ECG Guru - Instructor Resources - ST depression https://www.ecgguru.com/ecg/st-depression en Severe Triple Vessel Disease https://www.ecgguru.com/ecg/severe-triple-vessel-disease <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/severe-triple-vessel-disease"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/072923%20Triple%20Vessel%20Disease%20Ed.jpg" width="1800" height="1117" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The Patient:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: black; mso-color-alt: windowtext;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>This ECG is from a 63-year-old man who complained of epigastric pain for three hours. The pain was sudden in onset, burning in nature, and accompanied by nausea and palpitations.<span style="mso-spacerun: yes;">&nbsp; </span></span><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">The patient is a heavy smoker, diabetic and hypertensive&nbsp;with a long history of non-compliance to his medications.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">He was given crushed aspirin, loaded with clopidogrel and heparin, given high-intensity statins, and rushed to the cath lab.</span><span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The ECG:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;">&nbsp; </span>The rhythm is normal sinus, a bit fast at 90 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The intervals, frontal plane axis, and R wave progression are normal.&nbsp;&nbsp;</span>This ECG shows a very dreaded pattern:&nbsp; ST segment elevation in aVR and V1 with widespread ST depression, seen here in all other leads.&nbsp; This is an ECG sign of GLOBAL ISCHEMIA.&nbsp; There are several possible causes, all bad.&nbsp; The most common causes of this pattern are:</p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Severe triple vessel disease, with significantly decreased flow in the left anterior descending, right, and circumflex arteries.</span></p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><span style="text-indent: -0.25in; font-family: Symbol;">·<span style="font-variant-numeric: normal; font-variant-east-asian: normal; font-variant-alternates: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><span style="text-indent: -0.25in;">Significant narrowing and decreased blood flow in the left main coronary artery.</span></p><p class="MsoListParagraphCxSpLast" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Severe shock state, affecting perfusion in the entire body.</span><strong><span style="font-size: 8.0pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">&nbsp;</span></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The Outcome:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;">&nbsp; </span>The patient’s results in the cath lab include:</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="color: #222222;">LMCA: 80-85% occlusion</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">LAD: 90-95% occlusion&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">RCA: 75-80% occlusion&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">The first and second diagonal branches of the LAD: 60-65% occlusion</span><span style="color: #222222; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">There was near global hypokinesia, probably due to stunning of the cardiac muscle.&nbsp;</span><span style="color: #222222; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">His ejection fraction (EF): 25-30%&nbsp;(Normal is 60%).</span><span style="color: #222222; font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">A good lesson here is that not everyone experiences “crushing substernal chest pain, radiating to the left arm and jaw”.<span style="mso-spacerun: yes;">&nbsp; </span>The presentation and patient history are very important, and in this case very indicative of cardiac disease.</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">&nbsp;T</span><span style="color: #222222;">hank you to <strong>Dr. Mohammad Al-Shatnawi </strong>for providing this interesting case.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/300/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Severe Triple Vessel Disease 1/5</option><option value="40">Give Severe Triple Vessel Disease 2/5</option><option value="60">Give Severe Triple Vessel Disease 3/5</option><option value="80" selected="selected">Give Severe Triple Vessel Disease 4/5</option><option value="100">Give Severe Triple Vessel Disease 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-8FGbLW6FmC35U5DqbFNBEpBRHptw0hkTsPUeWYklG3s" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/triple-vessel-disease" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Triple vessel disease</a></div><div class="field-item odd"><a href="/ecg/global-ischemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Global ischemia</a></div><div class="field-item even"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fsevere-triple-vessel-disease&amp;title=Severe%20Triple%20Vessel%20Disease"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Sun, 30 Jul 2023 23:01:07 +0000 Dawn 855 at https://www.ecgguru.com https://www.ecgguru.com/ecg/severe-triple-vessel-disease#comments Anterior-lateral M.I. With Wide QRS https://www.ecgguru.com/ecg/anterior-lateral-mi-wide-qrs <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-lateral-mi-wide-qrs"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/AWMI128.jpg" width="1800" height="915" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">The Patient:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>An elderly man presents with chest pain, pallor, diaphoresis and weakness.