tag:blogger.com,1999:blog-549949223388475481.post425421116372571979..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A 60-something Woman with Chest Pain and a Wide QRSUnknownnoreply@blogger.comBlogger6125tag:blogger.com,1999:blog-549949223388475481.post-34729247845694355952020-09-18T21:39:33.817-05:002020-09-18T21:39:33.817-05:00There was no pacemaker. As per the history (provid...There was no pacemaker. As per the history (provided in the 1st sentence above) — this 60-something year old woman had previously been healthy.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-65120245782538846592020-09-18T12:44:11.909-05:002020-09-18T12:44:11.909-05:00Great case! I wonder can this be an atrial sense v...Great case! I wonder can this be an atrial sense ventricular pace rhythm? since there are notch before the nadir of S wave in aVR, v1, v2, referred as josephson sign, which are not the typical morphology for LBBB(also mentioned in brugada algorithm and vereckei algorithm). Or maybe this sign isn't specific enough?jerryjanhttps://www.blogger.com/profile/14840935210233417099noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-15289386121431635792020-09-17T22:52:41.350-05:002020-09-17T22:52:41.350-05:00rediction of the occluded coronary artery is not 1...rediction of the occluded coronary artery is not 100% accurate when there is sinus rhythm and a narrow QRS. Things such as anatomic variants — variations in collateral flow — multi-vessel diseaase — prior infarctions — etc. can all affect the accuracy of predictions. When there is sinus rhythm with bundle branch block, prediction of the “culprit” artery may be even more challenging. That said — sometimes you CAN still tell the location of the acutely occluded artery, despite the presence of BBB. We saw this in today’s case — in which despite the LBBB, the 2 serial ECGs showed acute evolving infero-postero-lateral infarction that allowed us to accurately predict acute RCA occlusion.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-14684525039077851452020-09-17T19:33:28.148-05:002020-09-17T19:33:28.148-05:00Thought I read comments on here that you cannot te...Thought I read comments on here that you cannot tell the location of the occluded coronary when interpreting wide complex.b-climbhttps://www.blogger.com/profile/06117587083757973747noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-15363993032753049372020-09-17T18:52:39.536-05:002020-09-17T18:52:39.536-05:00@ Marco Garrone — The original 3 criteria from the...@ Marco Garrone — The original 3 criteria from the 1996 Sgarbossa scale that are used to diagnose infarction in patients with LBBB were: <br />i) Concordant ST elevation > 1mm in leads with a positive QRS complex (score 5); <br />ii) Concordant ST depression > 1 mm in V1-V3 (score 3); <br />iii) Excessively discordant ST elevation > 5 mm in leads with a -ve QRS complex (score 2).<br /><br />A total score of ≥ 3 is reported to have a specificity of 90% for diagnosing myocardial infarction.<br /><br />In ECG #1 — I do not see concordant ST elevation — nor do I see concordant ST depression. Because the original Sgarbossa criteria do NOT account for relative proportionality — even criterion iii) is not satisfied, because the amount of ST elevation in leads III and aVF is clearly LESS than 5 mm — so NO, original Sgarbossa criteria would not have been met.<br /><br />The benefit of the Smith-modified Criteria — is that it DOES account for proportionality, as he illustrates in his comment above in which he explains how his Modified Criteria ARE met for this tracing. But particularly for ECG-1 — there are so many leads that are clearly abnormal in shape, in this patient with new-onset chest pain — that the diagnosis should NOT be missed. It DOES take some practice looking at these BBB tracings to appreciate these ST-T wave abnormalities (as well as to appreciate the abnormal QRS morphology in leads V5,V6) — but with careful attention to detail + increasing your comfort to recognizing what is “normal” with LBBB (and RBBB) patterns — and at-the-least, remembering to get FREQUENT serial tracings when doubt exists that you compare using the Lead-BY-Lead technique — acute OMI despite LBBB can often be recognized much of the time. Remember that in today’s case — in just 6 MINUTES — indisputable serial changes became evident! THANKS again for your question!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-12403315772163060202020-09-17T15:43:47.836-05:002020-09-17T15:43:47.836-05:00Am I wrong or the tracings would even meet the ori...Am I wrong or the tracings would even meet the original Sgarbossa<br />criteria? Not to say that we should use them as such, obviously.marco garronehttps://www.blogger.com/profile/11432802984516587916noreply@blogger.com