Dr. Smith's ECG Blog: ECG Podcasts on 12-Lead & Arrhythmias — Pearls, Pitfalls, OMI & AI and Lots More

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I recently recorded a series of 4 podcasts regarding KEY concepts in ECG interpretation.
Easy LINK — https://tinyurl.com/KG-Blog-431 —

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My New ECG Podcasts (5/28/2024):

These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ("Making Waves") — hosted by Dr. Anthony Kashou. They are found on the Mayo Clinic Cardiovasciular CME site.
You can adjust the speed of the recording (If the speed is "slow" for you — increasing to 1.25 speed should be optimal for you! ).
Note the Timed Contents that I detail below facilitate finding specific material.

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ECG Podcast #1 — Common Errors in ECG Interpretation (And How to Easily Correct these Errors!) — published by Mayo Clinic CV Podcast Series on 12/19/2023 (30 minutes).

0:00 — Intro by Dr. Anthony Kashou: Welcome to Mayo Clinic’s ECG Segment: “Making Waves” (Today's discussion — About today’s speaker = Ken Grauer, MD).
2:00 — Dr. Grauer: “How did you get so skilled at ECGs?”
3:30 — Me introducing today’s topic ( = “Common Errors in ECG Interpretation”) — and why I chose this topic.
4:35 — I’m sent a tracing. The 1st “Error” is either no History (or a History that does not tell me what I need to know).
6:40 — The need for a relevant History (Clinical examples!).

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KEY POINT: Be sure to list all antiarrhythmic drugs (Note rate-slowing meds — Herbal products! — and ask about beta-blocker eye drops! ).

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13:10 — Next Error = NOT forcing yourself to commit to a diagnosis!
14:10 — Next category of Errors = The need for a Systematic Approach (This will not slow you down! Instead — it speeds you up, improves your accuracy and makes you sound smarter!).
15:50 — My System for Rhythm Interpretation ( = First, look at the patient! — then, “Watch your Ps, Qs & 3Rs” ).
18:15 — The error of premature closure (Thinking there are only 2 answers = “VT or SVT” — because you forget the 3rd Answer = a relative probability statement!).
19:50 — Not appreciating statistical odds! (ie, What are the odds that a regular WCT without P waves will be VT?).
22:25 — What if you have a regular SVT ( = narrow-complex tachycardia) without obvious P waves? (The 4 common causes? — The most commonly overlooked cause?)

25:10 — My System for 12-Lead ECG Interpretation: (What are the 6 KEY parameters to look for?).

The 6 KEY Parameters I favor for my Systematic Approach ( = Rate - Rhythm - Intervals [PR-QRS-QTc] - Axis - Chamber Enlargement & QRST Changes).
Be sure to look at Intervals at an early point in the process!
27:50 — SUMMARY by Dr. Anthony Kashou.

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NOTE: For more on "My Take" regarding the ECG diagnosis of acute OMI — See my ECG Podcast #2 (LINK and detailed Contents below!)

Please also Check Out my new ECG Videos #406, 407 and 408 on this topic (CLICK HERE).
For links to ECG cases of artifact and other "technical misadventures" — Please check out My Comment at the bottom of the page of the February 18, 2024 post in Dr. Smith's ECG Blog.

And regarding arrhythmias:

For more on the regular WCT — See My Comment in the May 5, 2020 post and in the April 15, 2020 post in Dr. Smith's ECG Blog.
For more on the regular SVT — See My Comment in the October 25, 2022 post and in the March 6, 2020 post in Dr. Smith's ECG Blog
For more on recognizing AFlutter — See My Comment in the May 1, 2023 post in Dr. Smith's ECG Blog.

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ECG Podcast #2 — ECG Errors that Lead to Missing Acute Coronary Occlusion (Reviewing the concept of OMI — and why the "STEMI Paradigm" is outdated and misses too many acute coronary occlusions!) — published by Mayo Clinic CV Podcast Series on 1/16/2024 (33 minutes).