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">The ECG:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span>The rhythm is normal sinus at a rate of about 76 bpm with normal intervals. The QRS complexes are wide at about .14 seconds (140 ms).<span style="mso-spacerun: yes;">&nbsp; </span>There is ST segment elevation in all precordial leads, except for possibly V6.<span style="mso-spacerun: yes;">&nbsp; </span>The shape of the ST segments in the anterior wall range from coved upward in a “frowning” shape (V1) to very straight (V5 and V6).<span style="mso-spacerun: yes;">&nbsp; </span>There is also ST elevation in aVL with ST straightening in Lead I.<span style="mso-spacerun: yes;">&nbsp; </span>There is ST depression in the inferior leads, II, III, and aVF.<span style="mso-spacerun: yes;">&nbsp; </span>Lead II is equally biphasic while I and aVL are positive, indicating an axis that is shifted slightly to the left.<span style="mso-spacerun: yes;">&nbsp; </span>With his symptoms and this alarming ECG, he was sent promptly to the cath lab.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">Interpretation:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>The rather obvious ST-elevation M.I. is extensive, covering the entire anterior wall, and extending into the high and low lateral walls . This was confirmed in the cath lab, as the patient had an occlusion of the left anterior descending artery near the bifurcation of the circumflex.<span style="mso-spacerun: yes;">&nbsp; </span>The wide QRS meets the criteria for left bundle branch block (wide QRS, negative QRS in V1 and positive QRS in V6 and Lead I).<span style="mso-spacerun: yes;">&nbsp; </span>However, it doesn’t have the “look” of LBBB with the low-voltage seen in the anterior wall. After the offending artery was opened and stented, the wide complex became narrow and was considered to be an interventricular conduction delay that was due to the ischemia.<span style="mso-spacerun: yes;">&nbsp; </span>The ST depression in the inferior wall is most likely reciprocal.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">Take-home points:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp; </span></span>“Normal sinus rhythm” does not mean that everything is “normal”.<span style="mso-spacerun: yes;">&nbsp; </span>Also, the SHAPE of the ST segment is as important as the elevation.<span style="mso-spacerun: yes;">&nbsp; </span>ST segments can be elevated in conditions other than acute M.I., and ST segments can be quite low and still be very abnormal.<span style="mso-spacerun: yes;">&nbsp; </span>Coved upward or straight ST segments are indicative of M.I.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/300/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Anterior-lateral M.I. With Wide QRS 1/5</option><option value="40">Give Anterior-lateral M.I. With Wide QRS 2/5</option><option value="60">Give Anterior-lateral M.I. With Wide QRS 3/5</option><option value="80" selected="selected">Give Anterior-lateral M.I. With Wide QRS 4/5</option><option value="100">Give Anterior-lateral M.I. With Wide QRS 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.8</span></span> <span class="total-votes">(<span >9</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-ucrhEu5QuqjSzAQKiJQCWDp_2ozL8yRMYwXZ4k6iEyY" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/anterior-lateral-mi-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Anterior-lateral M.I.</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item odd"><a href="/ecg/wide-qrs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS</a></div><div class="field-item even"><a href="/ecg/hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hemiblock</a></div><div class="field-item odd"><a href="/ecg/fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Fascicular block</a></div><div class="field-item even"><a href="/ecg/ivcd" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">IVCD</a></div><div class="field-item odd"><a href="/ecg/interventricular-conduction-defect" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Interventricular conduction defect</a></div><div class="field-item even"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div><div class="field-item odd"><a href="/ecg/reciprocal-st-changes" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Reciprocal ST changes</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fanterior-lateral-mi-wide-qrs&amp;title=Anterior-lateral%20M.I.