Ken Grauer, MD

JULY 22, 2023

The ECG in Figure-1 was obtained from an elderly man with a history of coronary disease — who contacted EMS for "burning" chest discomfort that woke him at 3am. Some amount of time passed at home — during which his chest discomfort persisted The patient was hemodynamically stable at the time he was seen by EMS, when ECG #1 was recorded.

EKG/ECG 195

EKG/ECG Burns EMS Wellness 195

Ken Grauer, MD

MAY 28, 2024

I recently recorded a series of 4 podcasts regarding KEY concepts in ECG interpretation. Easy LINKS — tinyurl.com/KG-ECG-Podcasts — [link] — Other ECG Audio PEARLS I previously made for my ECG Blog can be found in the right column of each page on this blog just below this icon — under, "ECG Audio PEARLS".

EKG/ECG 277

EKG/ECG Wellness 277

Ken Grauer, MD

MARCH 18, 2023

The ECG in Figure-1 was obtained from a man in his mid-60s — who presented with new chest pain. Figure-1: T he initial ECG in today’s case. MY Thoughts on the Initial ECG: The rhythm in ECG #1 — is sinus at ~70/minute. Figure-2: I've labeled significant ST-T wave findings in the limb leads of ECG #1.

EKG/ECG 195

EKG/ECG Wellness 195

Ken Grauer, MD

APRIL 29, 2023

The patient whose initial ECG is shown in Figure-1 — is a middle-aged man who presented to the ED ( E mergency D epartment ) for new-onset CP ( C hest P ain ). QUESTIONS: In view of the above history — How would YOU interpret the initial ECG? WHY is it important to correlate severity of this patient’s CP with ECG #1 ?

EKG/ECG 195

EKG/ECG Wellness 195

Dr. Smith's ECG Blog

APRIL 22, 2024

EKG from triage: Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in comparison to an EKG in 2020 this is new. This change is due to a change in lead placement: in the first ECG (top), leads V1 and V2 were placed too high (P-wave inverted).

EKG/ECG 108

EKG/ECG Outcomes Ultrasounds Hospitals 108

Ken Grauer, MD

JANUARY 20, 2024

I was sent the tracing shown in Figure-1 — told only that this was a preoperative ECG obtained from an asymptomatic older woman scheduled for non-cardiac surgery. How would YOU interpret this ECG? Figure-1: Preoperative ECG from an asymptomatic older woman scheduled for non-cardiac surgery. The 12-lead ECG is very concerning.

EKG/ECG 231

EKG/ECG 231

Dr. Smith's ECG Blog

MARCH 17, 2024

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, it was not saved. His ECG is shown. ECG 1 Readers of this blog will have no trouble recognizing this as an OMI with some early reperfusion. < 0.033).

EKG/ECG 68

EKG/ECG Hospitals Wellness 68

Dr. Smith's ECG Blog

JANUARY 27, 2024

Below is the triage ECG, with a computer interpretation (Marquette 12 SL) of “normal” which was confirmed by the over-reading cardiologist. Should this patient continue to stay in the waiting room, without interruption of the physician to interpret the ECG, because the computer interpretation is normal? What do you think?

EKG/ECG 88

EKG/ECG Emergency Department Outcomes Wellness 88

Dr. Smith's ECG Blog

JUNE 5, 2023

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.

EKG/ECG 68

EKG/ECG Research Outcomes 68

Dr. Smith's ECG Blog

DECEMBER 7, 2023

Here is the Queen of Hearts interpretation with explainability: Smith comment: When Pendell and I taught version 1 of the Queen, we taught it OMI active or reperfused, acute or subacute. We would have taught her "acute reperfused" for this ECG. She does not specify whether active or reperfused. Hers is shown below.

EKG/ECG 92

EKG/ECG Poisoning Hospitals 92

Dr. Smith's ECG Blog

MAY 20, 2024

He arrived to the ED at 1413, where his first EKG was taken (BP at this time was about 187/126): He recorded this ECG at 1413, with a BP of 187/126: What do you think? If it is angina, lowering the BP with IV Nitroglycerine may completely alleviate the pain and the (unseen) ECG ischemia. The ST depressions in I and aVL have resolved.

EKG/ECG 110

EKG/ECG Hospitals Wellness Emergency Department 110

Dr. Smith's ECG Blog

MARCH 1, 2024

He had a prehospital ECG: What do you think? Here is the Queen's interpretation (the Queen always assumes a fairly high pretest probability of OMI): This version of the Queen (version 1) does not differentiate between active and reperfused OMI. So she will call Wellens' ECG "OMI". So she will call a Wellens' ECG "OMI".