0:00 — Intro by Dr. Anthony Kashou: Welcome to Mayo Clinic’s ECG Segment: “Making Waves” (Today's discussion — About today’s speaker = Ken Grauer, MD).
2:25 — Dr. Grauer: The 1st Error: Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”. (What do we really care about in the patient with new CP [Chest Pain]? ).
6:15 — Error #2: Overuse of the term, “NSTEMI” — which practically speaking is a useless term. Many (if not most) NSTEMIs are actually OMIs ( = acute coronary Occlusion MIs).
7:42 — Error #3: The ECG criteria for diagnosing an OMI?
9:25 — Are there hyperacute T waves?
11:37 — Can you find a prior tracing on the patient?
12:20 — Look carefully at neighboring leads!
13:10 — The “magical” mirror-image opposite relation! (Use of my Mirror Test to instantly identify posterior OMIs — and inferior OMIs by comparing leads III and aVL).
15:35 — Why posterior leads are not needed!
18:58 — Look for dynamic ST-T wave changes! (How often to repeat the ECG?)
20:25 — The 1st high-sensitivity Troponin may be normal.
21:00 — What to know about the prior tracing?
21:50 — The Biggest Error — is not correlating the History to each ECG that is done! (Because the provider does not appreciate the concept of spontaneous reperfusion!).
29:00 — Today's Final Error — is not learning from our cases!
31:28 — SUMMARY by Dr. Anthony Kashou.

ECG Podcast #3 — Computerized ECG Interpretation and AI in 2024 (Is there any computerized ECG program that can reliably help clinicians to better interpret ECGs?) — published by Mayo Clinic CV Podcast Series on 3/19/2024 (28 minutes).

0:00 — Intro by Dr. Anthony Kashou: Welcome to Mayo Clinic’s ECG Segment: “Making Waves” (Today's discussion — About today’s speaker = Ken Grauer, MD).
2:00 — Dr. Kashou to Dr. Grauer: "In 2024 — Where do you see computerized ECG interpretations and AI?"

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Please NOTE: I divided my comments into 2 "Eras, regarding the use of computerized ECG interpretations: i) The initial Era (ie, from the mid-1980s until very recently); — and, ii) The new QOH (Queen Of Hearts) Era — in which the QOH application for assessment of acute OMI is so quickly becoming widely available!

General Overview of this Podcast:

From 0:00-to-5:54 = Introductory material.
From 5:54-to-16:13 = Review of my experience with computerized ECG interpretation from the mid-1980s until very recently ( = the initial Era).
From 16:13-to-27:00 = How the new QOH application may dramatically improve rapid recognition of acute OMI. (For listeners primarily interested in QOH — Feel free to jump to 16:13 in this 28 minute podcast).
From 27:00-to-END — SUMMARY by Dr. Anthony Kashou.

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More Specific Breakdown of Contents:

2:20 — My "Disclaimer": What follows today reflects my opinion, based on my experience. I have no financial interest in any commercial product related to my comments.
I begin by offering some Pros & Cons of AI in our Life "outside" of the ECG World ...
5:54 — So how in 2024, do I think AI is impacting on ECG interpretation? How much "human oversight" is needed?
7:15 — A number of fundamental errors continue to be made! So — Where are we going with use of AI for ECG interpretations?
8:00 — To answer, it's worth looking at where have we come from? I trace my experience with computerized ECG interpretation, which literally began decades ago, in the 1980s! During these decades (and up to the present) — there continues the tendency for too-many-clinicians to accept without question what the computer says. This needs to change.
10:20 — How the computer can best assist clinicians with ECG interpretation? Realize that clinicians with different levels of experience and different training have different needs (ie, The needs of an experienced cardiologist or emergency physician are different than the needs of clinicians with far less training and experience in ECG interpretation).
11:35 — My views on: Will the computer ever be able to interpret complex arrhythmias?
12:15 — Regarding my experience from the 1980s until ~2010: How I went from hating computer interpretations to loving them (after I finally understood what the computer can and can not do).
14:45 — Using my definition — Are YOU an “expert” ECG interpreter? The computer saves experts time.
For “non-experts" ( = 90-95% of clinicians, even though many such clinicians may still be very good interpreters) — the computer provides a 2nd opinion.
16:13 — That was then ... What about now? (ie, What can AI offer us in 2024 as a way to improve our ECG interpretation?).