%20With%20Wide%20QRS"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 13 Nov 2019 05:56:24 +0000 Dawn 778 at https://www.ecgguru.com https://www.ecgguru.com/ecg/anterior-lateral-mi-wide-qrs#comments Ask The Expert https://www.ecgguru.com/expert-review/ask-expert-13 <div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p class="MsoNormal" style="line-height: 15pt; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;"><strong><span style="font-size: 12pt; font-family: 'Lucida Sans Unicode', sans-serif; border-width: 1pt; border-style: none; border-color: windowtext; padding: 0in;">Today’s expert is Dr. Jerry W. Jones, MD, FACEP, FAAEM</span></strong></p><p class="MsoNormal" style="line-height: 15pt; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;"><span style="font-size: 9pt; font-family: Verdana, sans-serif; border-width: 1pt; border-style: none; border-color: windowtext; padding: 0in;">Jerry W. Jones, MD FACEP FAAEM is a diplomate of the American Board of Emergency Medicine who has practiced internal medicine and emergency medicine for 35 years.&nbsp;<img src="/sites/default/files/headshot_0.jpg" alt="Dr. Jerry Jones" width="96" height="100" style="float: right;" />Dr. Jones has been on the teaching faculties of the University of Oklahoma and The University of Texas Medical Branch in Galveston. He is a published author who has also been featured in the New York Times and the Annals of Emergency Medicine for his work in the developing field of telemedicine. He is also a Fellow of the American College of Emergency Physicians and a Fellow of the American Academy of Emergency Medicine and, in addition, a member of the European Society of Emergency Medicine.&nbsp;</span></p><p style="font-size: 13.008px;">&nbsp;<span style="font-size: 9pt; font-family: Verdana, sans-serif; border-width: 1pt; border-style: none; border-color: windowtext; padding: 0in;">Dr. Jones is the CEO of</span><a style="font-size: 13.008px;" title="Medicus of Houston Website" href="http://www.medicusofhouston.com/"><span style="font-size: 9pt; font-family: inherit, serif; color: #0062a0; border-width: 1pt; border-style: none; border-color: windowtext; padding: 0in;">&nbsp;Medicus of Houston</span></a><span style="font-size: 9pt; font-family: Verdana, sans-serif; border-width: 1pt; border-style: none; border-color: windowtext; padding: 0in;">&nbsp;and the principal instructor for the&nbsp;<a href="https://medicusofhouston.com/">Advanced ECG Interpretation Boot Camp and the Advanced Dysrhythmia Boot Camp</a>.</span><span style="font-size: 10pt; font-family: 'Lucida Sans Unicode', sans-serif; border-width: 1pt; border-style: none; border-color: windowtext; padding: 0in;">&nbsp;</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 20.0pt; line-height: 107%; color: #548235; mso-themecolor: accent6; mso-themeshade: 191; mso-style-textfill-fill-color: #548235; mso-style-textfill-fill-themecolor: accent6; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">QUESTION:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 16.0pt; line-height: 107%; color: #548235; mso-themecolor: accent6; mso-themeshade: 191; mso-style-textfill-fill-color: #548235; mso-style-textfill-fill-themecolor: accent6; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">How can I explain to students that injury from an M.I. “localizes” on the ECG, but subendocardial ischemia/injury does not?</span></strong><strong style="mso-bidi-font-weight: normal;"></strong></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 20.0pt; line-height: 107%; color: #548235; mso-themecolor: accent6; mso-themeshade: 191; mso-style-textfill-fill-color: #548235; mso-style-textfill-fill-themecolor: accent6; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">ANSWER:</span></strong><span style="font-family: 'Arial Narrow', sans-serif; font-size: 20pt;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Allegory of Subendocardial Ischemia</span></p><div class="WordSection1"><div class="WordSection1"><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">&nbsp;For many years we have misunderstood the concept of subendocardial ischemia as it manifests on the 12-lead ECG.&nbsp; Previously, if one saw ST depression in leads II, III, and aVF, it would be labelled "inferior subendocardial ischemia" and, if the patient were momentarily having little or no chest pain, the patiet would be sent home.&nbsp; The same thing happened with ST depression in leads V4 - V6; "anterolateral subendocardial ischemia," probably chronic and again, the patient may be sent home.&nbsp; And of course, ST depression in leads V1-V4: "anteroseptal subendocardial ischemia" and often the patient was sent home.</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">Then a number of years ago, some disturbing information began to surface in various medical journals around the globe.&nbsp; Sometimes ST depression that was limited to just leads II, III, and aVF, for example, did not reveal any actual subendocardial ischemia in the inferior wall of the left ventricle.&nbsp; In some cases, subendocardial ischemia was indeed present but very little involved the inferior wall and most of the ischemia was elsewhere; but... the only ST depression present was in the inferior leads.&nbsp; Some articles began mentioning the same findings regarding ST depression in other leads as well.</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">What we have learned is that when ST depression indicates subendocardial ischemia, IT DOES NOT LOCALIZE!&nbsp; Just because there is ST depression in leads II, III, and aVF does NOT necessarily mean that the ischemia is located in the inferior wall of the left ventricle.&nbsp; It MAY be there, or there may be SOME ischemia there but most of it elsewhere, or there may be NO ISCHEMIA AT ALL there.</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">Some people still have difficulty conceptualizing this, so I developed an allegory of subendocardial ischemia using the concept of a vacant house at night.</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;"><br /></span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<img src="/sites/default/files/Subendocardial%20ischemia.png" width="594" height="302" /></span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;"><br /></span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">Imagine you have gone out for a walk one pleasant evening in your neighborhood.&nbsp; As you stroll down the street, you come upon a vacant house.&nbsp; You know it is vacant because the family that lived there moved out recently.&nbsp; However, you can see light coming from some of the windows of the house. You wonder what's going on, so you walk up to the house and look through a window into the living room.&nbsp; The room is illuminated but you don't actually see a light on there.&nbsp; You move around to another window and look into the dining room.&nbsp; Again, there is enough light for you to see everything in the room but you don't actually see any light fixture that is on. Finally, you move around to the window that looks into the kitchen.&nbsp; It's illuminated as well and you can see everything but, once again, the source of the light is not there.&nbsp; Is the light in a room that you cannot see or is it perhaps a closet light that has been left on somewhere in the house?</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">That - in essence - is <strong>subendocardial ischemia</strong>.&nbsp; Just because you see ischemia through the "windows" of leads II, III or aVF or the "windows" of leads V4 - V6 doesn't mean that the "source of the ischemia is in those "rooms."</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">Subendocardial ischemia manifested by ST depression does NOT localize reliably.&nbsp; So how should you report such ischemia?&nbsp; This is what I would say if I saw (for instance) ST depression in leads V4 - V6:&nbsp; "There is subendocardial ischemia present indicated by ST depression in leads V4 - V6."&nbsp; I would NOT call it "anterolateral ischemia."</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">Actually, this information has been available for a number of years.&nbsp; So, if you are reading textbooks, journal articles or posts on websites that still refer to "inferior ischemia", "high lateral ischemia", "anteriorlateral ischemia" etc., then you are reading information that is OUTDATED. If it was recently written, then you are reading information from someone who is NOT staying current with advances in electrocardiography.</span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;"><br /></span></p><p class="MsoBodyText" style="margin: 0.25pt 0in 0.0001pt;" align="left"><span style="font-family: 'Arial Narrow', sans-serif; font-size: 12pt;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span></p></div></div></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/subendocardial-ischemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Subendocardial ischemia</a></div><div class="field-item odd"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fexpert-review%2Fask-expert-13&amp;title=Ask%20The%20Expert"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 28 Aug 2019 04:56:03 +0000 Dawn 776 at https://www.ecgguru.com https://www.ecgguru.com/expert-review/ask-expert-13#comments Incorrect Machine Interpretation https://www.ecgguru.com/ecg/incorrect-machine-interpretation-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/incorrect-machine-interpretation-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/TP%20I00%20incorrect%20machine%20dx.jpg" width="3507" height="2550" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">This ECG is presented as an example of INCORRECT MACHINE INTERPRETATION.&nbsp; While there are many abnormalities in this ECG, it does <span style="text-decoration: underline;">not</span> represent a paced rhythm. While there are exceptions, most paced rhythms represent either AV sequential pacing, right ventricular pacing, or bi-ventricular pacing.</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">RECOGNITION OF A PACED RHYTHM</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Recognizing a paced rhythm can be difficult in some cases. Because pacemakers now have so many programmable features, there is a wide variety of ECG changes associated with them.&nbsp; Pacer “spikes” can be difficult to see in all leads.&nbsp; Finding evidence of the device on the patient’s chest or via patient history is a big help in reminding us to scrutinize the ECG for paced rhythm.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">An </span><a href="https://www.ecgguru.com/ecg/av-sequential-pacing-ventricular-tachycardia"><span style="font-size: 12.0pt; line-height: 107%;">AV sequential pacemaker</span></a><span style="font-size: 12.0pt; line-height: 107%;"> or a </span><a href="https://www.ecgguru.com/ecg/paced-rhythm"><span style="font-size: 12.0pt; line-height: 107%;">right ventricular pacemaker</span></a><span style="font-size: 12.0pt; line-height: 107%;"> will pace the ventricles via the right ventricle.&nbsp; This produces a <strong>WIDE QRS </strong>and a leftward axis, often causing Leads II, III, and aVF to be negative and aVL and aVR to be positive.&nbsp; Along with the wide QRS, we will see <strong>DISCORDANT ST CHANGES. &nbsp;</strong>That is, there will be ST depression and T wave inversion in leads with positive QRS complexes and ST elevation and upright T waves in leads with negative QRS complexes.</span></p><p class="MsoNormal"><a href="https://www.ecgguru.com/blog/jasons-blog-ecg-challenge-week-sept-2-9"><span style="font-size: 12.0pt; line-height: 107%;">Bi-ventricular pacing</span></a><span style="font-size: 12.0pt; line-height: 107%;"> can be a little more complicated to recognize, as the QRS can be narrow, with signs of fusion between the wave produced by the LV electrode and the RV electrode.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The frontal plane axis is usually far right – aVR will be positive. &nbsp;Lead I will be negative.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The machine is wrong: &nbsp;there is no indication of a pacemaker, and P waves are present, even though they are not noted in the "PR Interval" or "P Axis".</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">SO, THIS IS NOT A PACED RHYTHM – WHAT IS IT?</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">There are many abnormalities in this ECG, and they can be due to many different conditions. All ECGs should be evaluated in a clinical setting, with the patient’s symptoms, signs, and medical history all considered.&nbsp; That being said, I will point out what I see to be abnormal, and await our readers’ and experts’ opinions.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The rhythm is sinus, at a rate of 62 bpm.&nbsp; The PR interval is not given by the machine, but P waves are very obvious, and the PR interval is about .24 seconds, a first-degree AV block.&nbsp; The QRS complex is measured by the machine as 114 ms wide (.11 seconds).&nbsp; This is barely under the 120 ms usually required for diagnosis of wide-complex rhythm, and many would consider it adequate for a wide QRS.&nbsp; If we accept that this is a wide-complex QRS, then we should look for the ECG criteria for </span><a href="https://www.ecgguru.com/ecg/instructors-collection-ecg-week-september-23-2015-right-bundle-branch-block-0"><span style="font-size: 12.0pt; line-height: 107%;">RIGHT BUNDLE BRANCH BLOCK</span></a><span style="font-size: 12.0pt; line-height: 107%;"> and &nbsp;</span><a href="https://www.ecgguru.com/ecg/left-bundle-branch-block"><span style="font-size: 12.0pt; line-height: 107%;">LEFT BUNDLE BRANCH BLOCK</span></a><span style="font-size: 12.0pt; line-height: 107%;">. In RBBB, there will be an rSR’ pattern in V1 and a small s wave in Leads I and V6.&nbsp; &nbsp;In LBBB, Leads I, V5 and V6 should have a broad, monomorphic, upright QRS.&nbsp; In this ECG, V5 and V6 have small s waves that contribute to the total width of the QRS, while the R waves are narrow in appearance. The term for a wide-complex, supraventricular rhythm that does not meet the criteria for either right or left BBB is INTRAVENTRICULAR CONDUCTION DELAY. (IVCD)</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The frontal plane axis is -17 degrees, which is normal, but slightly to the left.&nbsp; That would be typical of left bundle branch block.&nbsp; However, the pronounced S wave in Lead II and the deep S wave in Lead III are not typical.&nbsp; In </span><a href="http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC1017695&amp;blobtype=pdf"><span style="font-size: 12.0pt; line-height: 107%;">a study</span></a><span style="font-size: 12.0pt; line-height: 107%;"> of S waves in these two leads, they have been found to be very rare in healthy hearts, and often associated with M.I. and cardiomyopathy.&nbsp; The abnormal S waves studied were deeper than the R wave was tall, however. S waves can be seen in Leads II and III in ventricular conduction defects that cause wide QRS – like LBBB and IVCD .</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The ST segments and T waves in this ECG are clearly abnormal. T waves are inverted in Leads II, III, aVF; Lead I; Leads V4, V5, and V6; and they are biphasic in V3 as they transition from V2 (positive) to V4 (negative).&nbsp; The inverted T waves are very shallow in most leads, so it is hard to determine if they are symmetrical (indicating ischemia) or asymmetrical (with many causes).