tag:blogger.com,1999:blog-549949223388475481.post4541801017125902763..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A 40-something male complains of worrisome chest pain and possible "fever"Unknownnoreply@blogger.comBlogger13125tag:blogger.com,1999:blog-549949223388475481.post-76051015892561529492020-10-26T22:17:42.931-05:002020-10-26T22:17:42.931-05:00Thank you Tom! — :)Thank you Tom! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-13107315390150510472020-10-26T21:29:34.717-05:002020-10-26T21:29:34.717-05:00excellent. thank you Deep! actually, i am now in ...excellent. thank you Deep! actually, i am now in Alameda, about 15 minutes from your shop!<br />and my close friend has worked with you (unless there are two "Deep"'s at Highland ER! i just showed her your case, and she referred me to your youtube video : " Sepsis the Highland Way"...! hope you don't mind me sharing that.<br /><br />thank you , Deep, for sharing this case. (and of course thank you to Steve and Ken)..<br />very enlightening.. pulling the trigger, ie, activating the cath lab cannot be done willy-nilly, and it's knowledge of the finer points discussed here that helps us in that critical decision.<br />thank you.<br />tom tfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-47199704446879230302020-10-26T14:01:07.955-05:002020-10-26T14:01:07.955-05:00Good comment! For exclusion in our study, we requ...Good comment! For exclusion in our study, we required a sum of 1 mm of STD in inferior leads, which this does not meet. This is very subtle here and may be significant. Emre Aslanger thought it was. I am not so certain.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-2947405974922974262020-10-26T13:44:26.863-05:002020-10-26T13:44:26.863-05:00Thanks for your comment. I agree that it would hav...Thanks for your comment. I agree that it would have been nice to see a follow-up ECG to ECG #1 prior to PCI. My understanding is that this was not done … because Deep recognized the need for cath from the findings in ECG #1 in association with the VERY worrisome history ( = new-onset chest pain that began just 2 hours earlier, and which worsened to attain a 10/10 intensity scale). This should BE ENOUGH to justify prompt cath ( = persistent, severe and worsening cardiac chest pain + an ECG that DOES show some definite worrisome signs, regardless of whether or not you accept that this ECG suggests acute OMI). This patient was fortunate that Deep was working that day with a cardiologist who agreed with his astute assessment.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-49284499788590361522020-10-25T18:33:37.069-05:002020-10-25T18:33:37.069-05:00Thank you for sharing this case. I think some of u...Thank you for sharing this case. I think some of us may have repeated the ECG after treating the patient's hypertension. Just wondering if this occured in parallel to activating the Cath lab?Anonymoushttps://www.blogger.com/profile/14197564675752704125noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-77815098548259282652020-10-25T13:23:40.189-05:002020-10-25T13:23:40.189-05:00@ Ryan — I completely agree with you. The emergenc...@ Ryan — I completely agree with you. The emergency physician in this case (Deep) recognized a number of clearly abnormal ECG findings in association with a very worrisome history of new-onset chest pain — which immediately prompted him to activate the cath lab. I emphasize in My Comment above, that no less than 7/12 leads in ECG #1 are abnormal. Therefore, Dr. Smith’s formula isn’t “needed” to make the diagnosis of suspected OMI. That said — Dr. Smith often likes to still refer to his formula, as it provides additional insight into the relative likelihood of an acute event. As described above by Dr. Smith in his discussion — today’s case provides one example in which there was a false negative formula value. This can happen — with the optimal response being exactly the way in which Deep proceded, namely to recognize that despite the negative formula value — ECG #1 was nevertheless very suggestive of acute evolving OMI.<br /><br />My understanding is that this type of tracing would be excluded from Dr. Smith’s data gathering. But I am passing your comment directly to him for his additional clarification of how he validates his data. Thank you again for your comment!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-20597681851880149832020-10-25T13:12:04.055-05:002020-10-25T13:12:04.055-05:00Muito obrigado (THANK YOU) Andereson for your comm...Muito obrigado (THANK YOU) Andereson for your comment! You are correct that the terminology (even among different cardiologists) is confusing! I will therefore give you “My Take” on the issue (realizing that others may favor a different approach to terminology). The problem with the term, BER ( = “Benign” Early Repolarization) — is that this is “a benign disease that can kill you … “. As described in this article by Ali et al (World J Cardiol 7(8): 466-475, 2015 — GO TO = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549780/ ) — certain patients with this type of ST-T wave appearance are at somewhat increased risk of sudden death. The overall increased risk is low — and extremely low in asymptomatic patients for whom a routine ECG shows incidental “early repolarization”. But risk may be increased IF a similar repolarization change is seen in a SYMPTOMATIC patient (ie, with syncope/presyncope or a sustained ventricular arrhythmia) or in a patient with a positive family history for malignant arrhythmias. <br /><br />As a result — I long ago stopped using the term “BER” — and I no longer say this type of ECG appearance is “benign” or “benign” early repolarization. I also generally do not use the term, “Normal Variant” — because of the potential (albeit very small) of increased risk (ie, in which case this ECG finding would retrospectively turn out to not have been a “normal” variant). Instead — I favor use of the term, “Repolarization Variant” — because this is an accurate description