tag:blogger.com,1999:blog-549949223388475481.post4691196793435296524..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: What is the Diagnosis in this 70-something with Chest Pain?Unknownnoreply@blogger.comBlogger7125tag:blogger.com,1999:blog-549949223388475481.post-37171990277434901092020-09-17T18:34:21.287-05:002020-09-17T18:34:21.287-05:00Hellow Jona. THANK YOU so much for your comments! ...Hellow Jona. THANK YOU so much for your comments! Regarding your 1st question — an excellent general rule regarding determining the clinical significance of any conduction defect (ie, BBB or Hemiblock or combination thereof) — is that it depends on the CLINICAL SETTING. In reading all ambulatory tracings for 35 providers over 30 years — I would very OFTEN see the combination of RBBB/LAHB in patients without new or recent symptoms, who had manifested this form of bifascicular block for many years. So the presence of RBBB/LAHB by itself is NOT enough to suspect OMI. It all depends on: i) the clinical History; and ii) IF there are any acute changes on the ECG. The problem with this 2nd point — is that whether or not there are ST-T wave abnormalities depends on the skill of the interpreter — since it is often much more challenging to recognize potentially acute ST-T wave changes when there is underlying BBB + hemiblock. In my experience — in addition to a history of recent or acute symptoms — there will USUALLY be (to “my eye” — and the eye of Drs. Meyers & Smith) at least some ECG abnormalities that provide support if this is an acute case. PLEASE send us tracings IF you have an example of new-onset symptoms with RBBB/LAHB in which you are uncertain if acute changes are present.<br /><br />Regarding the ECG diagnosis of the Hemiblocks — I discuss “My Take” on this subject in detail HERE = http://ecg-interpretation.blogspot.com/2014/06/ecg-blog-90-basic-concepts-3.html — The first half of this blog post reviews my thoughts on Axis determination. IF you are only interested in ECG diagnosis of the Hemiblocks — SCROLL DOWN all the way until you get to the Section entitled "HEMIBLOCKS: The Ventricular Conduction System". The 1st Figure in this sections is Figure-12. Let me know if after reading this you still have questions regarding the ECG diagnosis of the Hemiblocks.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-47446414647944490452020-09-17T17:51:16.035-05:002020-09-17T17:51:16.035-05:00Hi! I follow your amazing blog for a while now and...Hi! I follow your amazing blog for a while now and I’m really grateful for the way you changed and enriched my poor interpretation practice. <br /><br />My question: Is the presence of RBBB + LAFB in an Chest-Pain-Setting enough to suspect an OMI or is STE required to make that claim? <br /><br />PS. Is there a discussion of criteria for LAFB somewhere in your blog? I feel like the way I was taught (QRS-Axis ~ -45° & S in V6) isn’t the way you use to diagnose it? <br /><br />Thanks so mouch! Jona Weberhttps://www.blogger.com/profile/14377107070031950276noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-6241369016450194712019-07-31T00:00:34.042-05:002019-07-31T00:00:34.042-05:00thanks again, steve... very helpfulthanks again, steve... very helpfultfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-61584194172775413052019-07-29T07:44:40.572-05:002019-07-29T07:44:40.572-05:00just use powers of persuasion. One is this: "...just use powers of persuasion. One is this: "the art of diplomacy is letting other people have your way" In other words, make them think it is their idea. Or make a plea for help: "I need your help on this." People respond to being needed. If that fails, you say: "I am writing that I strongly believe this patient needs an emergent angiogram, right now. If you don't do it, and you're wrong, you will look very bad"Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-26366699657860865832019-07-28T23:39:38.082-05:002019-07-28T23:39:38.082-05:00Tired to post this once, so forgive me if this is ...Tired to post this once, so forgive me if this is posted twice! <br /><br />I have to ask, how do you deal with the cardiologist who rolled his eyes at you during that proximal LAD case? (Or the PA who handled the cardiologist at the receiving facility in this case). That would be so frustrating to me but it seems that you handled this quite often!Chasehttps://www.blogger.com/profile/03064467645495862337noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-75899703916021299052019-07-28T15:54:52.681-05:002019-07-28T15:54:52.681-05:00the RBBB is what is distorting lead I. Look at aV...the RBBB is what is distorting lead I. Look at aVL, which has a qR (almost all positive), and inferior leads which have an rS (almost all negative)Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-7793444335894482192019-07-28T11:18:36.694-05:002019-07-28T11:18:36.694-05:00To me the QRS in lead I is downgoing and makes it ...To me the QRS in lead I is downgoing and makes it difficult for me to appreciate the LAFB. The rest of the morphologies in the inferior leads fit but I would have a hard time identifying the LAFB and might have called it LPFB with concern for severe RAD. thoughts? Are you calling lead I QRS upgoing primarily?Anonymoushttps://www.blogger.com/profile/12064432725132724281noreply@blogger.com