A man in his 50s with shortness of breath
Sent by Tom Fiero, written by Pendell Meyers A man in his 50s presented with acute shortness of breath. Unfortunately we do not have access to the patients presenting vital signs.Here is his ECG:Original image, suboptimal qualityQuality improved with PM Cardio digitizationThe ECG is highly suggestive of acute right heart strain, with sinus tachycardia, S1Q3T3, and T wave inversions in anterior and inferior with morphology consistent with acute right heart strain. There is also STE in lead III with reciprocal depression in aVL and I, as well as some subendocardial ischemia pattern with STD in V5-V6 and STE in aVR. Thus...
Source: Dr. Smith's ECG Blog - March 26, 2024 Category: Cardiology Authors: Pendell Source Type: blogs

Palpitations and presyncope in a 40-something
Discussion: Putting all of the information together this patient is most likely suffering from arrhythmogenic cardiomyopathy (AC) better known as ARVC. The medical hx is typical, with sudden onset tachydysrhythmia during physical exertion. It is not uncommon for the initial presentation to be sudden cardiac death (SCD). In fact it is one of the leading causes of SCD in people age less than 40 years. Thus it is very important to identify this disorder. AC is a disease in which myocardium is replaced by fibrofatty tissue. This usually and predominantly affects the RV free wall and apical regions, but it can affect the left v...
Source: Dr. Smith's ECG Blog - March 24, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs

A 50-something with chest pain. Is there OMI? And what is the rhythm?
Written by Willy FrickA man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. His ECG is shown:What do you think?The history thus far is highly suggestive of OMI, so we must study the ECG very closely to see if we can confirm this. Looking at the rhythm strip, we see there is more going on than simple sinus rhythm, and in fact there are two different morphologies of QRS complexes. Take a closer look at the rhythm by itself and see if you can figure out what ' s going on before scrolling further....
Source: Dr. Smith's ECG Blog - March 22, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain
This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System.The patient presented to an outside hospitalAn 80yo female per triage “patient presents with chest pain, also hurts to breathe”PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB.HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA.  She reports associated SOB but no dizziness or LOC.  She was given NTG at home before coming to the hospital. This was the ECG obtained at triage.This ECG was recorded and was reviewed remotely by a...
Source: Dr. Smith's ECG Blog - March 19, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Why is the angiogram normal?
Written byWilly FrickA man in his 50s with a 15 pack-year smoking history presented to his primary care physician ' s office complaining of intermittent headache. He also complained of intermittent mild chest pain radiating into into both shoulders and his back, as well as occasional unexplained sweating. (Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive). The primary care physician ' s note indicates low suspicion for cardiac ischemia, but " for completion, check troponin and ECG. " If an ECG was obtained in the office,...
Source: Dr. Smith's ECG Blog - March 17, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs

Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?
This study had such low risk patients that not a single patient was ultimately diagnosed with ACS.  It is well known that NOMI usually has a normal ECG or nonspecific ECG. The fact that not a single one of these patients had ACS shows that the population studied could not possibly support their conclusion. It should never have been published.According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion.This is obviously unreliable data, as Dr. Smith ’s Blog has published51 cases of OMI with ECGs labeled ‘normal’, 35 of which were identified by the Queen ...
Source: Dr. Smith's ECG Blog - March 14, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

A man in his 40s with 3 days of stuttering chest pain
Written byWilly FrickA man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:What do you...
Source: Dr. Smith's ECG Blog - March 13, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs

Acute chest pain and ST Elevation. CT done to look for aortic dissection.....
Written byWilly FrickA 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. He had associated nausea, vomiting, and dyspnea.What do you think?This ECG together with these symptoms is certainly concerning for OMI, but the ECG is not fully diagnostic, and another consideration could be acute pericarditis. Mistaking OMI for pericarditis is a much more harmful error than the converse. Still, in the interest of studying the ECG, here are some findings that could support pericarditis:Absence of large T-waves (flat ST segments)Absence of any STD in aVL (which is s...
Source: Dr. Smith's ECG Blog - March 9, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs

Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart. A case of irregular accelerated idioventricular rhythm (AIVR)
A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this?  There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex.  It is irregular.  It is not fast (cannot be VT).  There is no atrial activity to suggest atrial fibrillation.  There are whatcould be interpreted as delta wavesif, and only if, th...
Source: Dr. Smith's ECG Blog - March 7, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart
A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this?  There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex.  It is irregular.  It is not fast (cannot be VT).  There is no atrial activity to suggest atrial fibrillation.  There are whatcould be interpreted as delta wavesif, and only if, th...
Source: Dr. Smith's ECG Blog - March 7, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

When the conventional algorithm diagnoses the ECG as COMPLETELY NORMAL, but there is in fact OMI, what does the Queen of Hearts PM Cardio AI app say? (with 10 case examples)
Conclusions Need Scrutiny.Proximal LAD Occlusion with STE in I and aVL, and hyperacute T-waves in V2-V6.Algorithm: Marquette 12 SL (GE)The Queen gets it rightCase 9 (prehospital and ED ECGs).  Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.  30 yo woman with trapezius pain. HEART Pathway = 0. Computer " Normal " ECG. Reality: ECG is Diagnostic of LAD Occlusion.Prehospital ECG:There are hyperacute T-waves in V3-V5.The Queen gets it rightFirst ED ECG:Hyperacute T-waves persist.  Called normal again! Algorithm: Veritas (on Mortara...
Source: Dr. Smith's ECG Blog - March 4, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

" Seizure " in a 60 year old male
This 60 yo male had an apparent tonic clonic seizure.  He had no history of seizures.  He was unconscious for 8 minutes and slowly awoke in the ambulance, complaining of nausea only.  First responders found him to bevery tachycardic, confused, perserverating and with no memory of the event.  There was tongue biting.  Lightheadedness continued.The tachycardia was gone by the time paramedics arrived.He had a prehospital ECG:What do you think?Interpretation.  There is terminal T-wave inversion in V2, highly suggestive of Wellens ' pattern.  But syncope or seizure alone, without chest pain, i...
Source: Dr. Smith's ECG Blog - March 1, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

How will you save this critically ill patient? A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.
Written by Pendell MeyersA woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. An ECG was performed:What do you think?Extremely wide complex monomorphic rhythm just over 100 bpm. The QRS is so wide andsinusoidal that the only real possibilities left are hyperkalemia or Na channel blockade. Hyperkalemia is by far more common.Indeed, further history revealed two missed dialysis sessions. And of course on exam she has a dialysis fistula.EMS reportedly gave 4 grams of calcium (unknown w...
Source: Dr. Smith's ECG Blog - February 22, 2024 Category: Cardiology Authors: Pendell Source Type: blogs

Tachycardia and hyperkalemia. What will happen after therapy with 1 gram of Ca gluconate and some bicarbonate?
A 20-something type, 1 diabetic presented by EMS with altered mental status.  Blood pressure was 117/80, pulse 161, Resp 45, SpO2 100 on oxygen.Here is the 12-lead ECG:Wide complex tachycardiaWhat do you think?The providers thought that this wide QRS was purely due to (severe) hyperkalemia.  They treated with 4 ampules (200 mL) of bicarb and 1 gram of calcium gluconate. Note: 1 g of calcium gluconate is insufficient. 1 g of calcium chloride has 3x as much calcium and is indeed a good start.His pulse on the monitor suddenly went down to 140 and another 12-lead ECG was recorded:Sinus tachycardia at a rate...
Source: Dr. Smith's ECG Blog - February 20, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Acute dyspnea in an older woman, is it OMI?
 Written by Willy FrickA woman in her 90s with a history of end stage renal disease and complete heart block status post dual chamber pacemaker presented from home with acute onset dyspnea. ECG is shown below.What do you think?The ST and T wave abnormalities jump off the page, but let ' s set that aside just for a moment to review the tracing systematically. The rate is 60 (and remember, slower heart rates are often seen in OMI). Close inspection revealsventricular pacing spikes, best seen in aVL. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it...
Source: Dr. Smith's ECG Blog - February 18, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs