# Dr. Smith’s ECG Blog > Expert ECG Interpretation and Emergency Cardiology Education ## Posts - [Fast, narrow, regular. What is it? More difficult: what to do??](https://drsmithsecgblog.com/fast-narrow-regular-what-is-it-more-difficult-what-to-do/): A middle-aged man with h/o asthma presented with SOB, especially with exertion. He also has positional chest pain. This started a few weeks ago and is worsening. Albuterol is not helping. He is a smoker and has a lot of weight loss as well. By the time I came to the case, the patient had already been worked up for pulmonary embolism and was found to have a large lung mass compressing bronchi and pulmonary arteries, and some “tumor thrombus” (the extension of a solid cancer into blood vessels, creating a blockage composed of cancer cells rather than just blood… - [How do you interpret this ECG without the clinical context (which I don't know)?](https://drsmithsecgblog.com/how-do-you-interpret-this-ecg-without-the-clinical-context-which-i-dont-know/): I came across this interesting ECG without clinical context: What do you think? Rhythm: This appears to me to be accelerated idioventricular rhythm (AIVR) [vs. junctional rhythm/escape with RBBB and LAFB] — (see Ken’s extensive discussion below). There are no P-waves. The ventricle is triggering at a rate faster than a slow sinus node. And you can also see retrograde P-waves following every QRS. How do I know it is AIVR? Wide, regular, slow (cannot be VT). It is escaping with a morphology of RBBB/LAFB, which means that it is escaping from the left posterior fascicle. What else? Even though… - [Fascinating Wide Complex Tachycardia and instructive ECGs during chest pain](https://drsmithsecgblog.com/fascinating-wide-complex-tachycardia-and-instructive-ecgs-during-chest-pain/): Written by Magnus Nossen Today’s patient is an 80-something male with a history of CABG. Since his bypass surgery years ago, he had not experienced any angina. He had chronic atrial fibrillation managed with oral anticoagulation, and longterm left bundle branch block (LBBB) on his ECG. After physical activity, he developed abdominal and chest discomfort that persisted despite rest. On EMS arrival, he reported ongoing chest pain. Vital signs were unremarkable, apart from tachycardia at 125 bpm. ECG # 1 was recorded during chest pain. How would you interpret this ECG? How would you manage this patient considering the described… - [Is this a wide complex rhythm? (And what is the etoliogy, after you hear the history)](https://drsmithsecgblog.com/is-this-a-wide-complex-rhythm/): What do you think? = = = = = = = = = = = = = = = This is NOT a wide complex tachycardia. This is atrial fibrillation with “Shark Fin” pattern, an OMI pattern, and this time it is in the inferior leads, with posterior involvement shown by the inverted shark fin in V2. The end of the R-wave merges with ST Elevation, which slopes down. This has also been called “Giant R-wave”. Medics had seen this on the monitor and thought that it was ventricular tachycardia. The Queen of Hearts knew better and appropriately flagged this… - ["Non-diagnostic" (even in retrospect) according to an entire conference full of ED docs and cardiologists.](https://drsmithsecgblog.com/non-diagnostic-even-in-retrospect-according-to-an-entire-conference-full-of-ed-docs-and-cardiologists/): Subtitle: It’s not the ECG which is “Non-diagnostic” — it is the physicians who are “Non-diagnostic!” This ECG was sent to me, with no information, by a former resident. What do you think? Smith: “Diagnostic of inferior OMI.” Response: “What makes you say that?” Smith: “III and aVF, with reciprocal STD in aVL. There are also hyperacute T-waves in V1-V3, so this is probably a proximal RCA occlusion with RV infarct (Proximal to the RV marginal branch).” His answer: “Yes, it was a proximal RCA occlusion.” Case presentation: A 45 year old man presented with chest pain. The above ECG… - [A 50-something with chest pain. Look what happens if you don't use the Queen of Hearts.](https://drsmithsecgblog.com/a-50-something-with-chest-pain/): I came across this ECG while reading through all the ECGs on the system. The computer interpretation, confirmed by a cardiologist, is: = = = What do you think? = = = This is my interpretation: there is subtle STE in III and aVF.  In aVF it is “coved” (upwardly convex).  The T wave is inverted in III and aVF, and reciprocally upright in aVL (and is very large, a reciprocally upright hyperacute T-wave), with reciprocal STD in aVL.  There is ischemic ST depression in V4-V6.  This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI.… - [Will this patient get care of the past or care of the future? (NSTEMI is a worthless diagnosis)](https://drsmithsecgblog.com/will-this-patient-get-care-of-the-past-or-care-of-the-future-nstemi-is-a-worthless-diagnosis/): Sent by anonymous A woman in her 40s presented with acute chest pain. Her vitals were within normal limits. Here is her triage ECG: Readers of the blog will not need any baseline ECG for comparison. But here it is for those who need it: What do you think? Will this patient actually get timely care at your facility? Here is what would happen if you know how to read ECGs, or use the Queen of Hearts: The presentation ECG shows obvious and diagnostic signs of acute LAD occlusion MI. There are HATW in V2-V5, and some STE (less than… - [A male in his 30s with cardiac arrest. What is the etiology?](https://drsmithsecgblog.com/a-male-in-his-30s-with-cardiac-arrest-what-is-the-etiology/): Written by Magnus Nossen A man in his early 30s was found unresponsive in bed by his wife. She immediately initiated CPR. Upon arrival, emergency medical services found the patient in V-fib. ROSC was achieved after approximately 15 minutes of resuscitation. The patient remained unresponsive and was intubated. The following ECG was recorded post-ROSC. ECG #1 ECG recorded in the ambulance after return of spontaneous circulation. The ECG shows atrial fibrillation with atypical ST elevation in leads V2–V6, I and aVL. Smith: there are bizarrely prominent J-waves in II and aVF. There are what resemble hyperacute T-waves in I, aVL,… - [Elderly F w h/o MI has nausea and vertigo, with RBBB. And what is the data on thrombolytics for patients without ST Elevation?](https://drsmithsecgblog.com/elderly-f-w-h-o-mi-has-nausea-and-vertigo-with-rbbb-and-what-is-the-data-on-thrombolytics-for-patients-without-st-elevation/): An elderly woman with h/o diabetes and prior MI with a stent presented with acute nausea and vertigo to a very remote hospital where acute OMI must be given thrombolytics prior to transfer. My former resident, Max Goder-Reiser saw her and, knowing that acute MI (OMI) can present without chest pain (especially in patients with Diabetes), and knowing that the patient has coronary disease with a previous stent, he was worried about acute MI and immediately recorded an ECG: This is the initial 12-lead: What do you think? There is RBBB and Left Posterior Fascicular Block. There is no ST… - [ED patient with esophageal cancer and need for G-tube replacement](https://drsmithsecgblog.com/ed-patient-with-esophageal-cancer-and-need-for-g-tube-replacement/): An elderly male presented to the ED with need for G-tube replacement. This was done, and an abdominal X-ray was done to confirm placement. This included much of the chest, and showed a pleural effusion and pulmonary edema. Due to pulmonary edema, an EKG was recorded: What do you think? The Queen of Hearts always asks this: Here is the Queen of Hearts interpretation if we answer that there is “No suspicion:” Here is what she would have said if we answered “yes”: I was shown this ECG in real time and I said: This could be OMI or could… - [A man in his 60s with chest pain. Are these very small T-waves hyperacute?](https://drsmithsecgblog.com/a-man-in-his-60s-with-chest-pain-are-these-very-small-t-waves-hyperacute/): Sent by Anonymous, written by Pendell Meyers A man in his 60s developed sudden chest pain, dizziness, diaphoresis, and shortness of breath shortly before ED arrival. Triage ECG: The patient had multiple risk factors and remote PCI. This ECG was compared to prior (not shown) and demonstrated STE in III and aVF with reciprocal STD in aVL, disproportionally large, broad T hyperacute T waves (HATW) in III and aVF, and flattening ST segment in V2-V2 concerning for inferior and posterior OMI. Smith: Notice that these hyperacute T-waves have an amplitude less than 2 mm!! That is because HATW are not… - [STEMI positive by conventional algorithm in a high risk post operative patient.](https://drsmithsecgblog.com/stemi-positive-by-conventional-algorithm-in-a-high-risk-post-operative-patient/): A man in his late 60s was convalescing in the hospital following bilateral lung transplantation for pulmonary fibrosis. Medical history is also significant for rheumatoid arthritis and chronic steroid use (a risk factor for coronary artery disease). On postoperative day 2, ECG was obtained. ECG 1 What do you think? The GE algorithm interpretation was ** ** ACUTE MI / STEMI ** ** Looking closely at this ECG we see: Smith: Unfortunately, in LAD OMI, concavity can be present in all leads with ST elevation. So that alone does not rule out the diagnosis. However, in this case, the concavity… - [Acute chest pain in a 50-something: resolves, recurs, resolves: Does the ED ECG show "Early Repol"?](https://drsmithsecgblog.com/acute-chest-pain-in-a-50-something-resolves-recurs-resolves-does-the-ed-ecg-show-early-repol/): My city of Minneapolis is being attacked and occupied by ICE right now and it is very frightening and anxiety provoking, especially for anyone who has brown skin. They are constantly breaking the law. I have personally witnessed gross and dangerous traffic violations: 1) driving 80 mph on 35W, 2) a convoy of 12 vehicles going directly through a red light, 3) an SUV passing at 60 mph in the oncoming lane of a city street, 4) an SUV going through a red light and then turning left across 8 lanes of trafffic. 5) a convoy driving on a street… - [A woman in her 60s with chest pain and "No STEMI"](https://drsmithsecgblog.com/a-woman-in-her-60s-with-chest-pain-and-no-stemi/): Sent by anonymous. A woman in her 60s presented with acute chest pain and normal vital signs. Here is her triage ECG: What do you think? It shows diagnostic findings of acute LAD occlusion, including the precordial swirl pattern (inappropriate STE and HATWs in V1-V2/V3, and reciprocal STD in V5-V6). Smith: there are hyperacute T-waves in V2-3, down-up T-waves in III, aVF, and V6. There are all highly specific for LAD Occlusion MI (OMI). Read more about precordial swirl pattern in our publication and this blog post: Sadly it was interpreted as “No STEMI”, which is the extent of normal… - [A Quiz on 10 ECGs](https://drsmithsecgblog.com/a-quiz-on-10-ecgs/): Created by Magnus Nossen This post consists of 10 ECGs and different clinical scenarios. Your task is simple. Match the ECG to the clinical scenario or provided ECG description that you that you think fits BEST. The quiz is DIFFICULT and not aimed at beginners. To ENLARGE the image on a computer: right click, then open in new tab. To ENLARGE the image on a phone or tablet: stretch the image. A comment on each ECG will be available when the Quiz is finished. Good luck! TAKE THE QUIZ= = = = = = = ====================================== MY Comment, by KEN GRAUER, MD… - [What does this ECG recorded 4 days prior (in clinic) tell us about the ECGs in the ED?](https://drsmithsecgblog.com/what-does-this-ecg-recorded-4-days-prior-in-clinic-tell-us-about-the-ecgs-in-the-ed/): Submitted by Evan (Kuan-Yu) Lin, edits by Willy Frick This ECG had been recorded in cardiology clinic: What do you think? Here is the case: An 84-year-old male with hypertension, hyperlipidemia, lichenoid reaction to losartan presented to the ED with chest pain that awoke pt from sleep at 2:30AM. Patient stated he got up to use the bathroom and started feeling left-sided substernal chest pain radiating to the left and right as well as down towards the epigastric area with associated shortness of breath. The pain was unrelenting, characterized as 8/10 pressure-like, prompting his wife to drive him to the… - [Narrow complex tachycardia; it recurs after adenosine. What should we do now?](https://drsmithsecgblog.com/narrow-complex-tachycardia-it-recurs-after-adenosine-what-should-we-do-now/): A 50-something male presented with palpitations. He had a fever and hypotension (BP 80/40). His volume status was low by ultrasound (flat IVC), and he had good LV function. He had no B lines. He had a history atrial fibrillaton and ablation, but has been in sinus rhythm recently. IV fluids were given, and because of his heart rate of 190 bpm, this ECG was recorded: Heart rate 156. What do you think? There is a narrow complex tachycardia without P waves (you must look carefully for P waves!! Especially in a patient with fever (thus, supraventricular tachycardia, or SVT).… - [COPD exacerbation, followed by cardiac arrest.](https://drsmithsecgblog.com/copd-exacerbation-followed-by-cardiac-arrest/): An elderly woman called 911 for SOB. She had a history of COPD. On arrival, she was cyanotic and had increased work of breathing. En route to the hospital, she had a bradycardic arrest. She had ROSC, and a Bedside echo showed a large RV and very small LV. The providers made a provisional diagnosis of pulmonary embolism based on this clinical presentation. Here is the first ECG: What do you think? There is atrial fibrillation. There is RBBB with right axis deviation (deep S-wave in I, with R/S ratio < 1), including a probable left posterior fascicular block. The… - [OMI or Subendocardial Ischemia (SEI)?](https://drsmithsecgblog.com/omi-or-sei-draft-ready/): A 79-year-old woman with a history of hypertension and a benign brain tumor was awakened by chest pain and dyspnea. She reported having similar but transient symptoms over several months, but on this occasion, her symptoms persisted. She contacted her primary care physician who referred her to the emergency department due to ST-segment depression (initial ECG unavailable). Vital signs in the ED were as follows: BP 159/87 mmHg, oxygen saturation 99%, RR 19/min, and she was afebrile. The below ECG was recorded. What do you think? ECG #1 What do you think? Smith: I would say this is a posterior… - [Narrow complex tachycardia, with interesting laddergram](https://drsmithsecgblog.com/narrow-complex-tachycardia-with-interesting-laddergram/): A woman in her late 70s presented with nausea, vomiting, and diarrhea. Her emergency department ECG is shown below: ECG 1 What do you think? This was interpreted as atrial flutter with 2:1 block. The patient received metoprolol 5 mg IV and converted to sinus rhythm. ECG 2 Do we still believe the diagnosis of atrial flutter? Remember that metoprolol has no ability to cardiovert atrial fibrillation or flutter. It helps those patients by slowing conduction through the AV node and preventing rapid ventricular rate, but it does nothing for the underlying arrhythmia. It is possible that a person could… - [A man in his 50s with altered mental status and abdominal pain. What treatment must be given immediately, and how much?](https://drsmithsecgblog.com/a-man-in-his-50s-with-altered-mental-status-and-abdominal-pain-what-treatment-must-be-given-immediately-and-how-much/): 50 year old male with PMH of ESRD, heart failure, pancreatitis and previous MI presents to the ED with chief complaint of epigastric pain. He was described as “altered” with limited history able to be obtained due to mental status on arrival. Here is his triage ECG: What are your initial thoughts? – This EKG looks sinusoidal and highly concerning for hyperkalemia – Wide complex – Rate too slow to be VtachPatient then divulges that he has not been dialyzed in 5 days, hyperkalemic treatment started with albuterol, insulin, dextrose, loklema and only 2g calcium gluconate. (Meyers note: this is… - [What pathology do all these ECGs manifest?](https://drsmithsecgblog.com/what-pathology-do-all-these-ecgs-manifest/): ECG 1: What do you think? Then you can look at the rest. ECG 1: This is hyperkalemia. As soon as I saw it, I knew it. The peaked T-waves of hyperK are not always tall a peaked. Sometimes they are just small triangles, as in this case. T-waves like this are not seen in anything else. To me, they are almost pathognomonic. Lab results: K = 6.3; ionized Calcium = 4.0 (slightly low, explains long ST segment — typical of dialysis patients) Extra credit: There is also right axis deviation and a large R-wave (R/S > 1) in V1,… - [A man in his 50s with chest pain. You must strongly advocate for your patient who has an NSTEMI-OMI ECG pattern.](https://drsmithsecgblog.com/a-man-in-his-50s-with-chest-pain-you-must-strongly-advocate-for-your-patient-who-has-an-nstemi-omi-ecg-pattern/): From Anonymous A man in his 50s experienced acute chest pain and shortness of breath. He presented quickly to the Emergency Department, where he had normal vital signs at triage except for bradycardia. Here is his triage ECG: Surely you understand this ECG if you read this blog? Sinus rhythm, normal QRS, anterolateral hyperacute OMI pattern. HATW in V2-V6, I, and aVL (leads V3-V6 also have STD, making them the de Winter subtype of HATW). There is no STEMI criteria due to lack of 2 consecutive leads with STEMI mm criteria. Fortunately for the patient, there is reciprocal STD in… - [What is this pattern?](https://drsmithsecgblog.com/what-is-this-pattern/): This was contributed by Amandeep Singh, from Highland Hospital In Oakland CA. A 54yo male presented to the ED with severe substernal chest pain lasting 15-20 min, associated with general weakness, mild dyspnea, and diaphoresis. Here is the initial 12-lead ECG: What do you think? There is STE in V1, V2, aVR, and aVL. (There is also a hyperacute T-wave in V3). Otherwise, there is diffuse ST depression: in inferior leads and in V4-6. So there is a superior ST vector. There is no question that this is a STEMI-OMI. But it is unusual in that the STE vector is… - [Electrophysiology: Wide Complex Tachycardia in a 70-something](https://drsmithsecgblog.com/electrophysiology-wide-complex-tachycardia-in-a-70-something/): Written by Magnus Nossen A 70-year-old man experienced sudden onset of palpitations and nausea while at rest. He immediately called EMS. Upon EMS arrival he was alert with GCS 15, denied chest pain and could inform the paramedics that he has a history of mechanical heart valve placement and multiple prior cardiac surgeries. An ECG (shown below) was obtained and transmitted to local ED which was a five-minute drive away. On arrival in the ED, his respiratory rate was 28/min, oxygen saturation 90%, and blood pressure 112/73 mmHg. He appeared diaphoretic. How would you manage this patient? ECG # 1… - [When should you get a CT scan on a STEMI patient to rule out aortic dissection?](https://drsmithsecgblog.com/when-should-you-get-a-ct-scan-on-a-stemi-patient-to-rule-out-aortic-dissection/): Answer: Almost Never 2 cases Case 1: This was sent to me by a reader whose partner managed the case: This was a 55 yo female non-smoker with a history of HTN. No CAD.   She presented with 3 hours of fluctuating cycles of SOB that would worsen over 15 minutes then improve partly, associated with Nausea. There was No chest or back pain.  Note: 1/3 of STEMI do not have chest pain. Here is the presenting ECG: This is clearly inferior and lateral OMI, though really it appears as if it is 1) subacute, with well-formed Q-waves in inferior and in lateral… - [See Inflated Hyperacute T-waves deflate after thrombolytics](https://drsmithsecgblog.com/see-inflated-hyperacute-t-waves-deflate-after-thrombolytics/): This was sent to me with no information (until later). The conventional computer algorithm says “Early Repolarization” The overreading cardiologist said “Early repolarization.” What do you think? Diagnostic of LAD Occlusion. There is sigificant STE and hyperacute, inflated, T-waves in V3-V6. Moreover, this is clearly a STEMI (+) OMI; there are 3 mm STE in V3 and 2mm in V5: that meets STEMI mm criteria. One would think that OMI that meet STEMI criteria would be easily diagnosed by physicians. There is very little good data on this, but anecdotal evidence suggests that MANY cases of OMI that meet STEMI… - [Chest pain, resolved. Reperfusion T-waves. Should the patient go emergently to the cath lab?](https://drsmithsecgblog.com/chest-pain-resolved-reperfusion-t-waves-should-the-patient-go-emergently-to-the-cath-lab/): Written by Emily Dawra, one of our superb EM G3 residents, with a few edits by Smith. Case: A patient presented to the emergency department from a clinic for a “STEMI activation”.  He had been having stuttering exertional chest pain and exercise intolerance for nearly 1 week. However, he had been out of the country and told us that he “didn’t want to go to the hospital there,” so he waited until his convenient appointment with his primary doctor in clinic in Minnesota. His physician astutely assessed the concerning history, obtained the initial ECG, which he recognized as very worrisome, and… - [4 patients with chest pain, LVH, and elevated troponin: which has Occlusion MI?](https://drsmithsecgblog.com/4-patients-with-chest-pain-lvh-and-elevated-troponin-which-has-occlusion-mi/): Written by Jesse McLaren Four patients presented with chest pain, an ECG showing LVH, and an elevated troponin. Which patient has an acute coronary occlusion? Patient 1: 50 year old, no past medical history, with chest pain that began on exertion but continues, and feels like heartburn – Patient 2: Prehospital ECG on a 55 year old with no past medical history, with exertional chest pain and syncope, EMS Code STEMI – Patient 3: 60 year old, history of hypertension, with one week of chest pain and shortness of breath on exertion – Patient 4: 55 year old, no past… - [An 87-year-old with dyspnea and intermittent WCT](https://drsmithsecgblog.com/an-87-year-old-with-dyspnea-and-intermittent-wct/): Written by Magnus Nossen The patient in today’s case is an 87 year old female with a history of dual chamber pacemaker and Afib. She presented due to weakness and dyspnea that had progressed over a number of weeks. At presentation, the patient was tachycardic with a heart rate of about 120 BPM. Other vital signs were unremarkable. A prehospital ECG was transmitted and is shown below. What do you make of the ECG? Prehospital ECG This ECG displays a regular rhythm featuring two distinct QRS morphologies. In the Cabrera format, the limb and precordial leads are recorded simultaneously. The… - [Sam Ghali video: A 55-year-old woman complaining of "severe indigestion"](https://drsmithsecgblog.com/sam-ghali-video-a-55-year-old-woman-complaining-of-severe-indigestion/): A 55-year-old woman presented to the ED complaining of “severe indigestion” with abdominal pain, nausea, and vomiting. Given her active vomiting and trembling in triage— this ECG was the best quality tracing that could be recorded. What’s the diagnosis? (See below) Watch this video breaking down this very important ECG case and see what happened! Smith: this is an easy ECG; it is a STEMI(+) OMI and the patient needs the cath lab now. However, it does not appear to be the ECG of an acute MI; rather, the ECG is suggestive of a SUBACUTE MI. Why? There are Q-waves… - [A man in his 50s with chest pain and dyspnea](https://drsmithsecgblog.com/a-man-in-his-50s-with-chest-pain-and-dyspnea/): A man in his 50s had chest pain and shortness of breath. EMS arrived and recorded this ECG. What do you think? There is sinus rhythm with preexcitation causing abnormal QRS complexes, and consequently, abnormal repolarization. There is concordant STE in V2-V5, however this is something I have observed occasionally in WPW. The T waves are not hyperacute. I would favor WPW causing a STEMI mimic pattern, but it could be baseline WPW with superimposed anterior acute transmural injury. Zoll interpretation on EMS monitor included “***STEMI***” Queen of hearts interpretation: PMcardio for Individuals now includes the latest Queen of Hearts… - [What is this pattern?](https://drsmithsecgblog.com/is-this-a-wellens-ecg/): This was texted to me with the following text: “Steve any thoughts? I’m interested in your initial reaction and then can give context 😊” What do you think? I texted back: “This is a classic ‘fake’ (mimic) of Wellens waves. I think this is a young thin person.” Why is it not Wellens’?? First, there is very high QRS voltage, including a narrow, large amplitude R-wave in V1 and narrow, large amplitude Q-wave in V6. Hypertrophic Cardiomyopathy is a possibility with high voltage and large R-wave in V1 and narrow deep S-wave in V5-6. There are also what appear to… - [Atrial fibrillation with RVR and ST depression: POCUS, cardioversion, Lewis leads, and is this Posterior OMI?](https://drsmithsecgblog.com/atrial-fibrillation-with-rvr-use-pocus/): An elderly man with a history of diabetes and HTN presented with lethargy and weakness, decreased urine output, and hypotension.  There was no history of any GI bleeding or other hemorrhage.  There was no fever. He had no CP or SOB, and it was unknown if there was a previous history of atrial fibrillation.  He was on atenolol, but it was not known if this was simply for hypertension, or for atrial fib. He was not anti-coagulated. Blood pressures ranged from 83/45 to 125/83, lower than usual.  HR ranged from 110 to 145. He had an ECG recorded upon arrival:… - [Should this patient get thrombolytics? When should PCI be performed after thrombolytics?](https://drsmithsecgblog.com/should-this-patient-get-thrombolytics-when-should-pci-be-performed-after-thrombolytics/): This was sent by an old friend, who was working with a physician assistant student, Lily McLean. She had just that minute downloaded the Queen of Hearts, and this case made her an OMI convert. They were at a hospital without PCI capability. Lily and my friend came on for the morning shift and were told this by the departing emergency physician: “60-something woman presented at time zero with left chest heaviness beginning 3.5 hours prior when she was up and about at home. It built steadily to 8 or 9/10. No radiation or SOB, mild nausea.” “No known CAD,… - [In chest pain, if the ECG is not diagnostic, can the medics safely leave the patient at home?](https://drsmithsecgblog.com/in-chest-pain-if-the-ecg-is-not-diagnostic-can-the-medics-safely-leave-the-patient-at-home/): 67 year old female complaining of epigastric pain that radiates to herchest. Relief with burping. Symptoms had been ongoing for about 1 hourprior to 911. Symptoms started after eating a high fat meal. On arrival, the crew did a workup on her complaints which included a12-lead ECG. What do you think? Smith: there is a clear hyperacute T-wave in lead V3. This is diagnostic of LAD OMI, but it is unusual to only be seen in one lead. I do wonder about lead placement. There is also very poor R-wave progression in V4-6, which contributes to a suspicion of LAD… - [A woman in her 50s with chest pain. No diagnostic STE (that worthless diagnosis: "NSTEMI"). What is it and what happened?](https://drsmithsecgblog.com/a-woman-in-her-50s-with-chest-pain-no-diagnostic-ste-that-worthless-diagnosis-nstemi-what-is-it-and-what-happened/): Sent by anonymous, written by Pendell Meyers A woman in her 50s presented with acute chest pain and shortness of breath. She appeared well with normal vital signs. Here is her triage ECG: What do you think? The ECG shows sinus rhythm with normal QRS complex and signs of acute LAD occlusion. This ECG shows the Precordial Swirl sign that we coined and published here. It includes STE and/or HATW in V1-V2, with reciprocal STD and/or TWI in V5-V6. At the time we submitted this manuscript, we didn’t yet have the ability to automatically quantify HATW. As the best available… - [Chest pain, serial ECGs STEMI negative, first troponin normal: cancel cath lab activation? Exemplary care by an emergency physician!](https://drsmithsecgblog.com/chest-pain-serial-ecgs-stemi-negative-first-troponin-normal-cancel-cath-lab-activation-exemplary-care-by-an-emergency-physician/): Submitted by Matthew McArthur, recent emergency physician graduate and regular reader of Dr. Smith’s ECG Blog, ECG Cases, and ECGweekly workout. On a weekend evening in a PCI capable centre, triage nurse comes to me with this ECG for a healthy 77 year old with a past history of HTN and BPH who had one hour of acute crushing/squeezing retrosternal chest pain with diaphoresis and nausea. = = = = = = = = = My eyes were drawn to the inferior ST depressions and elevation in aVL concerning for high lateral territory ischemia / South African flag sign. I… - [Atypical symptoms. Should we give thrombolytics?](https://drsmithsecgblog.com/atypical-symptoms-should-we-give-thrombolytics/): This was sent by an old friend who works at a hospital without PCI capabilities, and far from one that does. So if there is OMI, he gives thrombolytics. A very elderly patient with previous EF of 60% complained of shortness of breath for 2 weeks, with pleuritic chest pain. There was no pain on arrival. But the pain recurred while in the ED. His BP was 90 systolic. He recorded an initial ECG: What do you think? Is it “Nonspecific ST abnormality, as the conventional computer algorithm claims?” My friend thought there was inferior OMI. He applied the PMCardio… - [Dyspnea and chest pain. O2 saturation 88%.](https://drsmithsecgblog.com/dyspnea-and-chest-pain-o2-saturation-88/): This ECG was texted to me: dyspnea and chest pain. O2 saturation 88%. What was my response? My response: “She has some sort of chronic hypoxia and pulmonary hypertension. Maybe a right to left shunt.” The ECG shows massive right ventricular hypertrophy. There is right axis deviation, large R-wave in V1, VERY large R-wave in V2-3, and very typical ST-T abnormalities of severe RVH. Therefore, the patient has pulmonary hypertension. She may have an anatomic right to left shunt, or she may have pulmonary vessel hypertension. There is no right bundle branch block!! (the clinicians interpreted RBBB) This is important,… - [Chest pain in a rural hospital: is this pericarditis or does the patient need thrombolytics?](https://drsmithsecgblog.com/chest-pain-in-a-rural-hospital-is-this-pericarditis-or-does-the-patient-need-thrombolytics/): Written by Mazen El-Baba, with edits from Jesse McLaren A 60-year-old woman presented to a rural emergency department with sudden-onset, crushing chest pain that began 20 minutes prior to arrival. She described it as a 10/10 heaviness in the center of her chest, without radiation or shortness of breath. Past medical history: hypertension on perindopril. She took two aspirin tablets at home before coming to the ED. She was triaged to the resuscitation bay, and the first ECG was obtained, which the computer interpreted as pericarditis. What do you think? ECG interpretation: Sinus tachycardia, borderline left axis, early R-wave progression… - [Wide complex Tachycardia in an 85 year old](https://drsmithsecgblog.com/wide-complex-tachycardia-in-an-85-year-old/): An 85 year old called 911 for palpitations. Medics found her with good blood pressure but fast rate and recorded this ECG? Opinion of Zoll algorithm and medic: junctional tachycardia. My response: it is NOT junctional tachycardia. There are subtle waves showing that the underlying rhythm is atrial flutter at a rate of 256, with ventricular rate of 128 (2:1 conduction), and the wide complex is due to RBBB/LAFB. Here I point them out with red arrows: These are very subtle, but I was convinced. Let’s see if there is a baseline RBBB/LAFB So I found a Previous ECG, and… - [A man in his 70s with acute chest pain. How did management affect the outcome?](https://drsmithsecgblog.com/a-man-in-his-70s-with-acute-chest-pain-how-did-management-affect-the-outcome/): Sent by anonymous, written by Pendell Meyers A man in his 70s presented with acute chest pain, shortness of breath, nausea, vomiting, and diaphoresis. The pain started approximately 4 hours prior to arrival, and was still active at the time of EMS arrival. Vital signs were within normal limits. EMS ECG transmitted to ED physician: What do you think? There is sinus rhythm with left anterior fascicular block. There is STE in V1 and V2 which does not meet STEMI criteria. There is precordial swirl pattern LAD OMI, and the suggestion of nearly concordant STE in aVL (there should instead… - [New Lecture. October 23, 2025.  