tag:blogger.com,1999:blog-549949223388475481.post3368342875540467202..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: 60-something with wide complex tachycardia: from where does the rhythm originate?Unknownnoreply@blogger.comBlogger22125tag:blogger.com,1999:blog-549949223388475481.post-17364659117899875862020-04-20T18:34:24.173-05:002020-04-20T18:34:24.173-05:00I'm sorry I have been so busy I have not been ...I'm sorry I have been so busy I have not been able to answer these emails in a long time.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43489089694887603152020-04-20T16:24:56.294-05:002020-04-20T16:24:56.294-05:00@ Ahammed — For questions or comments regarding th...@ Ahammed — For questions or comments regarding the ECG(s) in this case — simply write your comment/question here. For submission to Dr. Smith of ECGs of potential interest for a new case on our Blog — You'll note in the RIGHT column, near the top — the "Contact for Interesting ECGs" — which when clicked sends an email to Dr. Smith. Please BE SURE any tracings you send provide pertinent clinical details, with ECGs that are upright and of high resolution. Thank you — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-84434793486214578302020-04-20T16:20:25.908-05:002020-04-20T16:20:25.908-05:00Thanks Jerry! — :)
Thanks Jerry! — :)<br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-79118357220527185162020-04-20T14:02:09.730-05:002020-04-20T14:02:09.730-05:00Hello sir, How can I send a ecg for clarification ...Hello sir, How can I send a ecg for clarification of findings? Your email id please.Ahammed Sadik Choklyhttps://www.blogger.com/profile/11569047044563832736noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-2445526910046218692020-04-20T13:21:15.489-05:002020-04-20T13:21:15.489-05:00Great comments, Ken. Just by looking at V1 and V2,...Great comments, Ken. Just by looking at V1 and V2, I would say that there is way too much daylight between the ascending and descending limbs of those r waves. That is just too much width for a LBBB which always begins normally.Jerry W. Jones, MD FACEP FAAEMhttps://www.medicusofhouston.comnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-36439067116352463952020-04-19T07:45:24.067-05:002020-04-19T07:45:24.067-05:00@ Aldo — Our pleasure! — :)@ Aldo — Our pleasure! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-5443752856011221172020-04-19T05:36:34.814-05:002020-04-19T05:36:34.814-05:00Thank you for the excellent description of the met...Thank you for the excellent description of the method to differentiate VT from other entities. Very clear and instructive treatise of a topic usually considered somehow "esoteric" by cardiac surgeons like me!<br /><br />AldoAnonymoushttps://www.blogger.com/profile/16165112131267236971noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-64708100119513836572020-04-17T23:37:49.254-05:002020-04-17T23:37:49.254-05:00@ Felipe — 50% is a surprisingly good EF for this ...@ Felipe — 50% is a surprisingly good EF for this patient — but that in no way rules out the possibility of VT. As per My Comment above — there are many indicators here of severe underlying heart disease in this elderly woman — so statistical odds that a regular WCT rhythm will turn out to be VT in this patient (even BEFORE you look at the actual ECG!) are >90% (as I describe above). THANKS for your comment — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-17485129132632160502020-04-17T23:33:34.844-05:002020-04-17T23:33:34.844-05:00Gracias a ti for tu interés! (Thanks to you for yo...Gracias a ti for tu interés! (Thanks to you for your interest — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43826932298779203272020-04-17T13:23:00.283-05:002020-04-17T13:23:00.283-05:00Was possible to predict that arrhythmia?
EF 50...Was possible to predict that arrhythmia? <br /><br />EF 50% was good ! Felipe Afonsohttps://www.blogger.com/profile/16015561549003035983noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-26365944545187970342020-04-17T10:14:18.760-05:002020-04-17T10:14:18.760-05:00Gracias por compartir su conocimiento. Excelente B...Gracias por compartir su conocimiento. Excelente Blog.Little Cardiologisthttps://www.blogger.com/profile/10678230049404603647noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-52462916720320983182020-04-17T07:59:20.743-05:002020-04-17T07:59:20.743-05:00Agree this looks like OMI in VT, but it was not.Agree this looks like OMI in VT, but it was not.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-35704910649657204232020-04-15T22:37:09.932-05:002020-04-15T22:37:09.932-05:00Our pleasure. Thanks for your support! — :)Our pleasure. Thanks for your support! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-90919392011860862832020-04-15T22:36:52.781-05:002020-04-15T22:36:52.781-05:00@ ECG Life — I assume you are asking about ECG #1,...@ ECG Life — I assume you are asking about ECG #1, which is the initial tracing in the ED, which shows tachycardia. The ventricular rate of ~185-190/minute is too fast for 2:1 AFlutter (would mean the atria would have to be ~370-380/minute, which is much faster than AFlutter typically is). If you are thinking those humps (under my RED arrows) are extra atrial waves — they are not — because if you use calipers, these do not march out 2:1 with any other deflection in the inferior leads. This is not AFlutter. QRS morphology (as I describe above in My Comment) superficially resembles LBBB and not RBBB — but as I mention, QRS morphology actually has very atypical features for lbbb. Therefore, this is VT (and that diagnosis was supported by EP study).ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-26752016873924498292020-04-15T19:50:50.929-05:002020-04-15T19:50:50.929-05:00great blog, thank yougreat blog, thank youUnknownhttps://www.blogger.com/profile/14463938438677742493noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-70773115719152375002020-04-15T18:58:31.943-05:002020-04-15T18:58:31.943-05:00@ Anonymous — Thanks for your comment. Astute obse...@ Anonymous — Thanks for your comment. Astute observation you made (!) about the “too high” J-point in ECG #1 (Please see insightful Comment by K.Wang below + My reply to his comment). Regarding ECG #2 — in my opinion, the Q waves in leads II and V5 are of questionable duration — but the Q waves in leads III, aVF and definitely in lead V6 are wider-than-I-think-they-shoud-be in a patient who has not had previous infarction. Of course, Q wave size and width is not a perfect criterion for assessing the presence of acute or previous infarction — and some of this assessment is indeed subjective. But to my measurement — Q wave width in lead III of ECG #2 is at least 1 little box in duration (ie, ≥0.04 second), which is “too” wide for me — and proportionately, there is NO way in my opinion that a “normal septal Q wave” in lead V6 should be as wide as this one is given the small amplitude of the R wave in this lead. THANKS again for your excellent comments! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-47980251556991679682020-04-15T18:49:43.947-05:002020-04-15T18:49:43.947-05:00@ Anonymous — Thanks for your comment. I know ther...@ Anonymous — Thanks for your comment. I know there are excellent clinicians who depend entirely on lead aVR for distinguishing VT vs SVT in a regular WCT. I always look at lead aVR in regular WCT rhythms — because if the QRS complex is ENTIRELY positive (no negativity at all!) — then specificity for VT approaches 100% — because this means the electrical impulse must be arising from the apex, and SVT’s don’t do that. That said, in the absence of an entirely positive QRS complex in lead aVR — I’ve not found this lead overly helpful in differentiating WCT rhythms because of difficulty I often have in confidently determining precise QRS morphology (ie, is there a QS complex in ECG #1 in this case — or are we seeing a tiny initial r wave in this lead?). I realize others may disagree with my opinion about the utility of lead aVR with WCT rhythms — and that’s fine — :)<br /><br />Otherwise — the “220 minus Age” rule is derived from exercise testing (ETT), and provides a quick estimate as to the expected maximal heart rate to be attained during FULL EXERCISE. When doing ETT in the office — I always tried (if possible) to attain at least 85% of a patient’s maximal predicted heart rate — since not achieving this heart rate goal meant reduced sensitivity and specificity for your results. That said — the “220 minus Age” does NOT apply to usual rate limits for a “horizontal patient” (ie, a patient who has not just performed maximal exercise). In my experience — it is unusual for sinus tachycardia to attain heart rates >170/minute for a “horizontal adult”. Please NOTE — I did NOT say impossible, as we all have seen occasional adult patients with sinus tachycardia at heart rates greater than this — but that’s not the usual. Please also NOTE that these limits do not hold true for pediatric patients — for whom sinus tach on occasion. may attain rate up to 200/minute or more. BOTTOM LINE — The above explanation is why I said the heart rate of ~185-190/minute in ECG #1 of this case was extremely unlikely to be sinus tach. THANKS again for your comment! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-49883243078500673002020-04-15T18:41:31.391-05:002020-04-15T18:41:31.391-05:00Thanks Dr S & KG..why not its Atrial Flutter w...Thanks Dr S & KG..why not its Atrial Flutter with underlying RBBB?ECG Lifehttps://www.blogger.com/profile/10933001219016192543noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-86652652080021645082020-04-15T18:34:01.686-05:002020-04-15T18:34:01.686-05:00SSmith Blog
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THANKS for your comment K!...SSmith Blog<br />==========<br /><br />THANKS for your comment K! Excellent point you make (and which we have made a number of times in previous blog posts in Dr. Smith’s ECG Blog). It apparently turned out in this case that there was no acute occlusion on cath — and there were no acute ECG changes on the post-conversion 12-lead … Although marked tachycardia sometimes results in ST elevation that resolves after rhythm conversion — I would not have expected THIS MUCH elevation of ST segments (with this much reciprocal ST depression in leads I and aVL) without there being acute occlusion — but as best I can tell from the information provided, there was no acute OMI in this case. But I should have mentioned this in my comment — so THANK YOU for pointing it out! I will pass on your comment to Dr. Smith to see if he has anything more to add — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-21193359047827281602020-04-15T16:37:20.444-05:002020-04-15T16:37:20.444-05:00The infero-lateral STEMI could have been told alre...The infero-lateral STEMI could have been told already from the QRSs in leads II, III, aVF and V5 during the VT (note the red arrow-heads by Dr. Ken Grauer in the ECG #1 above). Yes, QRSs originating from the ventricle, such as QRSs of PVC, accelerated idioventricular rhythm, VT or ventricularly paced rhythm, can reveal STEMI very effectively. So we should not say "it's no use looking at the ECG" because the patient is in VT".<br />K. Wang.Anonymoushttps://www.blogger.com/profile/04509940285330859355noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-17775328469929500292020-04-15T14:59:11.586-05:002020-04-15T14:59:11.586-05:00Nice case Dr Smith and comments Dr Grauer...
It hi...Nice case Dr Smith and comments Dr Grauer...<br />It hits indeed a number of points in Brugada algorithm...<br />Also if one only scrutinised aVR lead, then there is initial negative QRS deflection, i.e. QW which is >40ms (it's close to 80ms) as well as notching of the initial downstroke of negative QRS...<br />Amal Mattu in one of his talks mentioned think of max HR... its 220 minus your age if it is more than that, then it is not SR <br />And then of course age with Hx of CAD... <br />Interesting to read EP's interpretation too...<br />Good innings... <br />OR Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-82110535891456600322020-04-15T14:45:41.093-05:002020-04-15T14:45:41.093-05:00Great case as usual!
One question and one observa...Great case as usual!<br /><br />One question and one observation:<br /><br />-In the first ECG, isn't J point a little bit too "high" in the inferior leads and too "low" in the lateral leads, even in the presence of LBBB? Could this represent demand ischemia due to a very fast heart rate?<br />-In the second ECG, of course I agree about QRS fragmentation, but honestly Q waves didn't look that abnormal to me on first sight. I agree about duration which is over 40 msec, but they don't look too deep compared to QRS size.. I would have easily mistaken them for "appropriate" Q waves in the setting of LPFH.<br /><br />Thanks for sharing!Anonymousnoreply@blogger.com