of what we see on ECG — and it is a “variant” appearance of the textbook picture of “normal” ST-T waves. We KNOW that in asymptomatic patients — this “Repolarization Variant” pattern will almost always be benign — but I prefer NOT to add the word “benign” to my “official” interpretation, because of a possible rare adverse outcome. I hope this approach makes sense. I welcome other views from our readers — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-10725597103417028282020-10-25T07:58:07.908-05:002020-10-25T07:58:07.908-05:00This ECG #1 is really challenging. As per the grea...This ECG #1 is really challenging. As per the great physician William Osler taught us "<br />Listen to Your Patients. They're Telling You the Diagnosis!". I am in doubts, because I’m completely confused with some used terms.It's Normal Variant the same thing that Early Repolarization and benign ST Elevation(Normal Variant=Early Repolarization=Benign ST Elevation)? What is diference between them? <br />Thanks a lot my teachers. I LOVE ECG. <br />Anderson Santos from Brazil. O Poder da Eletrocardiografiahttps://www.blogger.com/profile/11143192155299060176noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-78052660160758031412020-10-25T07:48:23.803-05:002020-10-25T07:48:23.803-05:00Subtle ST depressions in I, aVL, and ?V6 should ne...Subtle ST depressions in I, aVL, and ?V6 should negate use of subtle STEMI algorithm, at least from my understanding of it. This is technically an obvious OMI. Would this ECG not have been excluded from your validation study for the algorithm?Ryan C.https://www.blogger.com/profile/05782616975849837672noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-33810520680479220112020-10-24T07:48:13.693-05:002020-10-24T07:48:13.693-05:00@ dr. R.Balaubramanian — THANK YOU for your commen...@ dr. R.Balaubramanian — THANK YOU for your comment! It would indeed be interesting to know more details about cardiac cath findings. The history given says only that chest pain began 2 hours prior to obtaining ECG #1 in a 40yo man — and, we only have 1 ECG to go on (given prompt recognition by the ED physician of the need for cath). My guess would be a more proximal LAD occlusion — because ST elevation begins (and is marked) already in lead V1 — although I’d usually expect some ST elevation in aVL and reciprocal inferior ST depression with proximal LAD occlusion. I’d expect more obvious inferior ST elevation if there was “wraparound”. Another possibility might be multi-vessel disease — although that would seem less common in a 40-year old. So I didn’t know how to “localize” the likely location of the culprit LAD without more info, serial tracings and/or cath results …ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-34543493482123310332020-10-24T02:26:08.941-05:002020-10-24T02:26:08.941-05:00Hello Dr. Smith,
Once again great post ( Fri Oct 2...Hello Dr. Smith,<br />Once again great post ( Fri Oct 23 2020 ), absolutely sparkling ! Excellent academic treat. Once the angio reveals 100% LAD occlusion, the suspense is over. However, for completion sake, we may need to know the exact site of occlusion and whether the LAD is of wrap-around type. The trivial but real 0.5mm ST depression in I & aVL speaks in favour of LAD occlusion and against Early Repolarization. By the same token, the 0.5 mm STD in I aVL can be taken as almost isoelectric and conclude that the LAD occlusion must be distal in a non wrap-around type.<br />With regards,<br />Dr.R.Balasubramanian.dr. R.Balaubramanianhttps://www.blogger.com/profile/10882266041266448279noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-8201142650959284672020-10-23T19:16:19.253-05:002020-10-23T19:16:19.253-05:00@ DrMusicMan — THANKS for your comments. Re your 1...@ DrMusicMan — THANKS for your comments. Re your 1st comment — I made a big point of this in My Comment above (Please see my “Input Type #3”). The reason I described this as “stuff-that-I-feel” but am not able to put into objective terms — is that there are 3 complexes in simultaneously-recorded leads V1,V2,V3 — and while the overall “shape” of the ST segment looks “more elevated” in lead V3 compared to V2 — there ARE slight differences in ST-T wave morphology from 1 beat-to-the-next (and there are only 3 beats …) — and I actually measure a slightly higher J-point in lead V2 for the 1st complex — about equal for the 2nd complex — and slightly higher in V3 than V2 for the 3rd complex. Given this slight-but-real variation in ST-T wave morphology among the 3 beats that we see — I think it difficult to know for certain which ST-T wave complex is “the accurate one” — and for that reason, I subjectively integrated what I saw as a suggestive “stuff-that-I-feel” finding (that lacks obective verification), but which DOES support the clearly disproportionate amount of ST elevation in V1 + the subtle-but-real ST straightening in the 4 lateral leads.<br /><br />Otherwise — I unfortunately do not understand what you are saying and asking in your 2nd comment about ST elevation in leads II and III. I do not see any ST elevation in leads II and III in ECG #1. Please clarify this for me. Thank you again — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-61615682090688470362020-10-23T15:06:26.651-05:002020-10-23T15:06:26.651-05:00I also think it's worth noting that the St ele...I also think it's worth noting that the St elevation is significantly more in lead 3 than lead 2. In combination with the features of V1 V2 and V3 I think this is further evidence that we need to be concerned about the right side of the heart.<br /><br />I haven't seen any research to this effect but my intuition is that because leads II and III are not that different from an axis standpoint when you have one that is clearly more St elevation than the other it's dangerous to discount this finding especially when it correlates with typical chest pain and suggestive precordial lead findings.DrMusicManhttps://www.blogger.com/profile/06719029236216127407noreply@blogger.com