tag:blogger.com,1999:blog-549949223388475481.post8070293260689775628..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: ST Elevation: is it due to old MI (LV aneurysm) or to acute STEMI? Unknownnoreply@blogger.comBlogger19125tag:blogger.com,1999:blog-549949223388475481.post-34295868931160961842020-12-15T18:17:35.326-06:002020-12-15T18:17:35.326-06:00Good question. LV aneurysm often has some shallow...Good question. LV aneurysm often has some shallow T-wave inversion. But even if the T-wave has started inverting, if the portion of that T-wave that is above the isoelectric line still gives a high ratio, then it is not due to old MI.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-80493384431479944652016-03-16T15:36:13.780-05:002016-03-16T15:36:13.780-05:00Congratulations on publication of this work! Yes, ...Congratulations on publication of this work! Yes, we both agree that ST-T wave morphology becomes more difficult to assess with tachycardia! THANKS again for posting this case.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-46201922566600577232016-03-16T07:41:51.855-05:002016-03-16T07:41:51.855-05:00Ken,
First, it is now validated and published: htt...Ken,<br />First, it is now validated and published: http://www.ajemjournal.com/article/S0735-6757(15)00190-4/abstract<br />Second, I would not be at all certain if the patient were still tachycardic, as tachycardia often exaggerates T-wave amplitude. Do you agree?<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-69204697444366281072016-03-16T05:46:06.463-05:002016-03-16T05:46:06.463-05:00Very NICE illustrative case on a concept that I kn...Very NICE illustrative case on a concept that I know you have been working on for some time now! I think the most insightful comment is in your answer to Ryan Tee’s question above = the reason for the helpful numeric rule is to facilitate communication of your near-instant perception that the ST elevation and T wave amplitudes are more-than-they-should-be for the QRS in the post-conversion ECG. Validation of your data with your soon-to-be-published work adds credibility.<br /><br />QUESTION: I agree that the 2nd ECG (post-cardioversion) look abnormal (and satisfies criteria in your equations). My question is if this patient was not cardioverted and the only tracing you had was the 1st ECG — How certain would you be that there was a new acute STEMI in addition to suspected LV aneurysm (ie, this tracing doesn’t look all that abnormal except for slightly-more-than-expected ST elevation in V5 … ).<br /><br />THANKS again for your insights!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-26479189046841184322014-10-10T09:43:47.722-05:002014-10-10T09:43:47.722-05:00It is like a Q-wave in the midst of the S-wave, lo...It is like a Q-wave in the midst of the S-wave, loss of anterior forces for a moment because of an area of infarct that has no anterior forces.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-90499725718287324562014-10-08T08:46:34.058-05:002014-10-08T08:46:34.058-05:00why notch in ascending part of QRS complex in V3 ?...why notch in ascending part of QRS complex in V3 ? Equbal , Family Physicianhttps://www.blogger.com/profile/15668924554489069795noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-77168749059838369012014-09-01T06:09:06.854-05:002014-09-01T06:09:06.854-05:00probably just forgot what I was doing and measured...probably just forgot what I was doing and measured different complexes (mistake). won't make a difference.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-30553175601772463042014-08-29T09:42:23.196-05:002014-08-29T09:42:23.196-05:00is there a reason you used different values for th...is there a reason you used different values for the QRS amplitude in V2 in rule 1 vs 2 (18.5, 21.5)ryannoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-28605547511470781872014-05-04T14:16:40.066-05:002014-05-04T14:16:40.066-05:00Good question.