Seizures 83

Seizures EKG/ECG 83

Dr. Smith's ECG Blog

DECEMBER 29, 2023

Below is the old ECG (on top) and then new ECG (on bottom). The old ECG has proportional ST elevation and T waves. But the new ECG has new Q waves in aVL and V2 (the distribution of the first diagonal artery) – and in the next context of Q waves, the T wave in V2 is upright and relative large. What do you think?

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EKG/ECG Documentation/Coding Emergency Department 67

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Willy is a cardiology fellow with a keen interest in the ECG in OMI. Smith : that subtle inferior STE with subtle reciprocal STD in I and aVL is highly suspicious for inferior OMI, but with the T-wave inverted in III, probably reperfusing OMI. A patient with OMI can have a totally normal ECG!" At midnight.

EKG/ECG 110

EKG/ECG Outcomes Documentation/Coding Academics 110

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). Here is his first prehospital ECG: 1st Prehospital ECG What do you think?

EKG/ECG 93

EKG/ECG EMS Stroke Outcomes 93

Dr. Smith's ECG Blog

JANUARY 3, 2024

On arrival, EMS recorded relatively normal vital signs and this EMS ECG: What do you think? Here is the Queen of Hearts interpretation: This ECG was transmitted to the nearest PCI center, where it was simply called "Not STEMI, just follow your protocol." No further ECGs were recorded. So the cath lab was not activated.

EMS 79

EMS EKG/ECG Wellness Outcomes 79

Ken Grauer, MD

JANUARY 26, 2023

The ECG in Figure-1 was obtained from a previously healthy older man — who complained of chest pain and “lightheadedness” while this tracing was recorded. In view of this history — How would YOU interpret the ECG in Figure-1 ? To improve visualization — I've digitized the original ECG using PMcardio ). He was not hypotensive.

EKG/ECG 195

EKG/ECG Wellness 195

Dr. Smith's ECG Blog

MAY 13, 2024

Here is the initial ECG at 13:17 with no prior ECG in the patient’s chart for comparison: What do you think? This is another version of the same ECG, lower quality, and with an additional filter applied. See Ken Grauer's additional comments about this ECG at the end of the post! The culprit mid LAD lesion was stented.

EKG/ECG 93

EKG/ECG Emergency Department Ultrasounds Documentation/Coding 93

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Here's the prior ECG: This confirms thew anterior ST depression is new. The first ECG was labeled “anterior subendocardial ischemia”, but subendocardial ischemia does not localize. So a patient with high pretest probability (prior CABG with new chest pain), had new ECG changes showing posterior OMI. Do you need posterior leads?

EKG/ECG 100

EKG/ECG Outcomes 100

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?

EKG/ECG 115

EKG/ECG Emergency Department Wellness 115

Dr. Smith's ECG Blog

MAY 18, 2023

Here is his ED ECG. There is coving of the ST segment in I and aVL, with large inverted T-waves and reciprocally upright large inferior T-waves (these actually suggest some reperfusion, but as the patient has persistent symptoms, one must assume there is continued ischemia). What do you think? Always abnormal.

EKG/ECG 52

EKG/ECG EMS 52

Ken Grauer, MD

APRIL 14, 2023

The ECG in Figure-1 was obtained from a 90-year old woman — who presented with a 2-to-3 day history of chest pain, that became worse on the day of admission. How would YOU interpret the ECG in Figure-1 ? Figure-1: The ECG in today’s case. ( To improve visualization — I've digitized the original ECG using PMcardio ).

EKG/ECG 195

EKG/ECG Wellness Hospitals 195

Ken Grauer, MD

APRIL 9, 2023

The 12-lead ECG and long lead II rhythm strip in Figure-1 was obtained from an 86-year old man — who presented to the ED ( E mergency D epartment ) with presyncope. How would YOU interpret the ECG in Figure-1 ? Figure-1: The initial ECG in today's case — obtained from an 86-year old man with presyncope, but no chest pain. (

EKG/ECG 195

EKG/ECG 195

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction.

EKG/ECG 104

EKG/ECG EMS Wellness Operations 104

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

Below is ECG #1 at triage. Are there any signs of occlusion or reperfusion? There are also subtle biphasic T waves in V3-4 of unclear significance (this can be seen in anterior or RV reperfusion, but this usually does not accompany infero-posterior occlusion). What do you think? And the biphasic T waves in V3-4 persist.

EKG/ECG 52

EKG/ECG 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

The following ECG was obtained. ECG 1 What do you think? The ECG shows sinus bradycardia but is otherwise normal. There is TWI in lead III, but this can be seen in normal ECGs. The following ECG was obtained around midnight. The machine read was "Normal sinus rhythm, normal ECG." ECG 2 What do you think?

EKG/ECG 92

EKG/ECG Burns Urgent Care Documentation/Coding 92

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.

EKG/ECG 72

EKG/ECG Documentation/Coding Emergency Department 72

Dr. Smith's ECG Blog

OCTOBER 30, 2023

Here is the first prehospital ECG (time 0, after one hour of pain): I do not see evidence of OMI, and neither did the Queen of Hearts Here is the 2nd prehospital ECG (time 10 minutes, after 70 minutes of pain): No change On arrival, the first ED ECG was recorded 20 minutes after the last one (90 minutes after pain onset): What do you think?

EKG/ECG 97

EKG/ECG 97

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Here is his triage ECG: 2045: What do you think? The ECG is subtle, but diagnostic of infero-posterior OMI. I sent the ECG with no information to Dr. McLaren, who instantly replied: "RCA?" (he A prior ECG was available: This ECG is normal, and thus confirms the concerns explained above.

EKG/ECG 52

EKG/ECG EMS Hospitals 52

Dr. Smith's ECG Blog

JULY 12, 2023

I come in early for every shift to read the ECGs on the system that have not yet been "confirmed". NORMAL ECG" What do you think? Be VERY careful when the computer calls the ECG "Normal". After the ECG was recorded, he was placed in the waiting room where he had been for over an hour. He was given aspirin and heparin.

EKG/ECG 65

EKG/ECG Wellness 65

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This ECG was recorded in triage. This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. I sent it to 5 of my OMI friends without any clinical information or outcome and all 5 independently responded with exactly the same diagnosis: "reperfused inferior OMI". LCX with moderate disease. Mild disease of RCA.

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EKG/ECG Resuscitation CPR Emergency Department 116

Dr. Smith's ECG Blog

DECEMBER 14, 2022

He reported several weeks of intermittent chest pain similar to the active pain, worsening over the past 2-3 days, some of them as long as an hour, but all spontaneously resolved and were of less intensity than the current symptoms. Here are his three EMS ECGs: EMS1 at 0735 This was sent to Dr. Smith with no other information.

EKG/ECG 52

EKG/ECG EMS Documentation/Coding Emergency Department 52

Dr. Smith's ECG Blog

APRIL 21, 2023

Written by Jesse McLaren, with comments from Smith A 50-year old patient on the medical wards developed acute chest pain, with an ECG labeled (see computer interpretation at the top) and confirmed as normal. I sent the ECG to Dr. Meyers without any other information. What do you think? This is diagnostic of inferoposterior OMI.

EKG/ECG 52

EKG/ECG Outcomes Research Hospitals 52

Dr. Smith's ECG Blog

JUNE 19, 2023

Here is his triage ECG which was obtained at 20:34 during active pain. 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 in aVF), but there is clear evidence of OMI findings on this ECG. This ECG is more difficult.

EKG/ECG 52

EKG/ECG Shock Emergency Department 52

Dr. Smith's ECG Blog

AUGUST 30, 2023

No prior ECG was available. Here is her triage ECG: What do you think? The ECG was sent to me with no information, and I replied "OMI". I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: V1 and V2 have abnormal STE, and V2 has a hyperacute T wave. Figure-1: The initial ECG in today's case. (

EKG/ECG 68

EKG/ECG Wellness Operations 68

Dr. Smith's ECG Blog

JANUARY 23, 2023

Close up of V3 with baseline in red Close up of V4 with baseline in red This ECG alone is highly suspicious for posterior OMI! Cardiology reviewed the posterior ECG and once again concluded that as there was no ST elevation in the posterior leads, there was no need for emergent PCI. This is a very specific marker of posterior OMI.

EKG/ECG 52

EKG/ECG Shock Emergency Department Ultrasounds 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

(photocopy of prehospital ECGs digitized by PMcardio) ECG #1 (top): there’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages. ECG # 2 (bottom): there’s sinus rhythm with normal conduction, normal axis, loss of R wave in V2, normal voltages. Will be missed easily.”

EKG/ECG 52

EKG/ECG Documentation/Coding EMS Wellness 52