Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

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? The Need for Immediate Transport?

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Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

Here is the ECG: Computer interpretation: Normal ECG Interventionalist after doing PCI: SUBTLE STT CHANGES IN LIMB LEADS To me, this first ECG is diagnostic of inferior OMI. I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: YOU TOO CAN HAVE THE PM Cardio AI BOT!! He walked in to triage.

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Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The baseline ECG is basically normal with no ischemia. hours: Second troponin increased to 26 ng/L.

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Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The pain was persistent and reportedly still present at the time of the ECG. But if the pain is persistent, as reported, then the patient must go to the cath lab even if the ECG suggests reperfusion. Translation from French: Acute Occlusion Myocardial Infarction with High Confidence.

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Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1]

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Dr. Smith's ECG Blog

JUNE 1, 2022

Here is his ECG: There is no clear evidence of OMI or ischemia. I showed conclusively that this is a common finding in normal ECGs, though it is more common in LAD Occlusion than in norml variant STE. Studies of normal ECGs show that the T-wave in V1 taller than T-wave in V6 is within the normal range.

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Dr. Smith's ECG Blog

DECEMBER 27, 2023

The following ECG was obtained. Note that the machine read is "normal sinus rhythm, normal ECG." ECG 1 What do you think? I sent this ECG to Dr. Smith and Dr. Meyers with no clinical context. Smith comment: this troponin alone should be enough data to activate the cath lab, regardless of the ECG. <0.049 ng/mL).

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Dr. Smith's ECG Blog

DECEMBER 6, 2022

Vital signs were normal and first ECG was labeled as normal by the computer and confirmed by the treating emergency physician and cardiology over-read. Repeat troponin declined to 2,500 and repeat ECG ECG was done after another 2 hours, also interpreted as normal. What do you think? Take home 1.

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Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

I greeted medics at the door to view the prehospital ECG. Because of this, it was very difficult to record an ED ECG, but eventually it became possible: What do you think? There was an old ECG available from 15 months prior: This shows no STE and no STD. The presenting ECG has a touch of STD in V3 and V4. It may indeed.

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Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.

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Dr. Smith's ECG Blog

DECEMBER 18, 2022

His ECG is shown below. Although not striking, this is clearly a diagnostic ECG for infero"posterior" myocardial infarction due to coronary occlusion (OMI), most likely due to left circumflex (LCx) artery occlusion. Emergency physician doubts the diagnosis and wants to see another ECG with posterior leads.

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Dr. Smith's ECG Blog

NOVEMBER 15, 2023

She has no previous cardiac history of which she is aware 911 was called and here is her Prehospital ECG: What do you think? link] Case continued She arrived in the ED and here is the first ED ECG. In comparison with the first ECG, I would guess that the artery is reperfusing. The LAD, circumflex, and RCA appear patent.

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Dr. Smith's ECG Blog

JANUARY 15, 2024

Colin is an emergency medicine resident beginning his critical care fellowship in the summer with a strong interest in the role of ECG in critical care and OMI. An ECG was obtained shortly after arrival: ECG 1 What do you think? The ECG has a lot of artifact, and the amplitude is very small, making interpretation challenging.

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Dr. Smith's ECG Blog

MAY 6, 2018

Here is his initial ECG: What do you think? Note that there is some ST elevation in V2 and V3, which is normal (ST depression in these leads is very abnormal) So the above first ECG is nearly diagnostic of inferior and posterior MI. When present, the infarct artery is more likely to be the circumflex. This is hard to tell.

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Dr. Smith's ECG Blog

MAY 10, 2023

I do not have her previous ECGs, but reportedly these T-wave inversions were not present previously. However, when there is evolution of the T-waves, as with the 2nd ECG, the specificity for Wellens' is much higher. The circumflex artery was normal in appearance and free of obstructive disease. Her initial cTnI returned at 0.25

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Dr. Smith's ECG Blog

APRIL 29, 2023

An ECG was immediately recorded: Computer read: Normal ECG What do you think? Another very astute faculty physician immediately recognized that the ECG is diagnostic of posterior and lateral OMI , and activated the cath lab. Another ECG was recorded as the patient's pain was improving. There is ST depression in V1-V3.

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Dr. Smith's ECG Blog

APRIL 20, 2018

This is her pre-hospital ECG: This is her first ECG in the ED: What do you think? However, the prehospital ECG is more worrisome: the T-wave inversion in V5 and V6 is preceded by ST Elevation. When I say " relative ," I mean relative to the previous ECG, which is the baseline, chronic, non-ischemic ECG.

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Dr. Smith's ECG Blog

JANUARY 16, 2020

She had a history of PCI to the circumflex and also of severe mitral regurgitation, status post bioprosthetic valve replacement. Angiogram showed a 99% left main thrombotic occlusion with TIMI-1 flow (this is considered "occlusion" even though there is some flow. They called 911. On arrival, the BP was 60/30.

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Dr. Smith's ECG Blog

JUNE 27, 2021

Medics recorded this ECG: There is a lot of artifact, but you can clearly see ST depression in V2 and V3. Here is the first ED ECG (there was no previous ECG on file for comparison): Sinus rhythm and LVH There is some (less than 1 mm) of STD in V3 and V4. ng/mL, and another ECG was recorded and was identical.

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Dr. Smith's ECG Blog

DECEMBER 14, 2016

Here was his ED ECG: I read this as normal --One might say there is ST depression in II, III, and aVF, but this is merely an atrial repolarization wave. --You We recorded a posterior ECG: V4-V6 are moved around to the back and are really V7-V9. Is it acute persistent occlusion? The troponin I returned at 4.1 mm STE in one lead.

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Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

This is his prehospital ECG: There is very subtle ST elevation in I and aVL, with very subtle ST depression in III and aVF. Is this due to coronary occlusion? Jason asked me if I thought it is due to occlusion (without either of us knowing the outcome), and this was my answer: This is a posterolateral MI.

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Dr. Smith's ECG Blog

OCTOBER 6, 2018

At 3:55 AM during that kind of a night shift, this ECG (among many others) was brought from triage for review by my team. We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. Here is the computer interpretation: So we have a triage-computer-normal ECG. No prior available.

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Cook County EM Blog

MAY 15, 2023

Ultimately the patient was taken to the cath lab which showed severe disease of the distal left main, mid left circumflex ostial OM1, distal D2, and distal RCA. There was 100% occlusion of the 1st obtuse marginal artery, a branch of the LCA which was felt to be the culprit for the patient’s presentation. link] Lowenstein, S.

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Dr. Smith's ECG Blog

MARCH 27, 2018

Two Cases Male Patient I was handed this ECG of a 40-something male patient. I brought her by wheelchair to the ED to a room and recorded this ECG 15 minutes after the first one: This time the computer called it: "Moderate ST depression." This is called" Acuteness " of the ECG of MI. It was recorded at triage.

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Dr. Smith's ECG Blog

AUGUST 28, 2020

I was texted these ECGs. This is highly suggestive of re-occlusion (Pseudonormalization of T-waves). This insistence on calling it lateral is due to a paper by Bayes de Luna -- [link] ] Case Continued I could only see the ECGs, not the echo. By the ECG, it is not necessarily subacute, but could be.

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Dr. Smith's ECG Blog

AUGUST 3, 2017

This is his 12-Lead ECG: What do you think?​ Firstly, subendocardial ischemia does not localize on 12-Lead ECG. The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! What's also interesting to note is that there is ST-elevation in V6 on the ECG.

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Dr. Smith's ECG Blog

DECEMBER 19, 2018

The pain had almost resolved by the time an ECG was obtained in the ED: Here is the computer diagnosis What do you think? But do you think the ECG is “normal?” Despite the computer interpretation, the ED physician was concerned about the ECG, and planned for serial troponins. Well, the computer thought so! It was not normal!

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Resus Review

OCTOBER 8, 2015

The location of atherosclerotic lesions can be suggested by provocative stress testing (exercise or pharmacologic stress, and multiple evaluation modalities including ECG, echocardiography, and nuclear medicine). The right coronary artery (RCA, Right circumflex) is the only major artery that originates from the right coronary cusp.

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Dr. Smith's ECG Blog

JANUARY 28, 2018

This post was written by one of our fantastic Hennepin County Medical Center Emergency Medicine interns who is an ECG whiz, Daniel Lee. This is his first ECG in the department, which I saw as it was being printed: What do you think? This is his first ECG in the department, which I saw as it was being printed: What do you think?

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Dr. Smith's ECG Blog

APRIL 2, 2014

Here is his prehospital ECG: Diagnosis? He had an immediate ED ECG: There is artifact, but the findings appear to be largely gone now The diagnosis is acute MI, but not STEMI. I saw these ECGs, and since there was no immediate urgency, allowed the resident to manage it without any comment. No evidence of RV MI. was much higher.

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Dr. Smith's ECG Blog

JUNE 12, 2017

I am working with a company that writes deep neural network software for interpreting ECGs. An ECG is recorded and the computer reads it as "normal". Here it is: Computer read: "Normal ECG" Aren't you glad that you looked at it? The ECG was alarming to the ED physician who did indeed review it. It is a matter of time."

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Dr. Smith's ECG Blog

JUNE 18, 2013

I have to tell this story from my point of view because I don't want anyone to think that the recognition of LAD occlusion was made in retrospect. The Case : I was reading dozens of leftover ECGs from over a weekend and saw this one: There are symmetric T-waves and poor R-wave progression. This is because of subtle ECG findings.

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Dr. Smith's ECG Blog

APRIL 24, 2020

Here was his ED ECG, which was identical to the prehospital ECG. ST vector In this ECG, the ST vector is both posterior (away from V3 and V4), upward, away from aVF, and rightward (away from I, II, V5, V6 and towards aVR. This is unfortunate in my view, as it complicates the retrospective analysis of the ECG!!

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Dr. Smith's ECG Blog

FEBRUARY 29, 2016

In accordance with the last case (in which the patient presented only with vomiting and diarrhea), an ECG was recorded : (Figure 1) Someone thought this was slow VT with a "northwest" axis (towards aVR, or -135 degrees), but there are definite P-waves (with a long PR interval). But in the above ECG, V5 and V6 only have a Q-wave.

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Dr. Smith's ECG Blog

NOVEMBER 26, 2018

Here is his initial ECG: What do you think? When the team saw this ECG, we obviously noticed the large STE in the inferior leads, with STD in V1-V5, I, and aVL, and STE in V6. Back to the interpretation of the ECG: Does the rhythm matter to you in this case? What will you do for this patient? How many problems does he have?

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Dr. Smith's ECG Blog

MAY 10, 2014

The following ECG was recorded: There is an obvious acute inferior STEMI. The inferior Q-waves suggest that there is an old inferior MI or that this one is subacute, but an old ECG was available and also had similar Q-waves. RV MI can only occur with RCA occlusion, as the RV marginal branches off the RCA.

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Dr. Smith's ECG Blog

NOVEMBER 26, 2015

Here is her 12-Lead ECG: There’s a sinus rhythm at around 70 bpm. It is difficult to answer this question based on this single ECG alone. Although not always available a prior ECG is probably the most helpful piece of information in these cases. This was written by Sam Ghali ( @ EM_RESUS ), with a few edits by me.

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