Replace STEMI/NSTEMI with OMI/NOMI, and AI in the Diagnosis of OMI](https://drsmithsecgblog.com/new-october-23-2025-replace-stemi-nstemi-with-omi-nomi-and-ai-in-the-diagnosis-of-omi/): This is from Cardiology Grand Rounds at Medical College of Wisconsin, via Zoom, on October 23, 2025. The woman you see there is Dr. Jacquelyn Kulinski, of the Dept. of Cardiology at MCW, who gave a very gracious introduction. = = = Click here to view the talk on OMI NOMI and AI = = = NOTE: You can find this lecture (as well as other lectures) at any time — at the above link in our Top Menu = = = ====================================== MY Comment, by KEN GRAUER, MD (10/25/2025): My Recommendation: For anyone who has recently participated in the decision to… - [Chest pain with "Non-diagnostic ECG". What is the finding? What do you think happened?](https://drsmithsecgblog.com/chest-pain-with-non-diagnostic-ecg-what-is-the-finding-what-do-you-think-happened/): Written by Magnus Nossen A 69-year-old woman with a 50-year history of smoking contacted EMS due to sudden onset chest pain. The chest pain was substernal and described as dull with an intensity of 8/10. The pain was accompanied by nausea, vomiting, and profuse sweating. The following ECG was recorded by EMS. ECG # 1 What do you think? The described clinical scenario in today’s case is textbook for ACS. Based solely on pretest probability and symptoms, cath lab activation is warranted if symptoms persist — and one can make an argument that this patient should go to the cath… - [Does this patient with wide complex tachycardia need an angiogram?](https://drsmithsecgblog.com/does-this-patient-with-wct-need-angiogram/): This case is divided into two separate hospitalizations about 9 months apart. Part 1 A man in his late 60s with hypertension, hyperlipidemia, type 2 diabetes mellitus, and a 50 pack-year smoking history presented at around 10 AM with acute onset chest pain which began several hours earlier while he was at home. He described it as a squeezing sensation across his chest radiating into the jaw. Before you see the ECG, you know the diagnosis. ECG 1 What do you think?                 This ECG is diagnostic for inferolateral OMI. Most blog readers… - [A 45-year old man with "Heartburn." There is much more to the ECG than initially meets the eye.](https://drsmithsecgblog.com/a-45-year-old-man-with-heartburn-there-is-much-more-to-the-ecg-than-initially-meets-the-eye/): A 45-year-old man presented to the ED complaining only of “heartburn”. There was no chest pain, no shortness of breath, nausea or vomiting. And this was his ECG … The diagnosis is obvious — but there is more. What do you think? (See below). The patient had mostly normal blood pressure, but did have one BP measured at 93/51. Watch this video breaking down this ECG case and see what happened! Watch the Video and listen to Sam’s excellent narration. This is a large MI (of inferior, posterior, and lateral walls, with Right ventricular MI!). RV MI often presents with… - [A 24 year old with chest pain — What happened?](https://drsmithsecgblog.com/a-24-year-old-with-chest-pain/): This was written up by one of our superb EM/IM residents, Emily Syverud. A 24-year-old man presented to the ED early in the morning with burning chest pain that had started suddenly the night before while watching TV, he also reported some associated nausea and vomiting. He played soccer earlier in the evening without any chest pain at all. A week earlier he had been sick with a URI-type illness, this had since resolved. Here is his initial EKG: What do you think? The conventional (Veritas) computer interpretation was this: SINUS BRADYCARDIA WITH SINUS ARRHYTHMIAST ELEVATION CONSISTENT WITH INJURY, PERICARDITIS,… - [What do you think happened to this woman with chest pain?](https://drsmithsecgblog.com/what-do-you-think-happened-to-this-woman-with-chest-pain/): By Pendell Meyers A woman in her 60s with multiple comorbidities presented to the ED with acute chest pain. Vitals were within normal limits. She described “burning” pain in the center of her chest, no radiation, and lightheadedness. Onset was within two hours of arrival. Here is her triage ECG (no prior available for comparison): What do you think? Here is the interpretation by the Queen of Hearts: “STEMI Equivalent = Occlusion MI (OMI)” The Queen sees at least anterior OMI with high confidence, with hyperacute T waves and some STE that doesn’t meet STEMI criteria. New PMcardio for Individuals… - [34 weeks pregnant. Heart rate of 180](https://drsmithsecgblog.com/34-weeks-pregnant-rapid-180/): A multiparous 41 y.o. female with history of an episode Atrial Fibrillation with Rapid Ventricular Response (AF RVR) in the setting of pregnancy 15 years prior and recent stillbirth presented with recurrent AF RVR in the setting of a 34 week gestation based on bedside US. The patient began feeling SOB with fast heart rate and dizziness the previous evening (approximately 12 hours prior).  Since it continued, she presented to a smaller hospital, where her EKG showed possible AF RVR with rates as high as 180 bpm, then down to 140s after metoprolol. Her d-dimer was also elevated at nearly… - [Extremely fast, narrow, regular](https://drsmithsecgblog.com/extremely-fast-narrow-regular/): This was emailed to me by a reader with this info: 39-year-old male with no past medical history presents with 3 days of palpitations and 2 episodes of syncope in the past 8 hours. (I later heard from a publisher that this is from their book and is copyrighted. The sender represented the ECG as from her own institution, and gave permission to use it. The publisher agrees to let me keep it here with attribution. I think the sender really believed that it came from a colleague at her own instutution. An honest mistake.) This comes from this book,… - [Worrisome chest pain and inferior ST Elevation](https://drsmithsecgblog.com/worrisome-chest-pain-and-inferior-st-elevation/): This is a 30-something year old male with 1 week of constant left substernal chest pressure. Patient states the pain is non-radiating, it is not worse with breathing. It is not exertional and may have a positional component. He endorses some intermittent shortness of breath during this time and is using his inhaler for asthma as needed.  Here is his first ECG: What do you think? This was sent to me by text message with the information that the PMCardio Queen of Hearts had already opined that it was Not OMI. Probably because of this, they had waited for a… - [A 60 yo presented to the ED with chest pain, ECG findings missed, then went into V-Fib cardiac arrest](https://drsmithsecgblog.com/a-60-yo-presented-to-the-ed-with-chest-pain-ecg-findings-missed-then-went-into-v-fib-cardiac-arrest/): A 60-year-old man presented to the ED with chest pain and this ECG was recorded. Computer read this as normal. What’s the diagnosis? (See below) The findings went unnoticed. He subsequently went into V-Fib cardiac arrest. Watch this video breaking down this very important ECG case and see what happened! When the conventional algorithm diagnoses an ECG as totally “normal”, it is often wrong. These algorithms especially miss specific but subtle findings of Occlusion MI (OMI). They not only miss them by calling “nonspecific ST-T abnormalities”, they miss by calling the ECG totally normal!! We showed that, among cases that… - [An elderly male with acute chest pain](https://drsmithsecgblog.com/an-elderly-male-with-acute-chest-pain/): Written by Magnus Nossen The patient in today’s case is a 90-something male with a medical history of prostate cancer and chronic AFib, on oral anticoagulants. The patient contacted EMS due to sudden onset chest pain. Below is the prehostpial ECG recorded by EMS. This ECG was recorded with a paper speed of 25 mm/s. The layout is in the Cabrera Format (See Dr. Grauer Comment in the October 26, 2020 post of Dr. Smith’s ECG Blog for review on the Cabrera Format). Below the ECG has been digitized using the PMcardio App. — What do you think of this… - [Acute Chest pain, 2 years in a row.](https://drsmithsecgblog.com/acute-chest-pain-2-years-in-a-row/): A man in his 30s presented for similar symptoms (acute substernal chest pain) twice, each visit one year apart. Visit #1 History including acute substernal chest pain, shortness of breath, and diaphoresis, within 3 hours onset. Obesity but no other cardiac risk factors. Vitals within normal limits. ECG: What do you think? Meyers: Many leads with STE, meeting STEMI criteria, but T waves are non-hyperacute, benign ST morphology, spodick sign, and some PR depression. DDX is pericarditis vs. normal variant. No signs of OMI. Notice how aVR must mathematically have ST depression because many leftward/downward leads have STE. Smith: I… - [Rapid SVT, diagnosis?](https://drsmithsecgblog.com/rapid-svt-diagnosis/): A 53 year old man with paroxysmal atrial fibrillation and multiple myeloma called EMS with chest discomfort and palpitations. When paramedics arrived, they found him awake and alert and said his chest felt “off.” 12-lead ECG is shown. What do you think? When a patient has hemodynamically unstable tachycardia, cardioversion is always reasonable. The EMS report indicates blood pressure 144/59 mmHg, respiratory rate 16, oxygen saturation 99% breathing ambient air. So no immediate need for cardioversion. What’s our differential diagnosis? The very fast rate (~212 bpm) forces us to consider ventricular tachycardia. However, the QRS duration is not particularly wide,… - [ECG interpretation can keep you out of the courtroom. And "viral infection" by itself is not an explanation for dyspnea](https://drsmithsecgblog.com/ecg-interpretation-can-keep-you-out-of-the-courtroom-and-viral-infection-by-itself-is-not-an-explanation-for-dyspnea/): This case was sent by Eric Funk of the Expert Witness Newsletter https://expertwitness.substack.com/p/death-after-ed-visit-for-covid A 21-year-old college student went to the ED for cough, chest pain, and shortness of breath. He was known to have COVID. Temperature was 36.3, Pulse 84, Resp 16, BP 134/86 and SpO2 = 97%. He was “well appearing.” An EKG was recorded: What do you think? This ECG was sent to our “EKG Nerdz” group without any clinical information, and all of us said “Pulmonary Embolism”. It is diagnostic of PE. “Domed” ST Elevation, T-wave inversion in V1-V3 AND in lead III. This post tells you… - [Several days of Shortness of breath. Other than the obvious atrial flutter, can PMCardio AI make the crucial diagnosis on the ECG?](https://drsmithsecgblog.com/several-days-of-shortness-of-breath-other-than-the-obvious-atrial-flutter-can-pmcardio-ai-make-the-crucial-diagnosis-on-the-ecg/): A 70-something male with no significant past history presented to a primary care clinic with some progressive SOB over weeks, much worse over last few days. The clinic recorded an ECG which is reported to show atrial flutter with rapid ventricular response. The internal medicine physician prescribed metoprolol and anticoagulation, and discharged him. As far as I can tell, no ultrasound machine was available. I do not have the ECG they recorded, but when he presented to the ED 2 days later in much worse condition, this was his ECG: What do you think? There is clear atrial flutter with… - [Found down, CPR, pulse regained. Here is the ED ECG. What is it?](https://drsmithsecgblog.com/found-down-cpr-pulse-regained-here-is-the-ed-ecg-what-is-it/): A man in his 60s was found down in the park. Bystanders initiated CPR, but when EMS arrived he had a pulse and it was not clear that he had actually arrested at all. He received naloxone with “some improvement” reported. He had unidentified pills in his pocket. His ECG is shown. ECG 1 What do you think? I sent this to the EKG Nerdz. Dr. Smith and Dr. Hellerman immediately replied that they thought it was “fake“. (This means they thought it was not an OMI, but rather an ECG that mimics OMI and could fool non-experts.) I sent… - [Chest pain and a very wide RBBB](https://drsmithsecgblog.com/brady-pregerson-ekg-he-thought-it-was/):  I was texted this ECG by a reader without any info: What do you think? The reader’s interpretation was this: “Patient supposedly has an old bundle, but doesn’t know what type. I thought the right bundle looked a little shark fin like.” Is this “Shark Fin“? No, this is not shark fin.  This is RBBB and LAFB, and the QRS duration is so long (about 195 ms) that it almost looks like a shark fin. But shark fin is due to the R-wave merging into the ST segment (see example below and many examples here). One might think of hyperK… - [Five Lessons from a Misleading ECG](https://drsmithsecgblog.com/five-lessons-from-a-misleading-ecg/): This was written by Emerson Floyd, with comments by Smith I first saw this this ECG (#1) when I woke up to a text message a fellow EM physician and friend between night shifts: “I accepted this patient in transfer from a remote hospital without a cath lab. Our IC said to hold on lytics based on the ECG. Transferring doc was worried about left main occlusion based on aVR. Sgarbossa+? I never saw the patient.” Smith: see @PMCardio Queen of Hearts interpretation below. The first things that caught my half-asleep eye were the extreme axis, the totally upright complex… - [A very elderly woman with sudden severe chest pain radiating to her back](https://drsmithsecgblog.com/a-very-elderly-woman-with-sudden-severe-chest-pain-radiating-to-her-back/): An 89-year-old woman with a history of hypertension only on propranolol and hydrochlorothiazide presented by ambulance with sudden onset of chest pain.  It radiated to her back.  Medics reported that there was a slight difference in blood pressure between the 2 arms.  They recorded a prehospital ECG: What do you think? It shows RBBB with OMI in V2-V6, I, aVL and reciprocal STD in inferior leads, diagnostic of proximal LAD occlusion. This is an easy ECG. On arrival she was in quite a bit of distress from pain. Vital signs were fine.  I confirmed her ECG findings and activated the… - [An 80-year-old with chest pain and a wide QRS. Should you give thrombolytics?](https://drsmithsecgblog.com/an-80-year-old-with-chest-pain-and-a-wide-qrs-should-you-give-thrombolytics/): Written by Magnus Nossen Today’s patient is an 80-year-old man with stage 5 chronic kidney disease (CKD), but not yet receiving dialysis. His medical history includes hypertension and a prior myocardial infarction, for which he underwent PCI with stenting of a marginal branch of the LCx. He called emergency medical services after developing sudden onset chest pain, rated as 8 out of 10, accompanied by shortness of breath. The following prehospital ECG was obtained 25 minutes after symptom onset. What do you think about the ECG and the clinical situation — and how would you manage this patient? Prehospital ECG… - [Severe chest pain, resolved. Serial troponins nearly undetectable at 3 ng/L](https://drsmithsecgblog.com/severe-chest-pain-serial-troponins-nearly-undetectable-at-3-ng-l/): A 50-something woman with PMH only significant for hypertension (treated) presented by car to the emergency department with one week of intermittent chest pain. Pt states that she had a sudden onset of central chest pain described as sharp and rated as 10/10 pain six days ago while at rest. Since then, she has been having recurrent episodes of pain lasting 2-3 minutes each time that can reach 10/10 in severity. At presentation there was only minimal chest discomfort. She stated that she attempted taking her gastroesophageal reflux medication without relief (comment: but this begs the question: “how could that… - [A 15 year old with acute chest pain](https://drsmithsecgblog.com/a-15-year-old-with-acute-chest-pain/): The cardiologists are not investigating the possibility of acute coronary occlusion simply because it is rare in a 15 yo. But rare does not mean nonexistent, and if you don't look, you can't make the diagnosis and can't save the heart. - [It's best to recognize OMI before deciding not to intervene](https://drsmithsecgblog.com/its-best-to-recognize-omi-before-deciding-not-to-intervene/): This is an elderly woman with a history of HFrEF (EF 20%), CKD, hypertension, dyslipidemia, decompensated Cirrhosis, Hepatic Encephalopathy, Hx of Esophageal varices, and A-fib with RVR on carvedilol, type 2 diabetes who presents to the ED with sore throat, generalized body pain, agitation, chest pain, and shortness of breath. She was a difficult historian and easily agitated. An EKG was ordered 24 minutes after arrival and completed 41 minutes after arrival.  What do you think? There is unfortunately a lot of baseline wander and artifact. Nevertheless, you can clearly see P-waves in lead I (sinus rhythm at a rate… - [A man in his 60s with acute chest pain. Is this precordial swirl?](https://drsmithsecgblog.com/a-man-in-his-60s-with-acute-chest-pain-is-this-precordial-swirl/): A man in his 60s experienced acute chest pain and called EMS. EMS arrived and recorded this ECG during 10/10 chest pain: What do you think? The EMS viewing system unfortunately truncates/clips the voltage at + or – 10mm from the baseline. This limits the view of the QRS complex in many leads. The question is whether there is anterior wall acute coronary occlusion MI, or not. The T waves are broad and seem to have large area for their QRS complexes. Is there reciprocal STD/TWI in V5-6? Is this precordial swirl sign? Queen of Hearts sees no signs of… - [A 40-something male with cough, dyspnea, and chest tightness.](https://drsmithsecgblog.com/a-40-something-male-with-cough-dyspnea-and-chest-tightness/): A 40-something man with h/o asthma presented with cough, sore throat, earache, shortness of breath and chest tightness. His wife had similar symptoms, but without the SOB. The patient received albuterol with some relief. He was being set up for discharge when the provider decided it would be a good idea to record an ECG. Here it is: The conventional Veritas computer interpretation was: ST ELEVATION, CONSIDER ANTERIOR INJURY  [MARKED ST ELEVATION W/O NORMALLY INFLECTED T-WAVE IN V2-V5]***ACUTE MI***  What do you think? = = = = = = = = = = = = I was shown this later,… - [A 30-something agitated male with a regular narrow complex tachycardia that will not terminate with adenosine](https://drsmithsecgblog.com/a-30-something-agitated-male-with-a-regular-narrow-complex-tachycardia-that-will-not-terminate-with-adenosine/): 30-something male presented by EMS for evaluation of agitation and tachycardia. Per EMS, patient was running through the street, yelling, and punching cars. EMS measured his pulse from 190-200. They administered 10 mg of droperidol in order to calm the patient sufficiently to record a 12-lead ECG. What do you think? There is a very fast SVT at a rate of about 204 bpm. They administered adenosine 6 mg without terminating the rhythm. They then gave 12 mg adenosine without results. They gave another 12 mg adenosine without termination. Why did it fail? The patient arrived in the ED and… - [Chest pain with acute RBBB: just another NSTEMI?](https://drsmithsecgblog.com/chest-pain-with-acute-rbbb-just-another-nstemi/): Written by Jesse McLaren, with comments from Smith A 75 year old with a previous MI and ischemic cardiomyopathy presented with 6/10 chest and epigastric pain ongoing for 4 hours. Serial ECGs were ‘STEMI negative’ but revealed an acute RBBB. Here are the serial precordial leads: what’s going on? Triage ECG: “ST depression” or reciprocal change? Here’s the baseline ECG and full triage ECG, with final interpretation. What do you think? Baseline ECG: Triage ECG: There’s normal sinus rhythm and high lead placement of V1-2 (negative P-wave in V2), normal conduction and axis, delayed R wave with old Q wave… - [A 35-year old woman with this post-ROSC ECG. What does "shark fin" morphology mean?](https://drsmithsecgblog.com/a-35-year-old-woman-with-this-post-rosc-ecg-what-does-shark-fin-morphology-mean/): Written by Magnus Nossen. The patient in today’s case is a 35-year-old overweight female. She experienced sudden onset chest pain and quickly called emergency medical services. Approximately 10 minutes later, she collapsed in the presence of witnesses. On EMS arrival, she was found to be in ventricular fibrillation. Return of spontaneous circulation was achieved after 10 minutes of resuscitation, and an ECG was obtained immediately and is shown below. What do you think? ECG #1 The ECG demonstrates a regular tachycardia at a rate of 145 bpm. There are clear sinus P waves before each QRS. Although the initial impression from the lateral… - [Chest pain, this ECG, and an undetectable troponin after 6 hours of pain](https://drsmithsecgblog.com/chest-pain-this-ecg-and-an-undetectable-troponin-after-6-hours-of-pain/): These ECGs were texted to me by one of our former ultrasound fellows, Will Smoot A Middle-aged male presented with acute chest pain. This initial ECG was recorded: Smith: there are definite hyperacute T-waves in V4-5. So this is diagnostic of LAD Occlusion. Queen of Hearts: Here she explains: Is she correct? New PMcardio for Individuals App 3.0 now includes the latest Queen of Hearts model and AI explainability (blue heatmaps)! Download now for iOS or Android.  https://www.powerfulmedical.com/pmcardio-individuals/ (Drs. Smith and Meyers trained the AI Model and are shareholders in Powerful Medical). Previous from 9 months prior It sure looks like the T-waves on… - [Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (PMcardio, queen of hearts), and comment by John Mandrola on "This Week in Cardiology Podcast"](https://drsmithsecgblog.com/accuracy-of-cath-lab-activation-decisions-for-stemi-equivalent-and-mimic-ecgs-physicians-vs-ai-pmcardio-queen-of-hearts-and-comment-by-john-mandrola-on-this-week-in-cardiology-podcast/): Here is the link to the study by Shroyer, Mehta, Thukral, Smiley, Mercaldo, Meyers, and Smith Here is a link to all the ECGs. This Week in Cardiology Podcast – August 01, 2025 — transcript here By John M. Mandrola, MD Disclosures August 01, 2025 AI vs Doctor ECG-Reading for Cath Lab Activation The American Journal of Emergency Medicine has a neat study out this week comparing the accuracy of cath lab activation (CLA) for ST-elevation myocardial infarction (STEMI)-equivalent and STEMI-mimic ECGs. I really like this study. And it’s an important problem, as the identification of STEMI in the first… - [Chest pain 6 days after a negative stress test](https://drsmithsecgblog.com/case-from-cody-pinnow/): This case comes from Cody Pinnow, a 2nd year EM resident who learned EKGs from this blog while working as a cardiac monitor technician, before medical school. A previously healthy 70 something y.o presented to the ER with 1 hour of dull, retrosternal chest pain radiating to the left shoulder. He reports no cardiac history and actually underwent a stress test (unclear type) 6 days prior, which was normal. The patient was given a clean bill of health by his cardiologist. An ECG was obtained at time 0000, no priors were available. What do you think? = = = This… - [87-year-old with chest pain](https://drsmithsecgblog.com/87-year-old-with-chest-pain/): Written by Magnus Nossen. This prehospital ECG was obtained form an elderly male with new onset chest pain. The pain was substernal 7/10, crushing in nature and radiating to the neck. He had a medical history significant for type II DM treated with insulin, DVT and abdominal surgery. How would you assess this ECG? Prehospital ECG (ECG #1) Interpretation: The ECG shows sinus rhythm with a heart rate of approximately 50 beats per minute. The QRS duration is 110 ms, and in lead I the QRS morphology, along with absent significant R waves in V1-V2, is consistent with incomplete left… - [Can you guess the diagnosis?](https://drsmithsecgblog.com/by-magnus-nossen-i-was-sent-this-ecg-by/): I was sent this ECG by a former colleague without clinical context and asked for an interpretation. Interpreting ECGs without clinical context should be avoided when it comes to actual clinical desicion making but it can be a fun exercise and a good way to learn pattern recognition. Without the benefit of clinical information how would you describe this ECG? If any, what are the features that concerns you? - [70-something with acute chest pain, Right Bundle Branch block, ST Elevation, and large T-waves](https://drsmithsecgblog.com/70-something-with-acute-chest-pain-right-bundle-branch-block-st-elevation-and-large-t-waves/): A 70-something with no cardiac history called 911 for acute chest pain. Here is the prehospital ECG: What do you think? There is right bundle branch block (RBBB) and left anterior fascicular block. There are 2mm of ST Elevation in V3 and V4. There is more than 1 mm STE in V5 and STE = 1 mm in V6. RBBB is “supposed to” have no ST Elevation anywhere. Usually, in V1-V3, there is ST depression discordant to a positive R’-wave. In this case, V3 does not have a positive R’-wave. Instead, there is a negative S-wave, and so one might… - [Acute chest pain and ST Elevation. Activate the cath lab?](https://drsmithsecgblog.com/acute-chest-pain-activate-the-cath-lab/): Written by Pendell Meyers A man in his 40s presented with acute chest pain. Here is his triage ECG: What do you think? The ECG above shows a dramatic artifact originating from the left arm electrode. Lead II is the only normal/unaffected limb lead present, meaning that there is no significant artifact coming from the electrodes that compose it: RA and LL. All other leads are affected by the artifact which must be coming from the LA electrode. Why are the precordial leads also affected? I believe this is because Wilson’s central is created from the limb leads and is… - [Chest pain and a fast rhythm](https://drsmithsecgblog.com/chest-pain-and-a-fast-rhythm/): My partner brought me this ECG during a shift, not sure how to interpret it. A 65 y.o. male with a past medical history significant for coronary artery disease, STEMI, NSTEMI, DVT, PE presented to the ED with chest pain and palpitations.  Patient reported that about an hour and a half ago he started to have a funny feeling in his chest patient reported that the pain at the time was about 3 out of 10.  This pain increased drastically to a 7 out of 10 radiated down his left arm felt stabbing in nature and he began sweating.  At… - [Even OMI that are STEMI are missed, and called "Not a STEMI"](https://drsmithsecgblog.com/even-omi-that-are-stemi-are-missed-and-called-not-a-stemi/): A 40-something woman with no previous medical history presented in the wee hours with 4 hours of chest pain. The pain had been intermittent for one week, but she attributed it to something she had eaten. An ECG was recorded at triage: Conventional computer interpretation What do you think? The ECG is diagnostic of LAD Occlusion (OMI), and also of STEMI! There is 1 mm of ST Elevation (STE) in lead V1. There is 1.5 mm STE in lead V2. (STEMI criteria for women are 2 consecutive leads with STE of 1 mm in all leads, except for 1.5 mm… - [Is it Always Best to Activate when Convinced of Acute OMI in a STEMI World?](https://drsmithsecgblog.com/is-it-always-best-to-activate-when-convinced-of-acute-omi-in-a-stemi-world/): Written by Emerson Floyd MD (Edits by Grauer, Meyers, Smith) Smith: Isn’t it sad that we need to be psychologists in order to try to persuade interventionalists to do the right thing? Emerson begins the CASE: I was shown the following ECG at 0345 am while I was walking down the hall to another patient’s room. My suspicion for acute coronary occlusion was immediately raised by this initial ECG. Lead aVL was the most concerning lead, and along with leads I and V2 — a clear picture of inferior injury with high lateral and “posterior” reciprocals painted. (As an aside,… - [Chest pain and nausea with a diagnostic ECG](https://drsmithsecgblog.com/chest-pain-and-nausea-with-a-diagnostic-ecg/): Written by Pendell Meyers, sent by anonymous A man in his 40s called EMS for acute symptoms including chest pain, abdominal pain, nausea, and diarrhea. Here is his EMS ECG: Critical hyperkalemia, with sine wave appearance. Please try to ignore the Zoll machine’s “***STEMI***”! PM Cardio Queen of Hearts does not cause a false positive STEMI alert in this case: New PMcardio for Individuals App 3.0 now includes the latest Queen of Hearts model and AI explainability (blue heatmaps)! Download now for iOS or Android.  https://www.powerfulmedical.com/pmcardio-individuals/ (Drs. Smith and Meyers trained the AI Model and are shareholders in Powerful Medical.) Paramedics administered 2gm calcium gluconate and… - [Why did it take 70 years for this to cause trouble? And what are the markers of risk in this ECG?](https://drsmithsecgblog.com/why-did-it-take-70-years-for-this-to-cause-trouble-and-what-are-the-markers-of-risk-in-this-ecg/): This patient was admitted after experiencing syncope while seated. What is the primary abnormality on this ECG, and what additional, more subtle ECG feature may predict future events? ECG #1 Paper speed 25mm/s. Standard ECG layout. This ECG shows sinus rhythm with a heart rate of 55 bpm. The PR interval is normal, the QRS complexes are narrow, and the QRS axis in the frontal plane is within normal limits. The T waves appear unusually prominent relative to the preceding R waves, particularly in leads I and aVL. At first glance, these might be mistaken for hyperacute T waves. However, this… - [Back to basics: ECGs are dynamic, get serial ECGs and learn the OMI progression](https://drsmithsecgblog.com/back-to-basics-ecgs-are-dynamic-get-serial-ecgs-and-learn-the-omi-progression/): Written by Pendell Meyers A male in his 40s experienced off and on chest pain at rest several times in the past 48 hours. The pain returned and was persistent for several hours when EMS arrived and recorded this ECG: Time zero (prehospital): Overall, I think this ECG itself would be suggestive of OMI in leads V3-V4, and inferior leads, but to me would not be diagnostic yet. There was no baseline available for comparison, and there is a question of whether the S wave voltage in V3 is being truncated at 10 mm. Queen of Hearts also does not… - [75 year old with acute chest pain: 6 bad reasons not to cath.](https://drsmithsecgblog.com/75-year-old-with-acute-chest-pain-6-bad-reasons-not-to-cath/): Written by Jesse McLaren, edits by Smith A 75 year old without cardiac history presented to the emergency department with 3 hours of acute chest pain, which radiated to the jaw and bilateral shoulders. The question “to cath or not to cath” was answered with 5 common reasons: Go through the case and at each step ask the question: to cath or not to cath? Here’s the triage ECG and repeat 30 minutes later: What do you think? There’s sinus bradycardia, normal conduction, normal axis, normal  R wave progression, and voltages. The minimal ST elevation in the anterior leads is… - [Wide Complex Tachycardia, intermittent](https://drsmithsecgblog.com/wide-complex-tachycardia-intermittent/): This was sent by a former resident, John Dunbar: “Had this one the other day. 60s, no medical history but didn’t go to the doctor. Had a “stressful event” 6 hrs before coming in and felt “weird”. Went to urgent care where an ECG was recorded, and was sent to us for his abnormal ecg.  No prior ekg except for the one done at urgent care. He mentioned he would get brief palpitations once in a while, mostly with heavy exertion, but very infrequently and none for years.” Here is the ED ECG: This was the ECG recorded 20 minutes… - [Recurrent Seizure. Or was it syncope? Diagnosis made after 20 years. But then changed again!](https://drsmithsecgblog.com/recurrent-syncope-diagnosis-made-after-20-years/): This was written by Magnus Nossen. Today’s case is a bit different from the usual case on Dr. Smith’s ECG blog. This case tells a patient history spanning many years. The patient is a 20-something female with a diagnosis of childhood epilepsy. She’s had a twenty year history of recurrent seizures. She has been on a variety of anticonvulsants but her seizures were never fully controlled. The below ECG was recorded during one of her many hospital visits. Do you see anything worrisome on this ECG? ECG #1 ECG #1, on file recorded when the patient was in her early… - [A subtle ECG and a subtle angiogram](https://drsmithsecgblog.com/a-subtle-ecg-kg-done-and-subtle/): Written by Willy Frick A man in his early 40s with no past medical history experienced acute onset crushing chest pain and dyspnea. The chest pain radiated into his left arm, and there was finger tip numbness. He rated it 10 out of 10. He took aspirin 325 mg and called EMS. The EMS report describes him as diaphoretic and clammy with extreme anxiety. His ECG is shown. ECG 1 What do you think?             