Blog.A 30-something adult with type 1 DM, but no cardiac disease, presented to the ED with nausea, vomiting, and abdominal pain. They had a history of multiple visits to the ED for gastroparesis (with or without DKA), and their symptoms were stereotypic for prior visits. Analgesia, fluid, and antiemetics were provided, and a basic metab...
Source: Dr. Smith's ECG Blog - August 9, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs

This ECG is NOT Pathognomonic of Brugada Syndrome
This was contributed by a friend and colleague from a Yale affiliated hospital, Brooks Walsh.Here is Brooks' caseI had a great opportunity to co-manage a patient with one of my partners, Dr. Charles Mize. He is not only an avid resuscitationist, but also a devoted reader of Dr Smith’s ECG Blog.A 30-something adult with type 1 DM, but no cardiac disease, presented to the ED with nausea, vomiting, and abdominal pain. They had a history of multiple visits to the ED for gastroparesis (with or without DKA), and their symptoms were stereotypic for prior visits. Analgesia, fluid, and antiemetics were provided, and a basic metab...
Source: Dr. Smith's ECG Blog - August 9, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs

A man in his 40s with a highly specific ECG
In conclusion, the presence of negative T waves in both leads III and V1 allows PE to be differentiated simply but accurately from ACS in patients with negative T waves in the precordial leads. "Witting et al. looked at consecutive patients with PE, ACS, or neither. They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6% of controls.  This does not contradict the conclusions of Kosuge et al. that when T-wave inversions in the right precordial leads and in lead III are indeed present, then PE may indeed by more common.  In m...
Source: Dr. Smith's ECG Blog - March 30, 2021 Category: Cardiology Authors: Pendell Source Type: blogs

A Middle Aged Male diagnosed with Gastroesophageal Reflux
This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain.  He had been at a clinic that day where he had complained of worsening GERD.  An EKG was recorded and interpreted as normal by the computer, the clinician, and by the overreading cardiologist.He had an ECG recorded in triage (I am not certain whether the patient had active pain at this time; I believe he didnot):What do you think?Here is the patient ' s ECG from several hours ago (which was essentially the same):This shows minimal inferior ST Elevation that is howeverall but diagnostic of inferior ischemia. There is the o...
Source: Dr. Smith's ECG Blog - July 16, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs