Written by Pendell Meyers Two patients with acute chest pain.  Do either, neither, or both have OMI and need reperfusion? Patient 1: Patient 2: Patient 1: A man in his 40s with minimal medical history presented with acute chest pain radiating to his R shoulder. Triage ECG: Click here to sign up for Queen of Hearts Access Three serial troponins were all undetectable. Here is a later ECG during the visit: Slightly different, with less TWI in inferior leads this time. He was discharged home. Patient 2 A man in his 50s with history of CAD and prior PCI, d ..read more

An elderly dialysis patient presented with chest pain. She has poor LV function. Previous echo 4 months ago (confirmed with ED bedside echo): The estimated left ventricular ejection fraction is 30%.   Severely decreased LV function. Regional wall motion abnormality-inferior, inferolateral, septum, anterolateral, anterior and apex, lateral. Here is her ECG: Regular Wide Complex Tachycardia.   What do you think? What do you want to do? --Regular means it can't be atrial fibrillation --Most regular wide complex tachcardia are VT, especially if the patient has poor LV ..read more

 Written by Sean Trostel MD I returned to my desk after seeing a patient and saw this screening ECG sitting on my desk to be read. The patient was a man in his 80s with chief complaint listed as: "hyperglycemia, weakness, ground level fall." ECG #1 @ 15:30 What do you think? Slow, irregular rhythm - likely slow atrial fibrillation Very wide QRS measuring ~180 ms in some leads, not fitting LBBB morphology and wider than vast majority of LBBB No signs of OMI, no modified Sgarbossa criteria Peaked T-waves in the lateral precordial leads Together, these findings are ..read more

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Edited by Smith He also sent me this great case. A 63 year old man with a history of hypertension, hyperlipidemia, prediabetes, and a family history of CAD developed chest pain, shortness of breath, and diaphoresis after consuming a large meal at noon.  He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.  He arr ..read more

Chest Pain – Benign Early Repol or OMI? Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain. He reported substernal chest pressure with radiation to his left arm that started at work several hours prior to arrival and had somewhat improved since onset. He noted that his father died from a heart attack in his early 50s prompting his presentation to the emergency department. Here is the initial ..read more

Submitted anonymously, written by Willy Frick A man in his late 30s with a 10 pack-year smoking history presented with acute substernal chest pressure radiating into his left shoulder with associated nausea, vomiting, and diaphoresis which began suddenly while he was getting ready for work. He described it as feeling like "a bulldozer on [his] chest." He rated it 10/10 intensity. With no additional information, the HPI puts this patient at very high pre-test probability of OMI. ECG 1 What do you think of his presenting ECG? Queen of Hearts interpretation with explainability: Alth ..read more

Written by Jesse McLaren, with additions from Smith Two patients presented with chest pain with ST elevation in aVR, and the same final ECG interpretation: “repolarization abnormality, severe global ischemia (LM/MVD).” Do either, both, or neither require the cath lab? Patient 1: 75 year old, history of aortic stenosis, with recent cough accompanied by shortness of breath and chest pain, then syncopal episode. There’s sinus tachycardia, first degree AV block, borderline right axis, and normal voltages. There’s significant ischemic STD in I/II/II/aVF and V4-6 (maximal V5-6) with rec ..read more

This ECG was handed to one of my partners who was working in triage.   The conventional algorithm stated "Nonspecific ST-T wave abnormalities." What do you think? My partner immediately diagnosed inferior OMI.  (Do you see: the subtle STE in III and aVF?  The terminal QRS distortion in aVF?  The ST depression in aVL?  The ST depression in V2-V4 of posterior OMI?  There is terminal T-wave inversion in III with terminal upright T-wave in aVL -- This strongly suggests reperfusion IF the patient's symptoms have subsided.  But they had not ..read more

A 30-something presented with chest pain, palpitations, and SOB.  He has had similar symptoms for 4 years, but has never been evaluated. Here is his presenting ECG, which was sent to me real time, along with the 2nd ECG below: Regular Narrow Fast without P-waves.  PSVT.   It is very difficult to tell if this is:  1) AVNRT or  2) orthodromic AVRT  (Orthodromic AVRT = WPW with orthograde conduction down the AV node and retrograde up an accessory pathway) See Ken Grauer's discussion below in differentiating AVNRT from orthodromic AVRT. Shortly after arrival, t ..read more

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED.  It was recorded at 0530: What do you think? The young ED tech immediately suspected LAD OMI. He interprets here: "This EKG is diagnostic of right bundle branch block and transmural ischemia of the anterior wall, most likely from an occlusion of the proximal LAD. There is a hyperacute distribution of T waves fro ..read more