The Queen of Hearts calls this negative for OMI, but the raw output is 0.48. The model output ranges from 0 to… - [65 year old with chest pain during dialysis](https://drsmithsecgblog.com/65-year-old-kg-done-with-chest-pain/): Written by Jesse McLaren, with edits by Smith   A 65 year old with history of CABG and end stage renal disease developed sudden chest pain and diaphoresis during routine dialysis, and was given three nitro sprays and then sent to the emergency department. On arrival, heart rate was 145 and BP 75/50. What do you think?             There’s a wide complex tachycardia which is regular (so not AF) and without preceding P waves (so not sinus tach). There is an LBBB appearance in the precordial leads, but the limb leads have rS complexes in… - [What is this Pattern? Is an initial troponin I of 45 ng/L diagnostic?](https://drsmithsecgblog.com/what_is_this_pattern_ps/): A middle aged male presented with acute chest pain.  He was seen by Emily Dawra, one of our 2nd year EM residents, about to become 3rd year in 3 days.   What do you think? This ECG is diagnostic of LAD occlusion and Emily immediately recognized it, as she has become very good at recognizing OMI that has little if any ST Elevation. Explanation: There is subtle STE in V1, a very hyperacute T-wave (HATW) in V2, and subtle HATW’s in V3-V6.  There is ST depression in V5 and V6.  ANY ST depression (except for in aVR) makes it impossible for… - [This is Excellent OMI Care](https://drsmithsecgblog.com/this-is-excellent-omi-care/): This is the first post on our new blogger, WordPress. Notice that the URL is different from before (drsmithsecgblog.com). We’re hoping this will give you a better experience, as the old Google Blogspot was no longer supported by Google and had very bad search characteristics. This case came from Drs. Luca Sala and Paolo Villa from a public hospital (Ospedale Luigi Sacco) in Milan Italy. CASE A 60-something male presented with one hour of “oppressive” chest pain radiating to the back and to the left arm.  He has a history of diabetes and COPD. This ECG was recorded: What do… - [Anteroseptal OMI? Accurate ECG interpretation is essential to correctly interpreting the angiogram.](https://drsmithsecgblog.com/anteroseptal-omi-accurate-ecg/): Written by Willy Frick A man in his early 40s with prior anterior OMI s/p bare metal stent to LAD in 2014 presented with acute chest pain, nausea, dyspnea, and diaphoresis. He was brought in by EMS. His first ECG is shown: ECG 1 Obvious STEMI (+) OMI. What would you guess is the culprit?  There is STE in V1 and V2 with lateral STD, a pattern known as precordial swirl, so…it should be LAD, right? Sure, there’s evidence of ischemia in lead III (and aVF to a lesser degree), but many patients have a long “wraparound” LAD that supplies the… - [A woman in her 50s with acute chest pain](https://drsmithsecgblog.com/a-woman-in-her-50s-with-acute-chest-pain-2/):  Written by Pendell Meyers A woman in her 50s with no significant past medical history experienced acute anterior chest pain that woke her from sleep and radiated to her back. She described it as “stabbing”, 8/10, constant, and associated with nausea. She denied preceding symptoms or recent illnesses.  Here is her triage ECG during active pain: What do you think? This ECG was recorded 30 minutes later with ongoing pain: Queen of Hearts says no signs of STEMI or Equivalent for both: New PMcardio for Individuals App 3.0 now includes the latest Queen of Hearts model and AI explainability (blue heatmaps)! Download now for iOS… - [60-something with h/o Coronary Bypass has acute chest pain](https://drsmithsecgblog.com/60-something-with-ho-coronary-bypass/): A 60-something with h/o Coronary Bypass called 911 for acute chest pain. Here is the first prehospital ECG:  What do you think? There is minimal ST Elevation in inferior leads which could easily be normal.  However, aVL has minimal STD supportive of the diagnosis of OMI.  More importantly, the ST depression in V2-4 is diagnostic of posterior OMI.  There is a hyperacute T-wave in V6, which is the lateral part of the posterior wall and a common supportive finding in posterior OMI. The Zoll algorithm impressively stated: ***STEMI*** A paramedic student had the PMCardio AI Queen of Hearts on his… - [36 year old with chest pain after chest wall surgery](https://drsmithsecgblog.com/36-year-old-with-chest-pain-after-chest/): Recent chest surgery.  Had been to surgeon’s office complaining of chest pain. Assumed to be post-surgical. SOB with pulmonary edema. acute hypoxic resp failure with “severe pressure on chest” put on BiPAP she is concerned about an increase in fluid accumulation, as she is experiencing chest pain and shortness of breath. A few days ago, she had some shortness of breath, but her surgeon was not concerned at that time. However, today she describes a sensation of “an elephant sitting on her chest.”  Cardiac ultrasound showed a possible decreased function, IVC without respiratory variation, and B-lines at the lung bases… - [Interns are not (yet) poisoned by the STEMI/NSTEMI paradigm](https://drsmithsecgblog.com/interns-are-not-yet-poisoned-by/): This case was written up by Kuan-Yu (Evan) Lin with some edits by Willy Frick. I (Willy) had the pleasure of working with Evan when he was a medical student. Now as an intern, he is exceptional at EKG interpretation because he was able to learn of the OMI paradigm and importance of pattern recognition before getting poisoned by years of learning STEMI. A 41-year-old South Asian male with history of hypertension, alcohol use disorder and hyperlipidemia, who has a strong family history of CAD presented with central substernal burning, pressure, and pain with associated diaphoresis. (When seeing a South… - [Hypertrophic Cardiomyopathy with dehydration and chest pain](https://drsmithsecgblog.com/hypertrophic-cardiomyopathy-with/): A middle-aged man with a history of HOCM presented with 24 hours of chest pain, still active.  He stated that he had been dehydrated for a day as well.  The pain was not at all severe, and localized to the left sternal border, without radiation.  The patient was in no distress and had normal vital signs. Here is his presentation ECG: What do you think? I thought it just looked like HOCM.  But because there were the dramatic HOCM findings, I did not look closely enough. We did a bedside ultrasound: This shows very thick LV walls and VERY small… - [The worst thing you can be when you have this ECG is to be a young woman](https://drsmithsecgblog.com/the-worst-thing-you-can-be-when-you/): This was contributed by a great paramedic, Drew Williams.  He now is his agency’s “Clinical Improvement Analyst for STEMI performance and quality assurance.” A 30-something woman called 911 for chest pain.  Medics report this: They recorded a prehospital ECG: What do you think? To me, this is an obvious proximal LAD occlusion.  However, I am always surprised at how what is obvious to me, is completely missed by many other physicians. There is a hyperacute T-wave in V2 and aVL, STE in V1, and ST depression in I, inferior leads, and V3-V6.  This should never be missed. This is a classic… - [Hypotension, chest pain, and precordial ST depression maximal in V3. Is this OMI?](https://drsmithsecgblog.com/hypotension-chest-pain-and-precordial/): One of my partners showed me this ECG of a 60-something male with a history of MI and stent who was hypotensive with chest pain, and asked, “Steve, should I activate the cath lab?” What do you think? Normally, a patient with coronary disease, chest pain, and maximal ST depression in lead V3 has posterior OMI and, yes, the cath lab should be activated.  But one should always be skeptical of ACS when vital signs are abnormal.  If there is tachycardia, hypotension, hypoxia/respiratory failure, I am always suspicious that the ECG findings are due to supply demand (subendocardial) ischemia (i.e., Type 2… - [Patient with Heart Transplant has ventricular fibrillation arrest -- resuscitated](https://drsmithsecgblog.com/patient-with-heart-transplant-has/):  2635859 A middle-aged male Immediate post-resuscitation. We were aware that ST Elevation can be a result of the low flow state in cardiac arrest, and resolve with time, but we activated the cath lab. The interventionalist stated that a transplanted heart does not have coronary disease. A chart review however, revealed the the patient had had an acute distal LAD occlusion one month prior. 15 minutes later LAD:LAD is a medium caliber vesselD1 is a small to medium caliber that tapers abruptly in the proximal segmentand is subtotally occludedD2 is a medium caliber branching vessel and D3 is smallDistal LAD… ## Pages - [Miscellaneous ECG Videos (Frick)](https://drsmithsecgblog.com/resources_31/miscellaneous-ecg-videos/): We’ve added the following selected ECG Videos … - [Additional ECG Videos (Grauer)](https://drsmithsecgblog.com/resources_31/additional-ecg-videos/): This page contains the following Educational ECG Videos that may be of interest to you: — Where to find the ECG Videos LINK in the Top Menu — = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1) Watch Your Ps, Qs, 3Rs (Systematic Approach to Rhythm Interpretation! ) = = = 2) Estimating Heart Rate, including when the rate is very Fast! (by Ken Grauer — from the Augst 13, 2025 post). = = = 3)… - [ECG Videos by Dr. Sam Ghali](https://drsmithsecgblog.com/resources_31/ecg-educational-videos/): What follows below are LINKS to Educational ECG Videos produced by Dr. Sam Ghali @EM_RESUS = = = — Where to find the ECG Videos LINK in the Top Menu — = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ECG Video Case #1: — This ECG Video reviews reviews the case of a patient with CP that was misdiagnosed (published in the October 4, 2025 post in Dr. Smith’s ECG Blog). = = = ECG Video Case #2: —… - [What is Voltage Discordance?](https://drsmithsecgblog.com/what-is-voltage-discordance/): = = = What is Voltage Discordance? - [Causes of Low Voltage](https://drsmithsecgblog.com/resources_31/causes-of-low-voltage/): ====================================== MY Comment, by KEN GRAUER, MD (8/3/2025): I’ve excerpted this page from the January 24, 2020 post in Dr. Smith’s ECG Blog — for the purpose of providing ready reference to a list of Causes of Low Voltage. For full details of this amazing case — See the above link to this 1/24/2020 post. Figure-1: The 3 serial tracings in this January 24, 2020 post. Clinical Points Regarding ECG #1: ECG #1 — shows sinus rhythm with bifascicularblock (RBBB/LAHB). There is marked anterior ST elevation with equally marked inferior ST segment depression. I’d add the following points: = = = What Has Happened After Cardiac Cath? (ie, in ECG #2): = = = ANSWER: The post-cath ECG ( = ECG #2)… - [LVH Criteria (7-27.1-2025)](https://drsmithsecgblog.com/resources_31/lvh-criteria-7-27-1-2025/): ========================== Grauer: See below for “My Take” on a user-friendly approach to ECG diagnosis of LVH. — From Dr. Smith ECG Blog Post on June 20, 2020 — A 75 yo with h/o CAD, CABG, and HFrEF presented after a syncopal episode.  