Written by Jesse McLaren   A 75 year old with a history of CABG called EMS after 24 hours of chest pain. HR 40, BP 135/70, RR16, O2 100%. Here’s the paramedic ECG (digitized by PMcardio). What do you think?   There’s sinus bradycardia, normal conduction, normal axis, delayed R wave progression, and normal voltages. There are inferior Q waves and lead III has mild concave ST elevation, with subtle reciprocal ST depression in I/aVL. This is diagnostic of inferior OMI, likely from the RCA. The patient has a history of CABG so some of these changes could be old, but with ongoin ..read more

A 50-something presented with acute chest pain. Here is her ED ECG.  It was texted to me while I was out and about.   He wrote: "Steve, what do you think about hyperacute T waves in this? 54-year-old female with CP. I initially interpreted as normal, but I am second-guessing myself, since she is hanging out in triage with me." What do you think, Dear Reader? Analysis: There is ST elevation in multiple leads.  There are tall T-waves in multiple leads.  So one might think this is an acute OMI with STE and hyperacute T-waves.   I immediately resp ..read more

A 40-something male presented by ambulance with one hour of chest pain that was improving after sublingual nitroglycerine and 325 mg of aspirin, chewed.    Here is his initial ED ECG: What do you think? I read this ECG without any history as reperfusing inferior and posterior OMI due to the Q-wave in lead III with minimal STE and reciprocal ST depression in V2-V4 (which should never be there).  The large upright T-wave in V2 is consistent with reperfusion. Any ST Depression Maximal in V1-V4 is OMI until proven otherwise I sent this ECG with no information to Pe ..read more

 Written by Pendell Meyers A woman in her 30s with minimal past medical history presented simply stating she was "feeling unwell." Her symptoms started suddenly about 48 hours ago, but had continued to worsen, including epigastric discomfort, nausea, cough, and dyspnea and lightheadedness on exertion. She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED. She was awake, alert, well perfused, with normal mental status and ov ..read more

A 20-something presented after a huge verapamil overdose in cardiogenic shock.   He had been seen at an outside institution and been given 6 g calcium gluconate, KCl, and a norepinephrine drip. The initial K was 3.0 mEq/L and ionized calcium was 5.5 mg/dL (sorry, Europeans, for the weird units) Here was the initial ED ECG: There is a junctional rhythm with retrograde P-waves (see the dip in the T-wave in lead II across the bottom; you can follow that up to all the other leads and see the retrograde P wave).   There is also Left Bundle Branch Block (LBBB). There is hug ..read more

Written by Pendell Meyers A man in his early 40s experienced acute onset chest pain. The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset.  EMS arrived and recorded this ECG: What do you think? See same ECG below with computer automated interpretation, using the Glasgow ECG algorithm which apparently is used by many different providers and devices Amazing that the computer calls this normal. Notice on the right side of the image how th ..read more

An elderly patient had a fall from probable syncope, and could not get up.  He complained of weakness and shortness of breath, but no CP.   Vital signs were normal. Here is the first ED ECG: COMPUTER INTERPRETATION: Electronic Atrial Pacemaker.  Marked ST Elevation, ***ACUTE MI*** What do you think? First, the QRS is incredibly wide! You should ask for more history.   Whenever a patient does not have chest pain, the pre-test probability of OMI is diminished.  Of course SOB, jaw pain, shoulder pain, etc can be a result of OMI, but the pretest ..read more

This case was provided by Steven Souchtchenko, a recent graduate of our Hennepin Healthcare EM/IM residency (i.e., a former trainee of mine). Case A 45 yo man with no previous cardiac history presented to an ED not associated with a cath lab.   He complained of jaw pain radiating to left shoulder for 6 hours.  He stated he had had a brief similar episode the evening prior. Here is his ED ECG. What do you think? When this was shown to me I immediately said "Proximal LAD OMI".  Then I ran it through the Queen of Hearts AI app and she said "OMI with high co ..read more

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Here is his triage ECG: What do you think? Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". I immediately responded: "cool fake! Not OMI. Do you have a prior? There is a reasonable chance of pericarditis in this case, or this could be a baseline."  It could easily be mistaken for a South African flag pattern anterolateral OMI, with STE in I, aVL, V2. But importantl ..read more

I was reading EKGs on the system and saw this one, with no other information. What was my interpretation of these apparently abnormal precordial leads? Smith: Normal variant ST Elevation and T-wave inversion, probably in a young African American male. The Queen of Heart PM Cardio Bot also states: "Not OMI with High Confidence" Additionally, as Ken notes below, the limb leads are reversed. I later went into the chart: This was recorded in a young African American female with altered mental status (severe agitation) due to an unidentified intoxicant. She rapidly awoke and was ..read more