Even in LV aneurysm, there is st...Good question. <br /><br />Even in LV aneurysm, there is still plenty of viable myocardium. Although the artery was open at cath, it was not necessarily open at the time of the ECG. Also, even though open, it had slow flow, inadequate flow. The proof is in the troponin elevation to peak of 22: there was enough myocardium to produce a large troponin leak with the infarct. Although you are right that tachycardia can exaggerate ST elevation, the final ECG shows almost no ST elevation to be exaggerated. This is definitely new STEMI superimposed on old LV aneurysm.<br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-31966654171501412242014-05-04T11:38:32.271-05:002014-05-04T11:38:32.271-05:00i am confused, can there be ischemia in already ne...i am confused, can there be ischemia in already necrotized tissue? He had acute 95% mid LAD stenosis and history of LV aneurysm.<br />My opinion this was not u true STEMI. He had significant mid LAD stenosis preveiosly vhich lead to LV aneurysm or it was just hibernating myocardium. And now rupture occurs that does not completly occludes the culprit vessel.<br />And tachycardia (109/min) contributes to ST elevation that is seen inV4-V6, but also in other lead where are q waves like in lead III or aVF.<br />Like in stress testing you may see STelevations in leads where is patological q wave.Anonymoushttps://www.blogger.com/profile/11606767107322555946noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-8931775746004232952014-05-02T11:29:11.778-05:002014-05-02T11:29:11.778-05:00Ryan, The reason I have a numeric rule is that is ...Ryan, The reason I have a numeric rule is that is the only way I know of to communicate my perception that the ST elevation and T-wave amplitudes are too great. I don't know of any other way to tell you how I "eyeballed" it!<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-52865318194556146112014-05-02T10:46:51.651-05:002014-05-02T10:46:51.651-05:00Dr Smith when u say " The ST elevation in V4 ...Dr Smith when u say " The ST elevation in V4 and V5, and the T-wave amplitude, appear to be too great for simple persistent ST elevation ", how did you really eye-balled it? Ryanhttps://www.blogger.com/profile/07887913972435356137noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-56011586827620341902014-05-01T19:25:22.119-05:002014-05-01T19:25:22.119-05:00Thank you for picking that up! That was a terribl...Thank you for picking that up! That was a terrible misprint.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-8056498460070226572014-05-01T19:17:40.869-05:002014-05-01T19:17:40.869-05:00I asked Nicolas to clarify, and this was his quest...I asked Nicolas to clarify, and this was his question:<br /><br />I should say, you use the formula, but without, do you have other signs to get the right diagnosis?<br /><br />Yes. The diagnosis of anterior LVA should be suspected in the setting of QS-waves or very poor R-waves. Without the Q-waves, the consideration is really not even present and one should not attempt to use this formula.<br /><br />Thanks for the great question.<br /><br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-84813390171074889822014-05-01T17:51:08.990-05:002014-05-01T17:51:08.990-05:00I see the STE in lead V5 a bit unusual, this maybe...I see the STE in lead V5 a bit unusual, this maybe the hint that clues me into thinking this is LVA on acute STEMI<br />By the way, I think u mean<br />Rule 1 : Any T/QRS ratio in V1-V4 > 0.36<br />Rule 2 : Sum of T / Sum of QRS in V1-V4 > 0.22 <br />Which supports the dx of acute STEMI in the setting of LVA Ryanhttps://www.blogger.com/profile/07887913972435356137noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-36011879662004662542014-05-01T15:50:12.647-05:002014-05-01T15:50:12.647-05:00Thanks for your comment. Because of the T-wave inv...Thanks for your comment. Because of the T-wave inversion and too high STE, I would refer to Cath-lab. My question: is there other differentials between aneurysm and STEMI with aneurysme than the formula?Nicolas Peschanskihttps://www.blogger.com/profile/07436778751052243538noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-75749951703199349822014-05-01T13:19:04.499-05:002014-05-01T13:19:04.499-05:00thank you dr steve for such anice and amazing case...thank you dr steve for such anice and amazing case<br />Dr emadhttps://www.blogger.com/profile/16674751839031264994noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43686203344503964992014-05-01T12:26:49.300-05:002014-05-01T12:26:49.300-05:00Nicholas, I would disagree with that. Late T-wave...Nicholas, I would disagree with that. Late T-wave inversion is very common in LV aneurysm.<br />See here: http://hqmeded-ecg.blogspot.com/2008/11/ecg-review-2_10.html<br />and here: http://hqmeded-ecg.blogspot.com/2008/11/is-this-wellens-syndrome.html<br /><br />It is as prevalent as an upright T-wave.<br /><br />I have many more.<br /><br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-83203875570048061432014-05-01T10:41:33.704-05:002014-05-01T10:41:33.704-05:00Dear Steven,
Besides, there is a late T-wave inve...Dear Steven,<br /><br />Besides, there is a late T-wave inversion in both V4 and V5 leads... Not usual in LV-aneurysmNicolas Peschanskihttps://www.blogger.com/profile/07436778751052243538noreply@blogger.com