There was no prodrome and no associated symptoms such as SOB or CP.  The medics recorded an ECG: There is STE in V1-V3 and aVL, with reciprocal ST depression in II, III, aVF.The medics were worried about STEMI, as it meets STEMI criteria. What do you think? = = = On arrival, BP was 150/80, with a pulse… - [Laddergrams in Dr. Smith's ECG Blog](https://drsmithsecgblog.com/resources_31/laddergrams/): = = = MY Comment, by KEN GRAUER, MD (7/27/2025): Learning to draw Laddergrams is challenging. I fully acknowledge that it took me significant time until I felt comfortable with this skill. That said — learning to read laddergrams is EASY — and important for enhancing your understanding of more complex arrhythmias. NOTE: If your browser does not show my Basics of Laddergrams Video that I have embedded below, then please — CLICK HERE — ECG VIDEO on “The Basics” of Laddergrams: This video (5:07 minutes) reviews the basics of what a Laddergram is. The laddergram that I briefly illustrate (beginning at ~4 minutes in the video) is excerpted from… - [Technical Misadventures (including Artifact & Reversals)](https://drsmithsecgblog.com/technical-misadventures-lead-reversals/): =================================== INTRO: We have added this Tab as the 4th link under Research & Resources in the Menu that appears at the top of every page in Dr. Smith’s ECG Blog: — Where to find the “Technical Misadventures LINK in the Top Menu! — All-too-often lead reversals, unsuspected artifact, and other “technical misadventures” go unrecognized — with resultant erroneous diagnostic and therapeutic implications.  ===================================  Sample CASE: How would you interpret the ECG in Figure-1? Figure-1: How would you interpret this ECG? QUESTIONS: We published this case on April 16, 2025. Click on this link for full discussion of this fascinating case! =================================== Grauer Suggestion: My favorite on-line “Quick GO-TO” reference for… - [How To Insert an Excel File into Blogspot (KG- 1-20.1-2025)](https://drsmithsecgblog.com/how-to-insert-excel-file-into-blogspot/):    =”0″ scrolling=”no” src=”https://onedrive.live.com/embed?  =============================  NOTE: This web page reviews the process I used to embed an Excel file into Blogspot (specifically this was for the QTc Calclator that we published on Dr. Smith’s ECG Blog on 1/12/2025). Please be aware that I used a Mac computer — and Safari for my browser to embed this Excel file.  After doing so — this embeded Excel file worked on Mac computer — ipad — and iphone using Safari, Firefox and Safari browsers. I suspect this embedding process will work on any device — although specifics for the embedding process might vary, depending on the device/browser you… - [New OMI QUIZ — Test yourself against the Queen of Hearts](https://drsmithsecgblog.com/new-omi-quiz-test-yourself-against/):   Take the OMI Quiz and Test yourself against the Queen of Hearts OMI QUIZ - [Neuroprotective CPR (Head Up CPR)](https://drsmithsecgblog.com/neuroprotective-cpr-head-up/): There is a growing body of literature that supports head up CPR also called neuroprotective CPR. It is far more effective at restoring circulation and improving defibrillation than previous standard CPR.  Some now call it the standard of care.  I believe that this will revolutionize CPR and resuscitation from Cardiac Arrest. My colleagues at Hennepin Healthcare Research Institute, Keith Lurie (electrophysiologist) and Johanna Moore (Emergency Physician at Hennepin Healthcare) are the creators of Head Up CPR and have done years of brilliant research on it.  Here is a link to Keith’s research on Researcgate.  Here is Johanna’s Google scholar profile.… - [OMI Pocket Guide](https://drsmithsecgblog.com/omi-pocket-guide/): OMI Pocket Guide  The OMI Pocket Guide (https://omiguide.org) is a user-friendly online resource designed to help healthcare professionals learn how to recognize subtle signs of acute coronary occlusion on the ECG which represent occlusion myocardial infarctions (OMI).  Learning to recognize OMIs is an important clinical skill because it helps identify the subpopulation of “NSTEMIs” who are likely to be found with total thrombotic occlusion at the time of cardiac catherization. Although there are more criteria to consider when looking for OMIs compared to STEMIs, anyone can learn them, and this guide is intended to help accelerate that process! The guide organizes OMIs… - [The OMI Quizzes](https://drsmithsecgblog.com/the-omi-quizzes/): Take the OMI Quiz and Test yourself against the Queen of Hearts OMI QUIZ There are 4 more quizzes here on OMI ECG diagnosis: Beginner Novice Intermediate Adavanced The first link on the page is to an ECG guide as a primer on OMI ECG diagnosis. These quizzes were written by Gregory Yates (an “FY 2 doctor” in the UK), Maddy Kahle (who is just finishing her 4th year of medical school at the U of MN), and aided by Romi Lee (another U of MN med student). All quizzes were of course reviewed by Smith and Meyers. Here is… - [OMI Facts and References](https://drsmithsecgblog.com/omi-facts-and-references/): This page is used to reference important facts and figures regarding OMI. What were those new “STEMI equivalents” per the ACC in 2022? How do we know that missed NSTEMIs with OMI have double mortality compared to NSTEMIs without OMI again? What is the reference for that? See below! How many NSTEMI have Total Coronary Occlusion without collateral circulation?  25-30% References Koyama Y, Hansen PS, Hanratty CG, Nelson GIC, Ramussen HH. Prevalence of coronary occlusion and outcome of an immediate invasive strategy in suspected acute myocardial infarction with and without ST-segment elevation. Am J Cardiol. 2002;90:579–584. https://www.sciencedirect.com/science/article/abs/pii/S0002914902025596 Hung C-S, Chen… - [OMI Literature Timeline](https://drsmithsecgblog.com/omi-literature-timeline/): 2018 Meyers & Smith The OMI Manifesto 2019 Meyers & Smith International Journal of Cardiology Prospective, real-world evidence showing the gap between ST elevation myocardial infarction (STEMI) and Occlusion MI (OMI) 2020 Aslanger, Smith, et al. International Journal of Cardiology Heart & Vasculature DIFOCCULT Study DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction Meyers, Bracey, Smith, et al. Journal of Emergency Medicine Comparison of the ST elevation myocardial infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI paradigms of acute MI 2021 Tziakas, Chalikias, Al-Lamee, Kaski International Journal of Cardiology Total coronary occlusion in non… - [Teaching Images](https://drsmithsecgblog.com/teaching-images/): The OMI Progression on ECG Click here for STEMI(-) Occlusion MI Patterns Reference Sheet The ACS Spectrum using OMI vs. NOMI Primarily The ACS Spectrum using STEMI vs. NSTEMI Primarily Mortality Effects of Thrombolytics for Each Paradigm Extrapolated from FTT Meta-analysis Differentiation of Anterior ST Depression: Posterior OMI or Global Supply/Demand Mismatch? Click here for Terminal QRS Distortion Infographic with links to examples Tachycardias Diagram (simplified) Full Tachycardia Algorithm ECG Leads and Myocardial Territories SVT Video: - [Lectures Recorded](https://drsmithsecgblog.com/lectures-podcasts/):   New October 23, 2025.  Replace STEMI/NSTEMI with OMI/NOMI and AI in the Diagnosis of OMI New March 2025:    Replace STEMI/NSTEMI with OMI/NOMI and AI in the ECG Diagnosis of OMI   Webinar February 2024: Subtle Acute Coronary Occlusion and its Mimics   Webinar November 2023: Beyond STEMI: Diagnosing Acute Coronary Occlusion on the ECG. The Queen of Hearts can do it for you!! Grand Rounds at Kaiser August 2023.  Most up-to-date lecture including Queen of Hearts Interpretations: Selected Cases of Occlusion MI (OMI), or not, on the ECG   Neuroprotective CPR by Keith Lurie at Florida EMS Webinar Grand… - [Rules + Equations](https://drsmithsecgblog.com/rules-equations/): Smith-Modified Sgarbossa Rule for Diagnosis of STEMI in the Presence of Left Bundle Branch Block [ click here for PDF ] New 4-variable Formula to Differentiate Normal Variant ST Segment Elevation in V2-V4 (Early Repolarization) from Subtle Left Anterior Descending Coronary Occlusion This is the original paper on the 3-variable formula:  Smith SW et al. Electrocardiographic Differentiation of Early Repolarization From Subtle Anterior ST-Segment Elevation Myocardial Infarction. Annals of Emergency Medicine June 2012. We subsequently published the 4-variable formula: Driver and Smith. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior… - [Resources](https://drsmithsecgblog.com/resources_31/): Protocols: — Abbott High Sensitivity Troponin Algorithm at Hennepin Healthcare ECG Educational Videos (on various ECG-related Topics) — ECG Videos by Dr. Sam Ghali — Additional ECG-related Videos … Laddergrams (How to Read and/or Draw Laddergrams): — Laddergrams in Dr. Smith’s ECG Blog — More Laddergrams (from Dr. Ken Grauer’s ECG Blog) LVH (ECG Criteria for LVH and LV “Strain” ): — ECG Criteria for LVH — ECG Criteria for RVH (See My Comment in the February 12, 2023 post). — ECG Criteria for RAA and LAA ( CLICK HERE ). Systematic Approach to ECG Interpretation — See My Comment… - [About](https://drsmithsecgblog.com/about-2/): Stephen W. Smith, MD Dr. Stephen W. Smith is a faculty physician in the Emergency Medicine Residency at Hennepin County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine at the University of Minnesota. Dr. Smith’s Book The ECG in Acute MI PDF [ view Dr. Smith’s Google Scholar Profile ] Clinical Expertise Emergency Medicine, with an emphasis on Emergency Cardiac Care, especially with regard to Chest Pain, Electrocardiogram (ECG) and Troponin interpretation; Gamma-Hydroxybutyrate toxicity, addiction, and withdrawal. Credibility American Board of Emergency Medicine Honors Professor of Emergency Medicine, University of MN Blog ranked 6th world wide among Free… - [The OMI Manifesto (Occlusion MI: OMI - NOMI dichotomy takes the place of STEMI-NonSTEMI)](https://drsmithsecgblog.com/the-omi-manifesto-occlusion-mi-takes/): PDF Version of The OMI Manifesto [comment]: # (Generated by Hostinger Tools Plugin)