I emphasize these 4 concepts in these last 11 minutes (16:13-27:00):

— i) All ECG programs that I am aware of prior to development of QOH — are out-of-date, and of little-to-no use in emergency care!
— ii) Computerized interpretations are not helpful for arrhythmia assessment (The simpler arrhythmias are obvious to capable clinicians — and the computer makes too many mistakes for complex tracings);
— iii) The new QOH application is already amazingly accurate in recognizing acute coronary Occlusion in cases when outdated STEMI criteria are not fulfilled (with rapid recognition of acute OMI that prompts early reperfusion saving valuable myocardium!). Future generations of QOH will continue to improve (See Dr. Stephen Smith's ECG Blog for numerous clinical cases illustrating features of this QOH application for OMI diagnosis); — and,
— iv) Optimal clinical diagnosis of acute OMI at an early point in the process is best attained by the combination of a capable ECG interpreter who is open to receiving QOH input.
27:00 — SUMMARY by Dr. Anthony Kashou.

ECG Podcast #4 — All About Comparison ECGs for 12-Leads and Arrhythmias (Comparing ECGs seems so "easy" to do — but so often is not done correctly!) — published by Mayo Clinic CV Podcast Series on 5/21/2024 (35 minutes).

0:00 — Intro by Dr. Anthony Kashou: Welcome to Mayo Clinic’s ECG Segment: “Making Waves” (Today's discussion — About today’s speaker = Ken Grauer, MD).
1:50 — Dr. Kashou to Dr. Grauer: “What can we learn from ECG comparisons?” — and — “How best to compare tracings in time-efficient fashion?”
2:15 — ME introducing today’s topic — and WHY I chose to speak about this often-neglected but important clinical issue.

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Please NOTE: My comments are divided into 2 "parts" regarding the use of comparison tracings: i) Comparison of one 12-lead ECG with another (ie, including use of serial ECGs in a patient with chest pain — and how BEST to use a prior "baseline" tracing); — and — ii) Optimal use of comparison tracing with cardiac arrhythmias!

2:50 — Let’s start with comparison of 12-Lead ECGs. What are the problems? How to optimize the technique for comparison in time-efficient fashion?
3:20 — First determine, "What are you comparing?" (ie, WHAT was going on at the time that the "prior" 12-lead ECG was done? — that is, Was the patient asymptomatic? — or — Was your "baseline" tracing recorded at the time of a previous infarction?) = WHAT are you comparing?
5:25 — Moving on to serial ECGs. By correlating each ECG with whether CP (Chest Pain) was present (and if so — how severe?) — you can often tell IF the “culprit” vessel is now open or closed!
KEY Point: It's essential to correlate each ECG with the status of CP at the time each tracing is recorded! (Write this on the actual ECG and in the chart – or else it will not be remembered).
8:35 — Illustrating how correlating serial ECGs and the presence and severity of symptoms can diagnose an acute OMI (with need for prompt cath) — even when the initial ECG was “only" nonspecific.
9:50 — How often to repeat the ECG in a patient with CP? (Answer: As often as is needed until you become certain about acute OMI or no OMI!).
NOTE: — Do not give morphine until you know what you will do with your patient! (ie, until you know if the cath lab needs to be activated!).
10:50 — An acute evolving OMI may sometimes change in less than 5-to-10 minutes. As a result — ECGs may need to be repeated within a period of minutes! (especially IF there is a change in the presence or severity of CP).
11:45 — Look for “dynamic” ST-T wave changes on serial tracings! These may be subtle — but when they occur in a patient presenting with CP, it is often (usually) an indication for prompt cath!

12:15 — My "Take" on the “optimal” time-efficient and accurate technique for comparing 12-lead ECGs?

KEY Point: You have to go Lead-by-Lead from 1 tracing-to-the-2nd tracing! (because if you don’t — you will overlook subtle-but-important changes!).
NOTE: Careful lead-by lead comparison actually takes less time than the random way most clinicians compare 1 ECG with another. (Confession: I miss subtle "dynamic" changes when I do not do meticulous lead-by-lead comparison).
14:05 — With serial 12-lead ECGs — “Be sure you are comparing apples with apples, and not with oranges”. That is — IF the frontal plane axis and/or precordial lead placement is not the same for the 2 tracings that we are comparing — this needs to be taken into account when we do serial comparison!
16:50 — IF you see excessive artifact and/or other "technical misadventure" in a patient with new CP for whom you need to determine IF an acute OMI is ongoing — Repeat the ECG immediately! (ie, Don't wait to repeat the ECG ...).
18:15 — Examples of technical “misadventures” (ie, Lead I should never normally show global negativity).
18:40 — Regarding technical “misadventures” (ie, “Things that I wish I knew last year" ) — Be aware of PTA (Pulse-Tap Artifact) — which once you have seen it — can be instantly recognized! (to the amazement of your colleagues who are not aware of PTA!).

22:25 — Using serial tracings for optimal Rhythm interpretation!

KEY Point: Look for additional simultaneously-recorded leads = “12 Leads are Better than One!” (ie, For example with tachycardias — the QRS may look narrow if all you have is 1 or 2 leads — whereas if part of the QRS lies on the baseline in the single lead you are looking at, this might be VT!).
24:10 — The 5 BEST leads (in my opinion) for looking for atrial activity in a tachycardia are lead II (ie, The P must be upright in lead II if there is sinus rhythm — unless dextrocardia or lead misplacement) — and then leads V1; III, aVF; and lead aVR (these 5 leads being my “Go-To-Leads” for finding subtle flutter waves — as well as for finding subtle retrograde activity and subtle AV dissociation).
25:00 — The advantage of getting a 12-lead in an unknown tachycardia = “12 Leads are Better than One” ( = You have 12 leads to tell if the QRS is wide or narrow!).
26:10 — Even though initial emergency treatment of a regular SVT rhythm will be similar (if not identical) regardless of what type of SVT the rhythm is — ultimate management will be better IF at some point you can determine for certain what type of SVT rhythm this was! — Get a post-conversion 12-lead ECG — and compare this to the initial 12-lead ECG obtained during the tachycardia!
Doing so helps to distinguish between the 4 most Common Causes of a regular SVT at ~150/minute, but without sinus P waves = i) Sinus tach; ii) Atrial tach; iii) Reentry SVT ( = AVNRT vs orthodromic AVRT); or iv) AFlutter (which is by far, the most commonly overlooked arrhythmia!).
29:20 — And my last few minutes on, "HOW does a comparison ECG help you when interpreting a regular WCT (Wide-Complex Tachycardia) rhythm?

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NOTE: Because of time restrictions — I did not expand on the differential diagnosis of a regular WCT rhythm — which for practical purposes is: i) VT, VT, VT until proven otherwise!; ii) SVT with either rate-related aberrant conduction or a preexisting BBB (which is where a prior tracing can be so helpful!); — or — iii) Something else! (ie, a WPW-related tachyarrhythmia — Hyperkalemia! — some toxicity).

See ECG Podcast #1 below for more 12-lead and problematic arrhythmia interpretation.

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33:30 — SUMMARY by Dr. Anthony Kashou.

Wednesday, July 24, 2024

ECG Podcasts on 12-Lead & Arrhythmias — Pearls, Pitfalls, OMI & AI and Lots More

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