tag:blogger.com,1999:blog-549949223388475481.post8726575059686226285..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: Tachycardia, hyperthyroid, and ST elevation. What is it?Unknownnoreply@blogger.comBlogger12125tag:blogger.com,1999:blog-549949223388475481.post-35753477591386059532018-12-02T11:47:55.639-06:002018-12-02T11:47:55.639-06:00I’m not expert enough to assess LV wall dimensions...I’m not expert enough to assess LV wall dimensions from the bedside echo done in this case. I do have another opinion regarding the possibility of LVH based on the ECGs in this case — namely that in addition to dramatically increased QRS amplitude — the shape of the ST-T waves in correctly placed leads V1-V3 could be consistent with ST-T wave repolarization changes of LV “strain”. That said, ECG is far inferior to formal Echo study for assessment of true chamber enlargement — and this case is further complicated by: i) tachycardia; ii) hyperthyroidism with increased LV contractility; and iii) superimposed repolarization variant changes. As a result — I don’t think ( = my opinion) we are able to rule out true chamber enlargement from this single tracing. I’d LOVE to see results of formal Echo study on this patient to find out with more certainty.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-83843420509145441022018-12-01T15:50:51.907-06:002018-12-01T15:50:51.907-06:00I think it is just a benign variant, without acuta...I think it is just a benign variant, without acutal anatomic LVHSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-64094139144113165732018-11-28T03:45:14.824-06:002018-11-28T03:45:14.824-06:00Can we say that the changes are repolarisation cha...Can we say that the changes are repolarisation changes secondary to high voltage or may be calling it LVH with strain if there was no ECHO report available ? MGhttps://www.blogger.com/profile/06233522417024317416noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-60183089766164215072018-04-16T07:01:36.793-05:002018-04-16T07:01:36.793-05:00Also, as for the formula: strictly speaking, becau...Also, as for the formula: strictly speaking, because there are QS-waves, one should not use this formula, but rather the formula for differentiating old MI with persistent ST elevation (LV aneurysm) from acute STEMI. But this is clearly not LV aneurysm either. You could use both formulas and both would tell you that it is not STEMI: 1) BER: R-wave so tall in V4 that the formula would be negative 2) LVA: T/QRS ratios in all leads is low (T-wave is not tall, therefore not acute STEMI). <br /><br />See this post: http://hqmeded-ecg.blogspot.com/2017/04/st-elevation-and-qs-waves-in-patient.htmlSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-40695262248586175372018-04-16T06:57:07.249-05:002018-04-16T06:57:07.249-05:00Tom,
Most easily, STEMI rarely has a heart rate th...Tom,<br />Most easily, STEMI rarely has a heart rate this high unless there is poor stroke volume. As you can see from the bedside echo, the stroke volume is very high, with very high ejection fraction. Furthermore, once you've seen enough of these (partly by reading this blog), you'll recognize this morphology as a benign one.<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-32301881076308890072018-04-15T23:13:26.176-05:002018-04-15T23:13:26.176-05:00Steve, would this EKG qualify to be tested using y...Steve, would this EKG qualify to be tested using your BER vs STEMI equation? if not, why? (the LVH?).<br /><br />so this is an EKG that "meets STEMI criteria". when shall i be brave enough, knowledgable and confident enough, NOT to call and arrange for cath lab, i wonder. an all the more important question in my shop, where the patient must be transferred to another distant institution.<br />thank you Steve ( and hello to Ken)tom fieronoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-29293897657859806212018-04-14T23:31:33.966-05:002018-04-14T23:31:33.966-05:00Nice clinical case. ThanksNice clinical case. Thanksbsbuitruonggianghttps://www.blogger.com/profile/09138446029681438391noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-48036522883527594172018-04-14T23:31:17.847-05:002018-04-14T23:31:17.847-05:00Nice clinical case. ThanksNice clinical case. Thanksbsbuitruonggianghttps://www.blogger.com/profile/09138446029681438391noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-53849172877983012612018-04-11T08:13:49.080-05:002018-04-11T08:13:49.080-05:00Thanks, Ken!Thanks, Ken!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-5998197847310372552018-04-11T08:13:21.428-05:002018-04-11T08:13:21.428-05:00Calcium normalCalcium normalSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-4444558355169310512018-04-10T18:20:41.203-05:002018-04-10T18:20:41.203-05:00NICE case to illustrate a number of important poin...NICE case to illustrate a number of important points. I’d add the following thoughts to comments by Dr. Smith: i) In addition to illogical R wave progression — reasons we know the 1st ECG was recorded with erroneous precordial lead placement are that there is ALSO illogical P wave AND illogical ST-T wave progression. There is often at least some negativity to the P wave in leads V1, V2 — but really no reason why the P wave in this 1st ECG should be all positive in V1 — then biphasic in V2 — then all negative in V3 — and then all positive in subsequent leads. Similarly, the curved (ie, “frowny”-configuration) ST-T wave shape with ST elevation in lead V1 in the 1st ECG makes no sense given the very different slope of the ST segment in V2,V3 — before once again seeing coving with ST elevation in V4. The “take home” point — is that when such illogical progression is seen for P waves, QRS complexes AND ST-T waves — THINK of alternative lead placement possibilities. For example, if leads V1 and V3 would simply be swapped — progression of P waves, QRS complexes and ST-T waves instantly reverts to what should be expected. ii) Once chest leads are correctly placed (as in the 2nd ECG) — the principal findings include RAA + dramatically increased voltage for LVH. Voltage criteria for LVH are easily met in the limb leads (R wave amplitude clearly exceeds 20mm in ≥1 inferior lead) — as well as in the chest leads (Sum of deepest S in V1,V2 + tallest R in V5,V6 ~45mm {only ≥35mm is needed} — as well as showing tremendously increased S and R wave amplitudes in leads V3 and V4, respectively). Flipping over the QRST complex in leads V2 and V3 in this 2nd ECG (ie, performing a “mirror test”) — results in ST-T wave shape in V2,V3 that is the mirror image of LV “strain” (ie, anterior leads in patients with marked LVH often manifest this shape of ST-T wave abnormality — which strongly suggests LV “strain” rather than infarct-related ST elevation as the cause). iii) ST-T wave abnormalities in the 2nd ECG are generalized — rather than showing the more localized pattern characteristic of an OMI — and there really are no “reciprocal changes”. It is helpful to remember that the ST-T wave pattern seen in this 2nd ECG is characteristic of a type of repolarization variant in which there may be generalized ST segment coving with surprisingly deep T wave inversion. Often, there is more ST elevation in this pattern than is seen here. Perhaps the reason for this relatively limited amount of ST elevation (except for lead V3) — is that it has in part been cancelled out by the marked LVH that would otherwise have shown ST depression … THANKS again to Dr. Smith for posting this interesting case!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-86830774036465905132018-04-10T15:04:34.019-05:002018-04-10T15:04:34.019-05:00Any signs of Hypercalcemia? Parathyroid issues not...Any signs of Hypercalcemia? Parathyroid issues noted?<br /><br />Another great post as always. Thanks for the many years of teaching. My practice as a Paramedic has benefited greatly. Anonymousnoreply@blogger.com