tag:blogger.com,1999:blog-549949223388475481.post4226102631445267867..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: An ECG sent to me with concern for hyperacute T-wavesUnknownnoreply@blogger.comBlogger8125tag:blogger.com,1999:blog-549949223388475481.post-17541141185845763282019-08-31T23:52:49.259-05:002019-08-31T23:52:49.259-05:00very cool discussion, very interesting case and ec...very cool discussion, very interesting case and ecg. thank you Pendell, et al.<br /> one ecg begets another.<br /><br />tomtfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-2616329327956318392019-08-28T18:19:31.431-05:002019-08-28T18:19:31.431-05:00Thanks (as always!) for your comment Jerry. To fol...Thanks (as always!) for your comment Jerry. To follow-up on your important point that “chest pain” (CP) is NOT needed for there to be an acute MI — I always refer back to the Framingham studies which showed AT LEAST 1/4 (if not 1/3) of all MI’s in their MANY-year follow-up studies were “silent” — in that they were not associated with chest pain. But OF THOSE 1/4-to-1/3 of all MIs in the Framingham studies — about HALF of that group had NO chest pain at all — and the other HALF had “something else” in association with their MI. The most common “something else” ( = non-CP) symptom was shortness of breath — but other non-CP symptoms incuded GI upset; “flu”-like symptoms; weakness; mental status changes; and syncope. We always look for "chest pain" when taking our history — but especially in a population of a certain age, any NEW symptom that temporally correlates with what you are seeing on ECG could be a non-CP "equivalent" symptom. HISTORY is key! Thanks again for your input! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-10277026553626396652019-08-28T18:06:20.433-05:002019-08-28T18:06:20.433-05:00Thank you Aldo for your excellent question. As per...Thank you Aldo for your excellent question. As per Dr. Meyers — qualitative assessment is the current standard — though in addition to the point you mention — I’ll ADD a few descriptive points regarding the example of TRUE POSITIVE Hyperacute T waves that Dr. Meyers added (showing leads II, III, aVF & aVL) above. These are: i) As per Dr. Meyers, this true positive example looks “fat” not only at the T wave peak, but ALSO at the wide T wave base; ii) The short ST segment prior to the upslope of this hyperacute T wave is FLAT (instead of gently upsloping); iii) The junction of this flat ST segment with the initial upslope of the T wave is ANGULATED (ie, abrupt, instead of gently upsloping); iv) The changes in i,ii,iii are seen in ALL 3 inferior leads; and v) The negative T wave in lead aVL is the MIRROR-IMAGE opposite picture of what we see for the T wave in lead III, in that the negative T in aVL is WIDE and FAT at its nadir. Not all hyperacute T waves have all of these changes — but the example shown by Dr. Meyers DOES — so “qualitatively”, we CAN state with certainty (until proven otherwise) that this is a TRUE positive. That said — in order to achieve an acceptable (ie, >95%) level of certainty to RULE OUT the possibility that the taller-than-they-should-be inferior T waves in the case presented here (in this patient with new syncope) were NOT due to an acute event — additional testing (serial ECGs, Echo, troponin) was needed. Grazie ancora per il tuo ottimo commento! (Thanks again for your excellent comment!) — :)<br /><br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-63412050634301255212019-08-28T08:52:00.970-05:002019-08-28T08:52:00.970-05:00Jerry, agreed. We should always err on the side of...Jerry, agreed. We should always err on the side of more false positives than false negatives. If no CAD is present, then no intervention is needed; if no intervention, the risk of the PCI to the patient is quite low. Thus a false negative is not so untenable (unless you ask the cath team). <br /><br />So for those who are not at the stage of learning to differentiate things like this case from true positive hyperacute T-waves, I totally agree that this case should be met with immediate concern which may justify cath lab activation.Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-47113662388917557972019-08-28T08:43:54.110-05:002019-08-28T08:43:54.110-05:00Thanks for the feedback, happy to hear it helps yo...Thanks for the feedback, happy to hear it helps your practice!<br />I have not considered the concept of that angle before, but it does seem that a wider angle may correspond with a "fatter" T-wave. We are in the beginning stages of studying hyperacute T-wave more definitively. Our first analysis will be aimed at the area under the curve of the ST-T complex compared against the size/area/etc of the QRS complex. Perhaps your angle idea would also be helpful. Until we have better data, it remains to be human pattern recognition. Thanks!Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-14869851047132794152019-08-28T04:58:25.681-05:002019-08-28T04:58:25.681-05:00Dr. Meyers...
Thanks for a very informative prese...Dr. Meyers...<br /><br />Thanks for a very informative presentation. Whether the T waves were hyperacute or not is not an easy call in this case for anyone, so those who are relatively new to ECG interpretation should not feel too bad if they called it wrong. If one is going to err, it's much better to err on the side of caution. As both Dr. Meyers and Dr. Grauer indicated, you need to base your decisions on more than just the ECG. I think activation of the cath lab here was probably unavoidable based on the history and presentation. I would have felt more comfortable holding the patient and repeating the ECG every 15 - 20 minutes if there had been less of an issue with the ECG (though lack of WMA on echo or a positive troponin could also have been significant factors in deciding whether or not to wait).<br /><br />Regarding the contribution of history of present illnes in this case, one should always be very cautious of the combination of older age group, female gender and diabetes in a patient. Any of the three can result in atypical symptoms experienced by the patient so one should never require chest pain as a symptom of OMI when any one of these background factors are present and certainly not when more than one are present.<br /><br />Thanks to Drs. Meyer and Grauer for their comments and for a very educational presentation.<br /><br />If I may make a practical suggestion to those who are just developing their skills at ECG interpretation - even to this day I keep copies of three or four NORMAL ECGs next to my computer for the sake of comparison. Even though I am not comparing ECGs from the same patient, it often helps in getting a "feel" for what is normal, what is abnormal and what is "suspicious."Jerry W. Jones, MD FACEP FAAEMhttps://www.blogger.com/profile/10333187745825224414noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-80110724232469205832019-08-27T14:17:25.566-05:002019-08-27T14:17:25.566-05:00Dear dr Smith,
I'm a cardiac surgeon working i...Dear dr Smith,<br />I'm a cardiac surgeon working in Milan, Italy. I'm deeply indebted to you for this fantastic blog and your book about ecg in mi and reperfusion. They are really improving my clinical practice.<br />In order to achieve objective criteria for hyperacute T waves, could it be useful to measure the angle between ascending and descending T limbs?<br />Thank you. <br />Best regards, <br />Aldo Cannata, MDAnonymoushttps://www.blogger.com/profile/16165112131267236971noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-27859977933888362012019-08-27T10:59:17.112-05:002019-08-27T10:59:17.112-05:00This is an excellent “false positive ECG” case to ...This is an excellent “false positive ECG” case to learn from.<br /><br />I agree entirely with Dr. Meyers and prof. Grauer: I wouldn’t activate cath lab on the basis of this ECG alone, rather I would have made the usual management of any suspicious ACS (close observation, serial ECGs and troponins, bedside echo).<br />As to the ECG findings, I would add another ECG sign and I refer to the difference between the ischemic versus non-ischemic hyperacute T waves (applying also to ischemic or non-ischemic STE).<br />In the case at hand, we can see the abrubt passage from the isoelectric ST-segment to the hyperacute T wave in true OMI (abrupt angle), whereas we can see a more gentle angle (if any) in non-ischemic ECG. The above ECG sign is not of course standardized or proved by clinical trials, it's a tiny detail but is often (=not always), at least in my experience, very useful.<br />Thanks for sharing this instructive case.<br />Mario ParrinelloAnonymousnoreply@blogger.com