&nbsp;&nbsp; In cases of wide QRS, we expect to see DISCORDANT ST AND T WAVE CHANGES.&nbsp; That is, the ST and T waves will go opposite the main direction of the QRS.&nbsp; Right chest leads like V1 and V2, which have negative QRSs will have some ST elevation and upright T waves.&nbsp; The opposite is true over the left side, where we expect upright QRS complexes (I, aVL, V5, V6) and, in the case of wide QRS, depressed ST segments with inverted T waves.&nbsp; This is seen for the most part in this ECG, but Leads III and aVF seem to have CONCORDANT STs.&nbsp; It would be very helpful to know this patient’s current symptoms and recent medical history.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">There are also Q waves in V1 and V2 that meet the criteria for "pathological Q waves", a sign of necrosis. &nbsp;However, large Q waves (or more accurately, loss of initial R waves) are common in V1 and V2, and may not be related to acute M.I. &nbsp;This is where knowing the patient's presentation and history would be very helpful.&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">As stated, the MAIN REASON for posting this ECG is to show students, beginners and advanced alike, that the machine’s interpretation should be taken with a “grain of salt”, and the interpreter should never rely solely on that interpretation.&nbsp; But we must also make the point that every ECG should be interpreted, when possible, in the setting of the patient’s presentation. </span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">&nbsp;</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/300/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Incorrect Machine Interpretation 1/5</option><option value="40">Give Incorrect Machine Interpretation 2/5</option><option value="60">Give Incorrect Machine Interpretation 3/5</option><option value="80">Give Incorrect Machine Interpretation 4/5</option><option value="100">Give Incorrect Machine Interpretation 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="empty">No votes yet</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-B70MariujFq3tjn2g4_tTWynCGfjlZe9R6YWIqPxFow" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/incorrect-machine-interpretation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Incorrect machine interpretation</a></div><div class="field-item odd"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div><div class="field-item even"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fincorrect-machine-interpretation-0&amp;title=Incorrect%20Machine%20Interpretation"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 02 Mar 2017 05:07:24 +0000 Dawn 726 at https://www.ecgguru.com https://www.ecgguru.com/ecg/incorrect-machine-interpretation-0#comments Circumflex Occlusion with Posterior-lateral M.I. https://www.ecgguru.com/ecg/circumflex-occlusion-posterior-lateral-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/circumflex-occlusion-posterior-lateral-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/OMI%20100_0.jpg" width="1800" height="1320" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p><span style="font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; line-height: normal;">This ECG was obtained from a woman with chest pain who was taken to the cath lab and found to have a 100% occlusion of her circumflex artery. &nbsp;</span></p><p><span style="font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; line-height: normal;">There are obvious ST segment elevations in Leads I and aVL, as well as in Lead II. &nbsp;Lead II is the most leftward of the inferior wall leads, and I and aVL reflect the high lateral wall. She also has ST depressions in V1 through V3. &nbsp;If you look closely at the R wave progression in the anterior leads, you will readily note that it appears that V1 and V3 wires have been reversed. &nbsp;That being said, the "real" V2 and V3 have taller-than-normal R waves. &nbsp;The tall R waves and ST depression are signs of "posterior wall M.I." &nbsp;Recently, the actual definitions of the "lateral" wall and "posterior" wall have come into <a title="Circulation LV walls defined" href="http://circ.ahajournals.org/content/114/16/1755.full">question.</a> &nbsp;However, the important thing clinically, is that this patient IS experiencing an ST elevation M.I. (STEMI), which was confirmed in the cath lab. &nbsp;The locations of the ST changes were consistent with the 100% occlusion of her circumflex artery.</span></p><p><span style="font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; line-height: normal;">For our more advanced readers (and our "Gurus"), there is an interesting rhythm. &nbsp;The P wave morphology changes frequently, even though the rhythm remains regular. &nbsp;The rate, at 62 BPM, was adequate, and the patient did not suffer any consequential dysrhythmias during her procedure. &nbsp;We don't have long-term followup information on her.</span></p><p><span style="font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; line-height: normal;"><br /></span></p><p><span style="font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px; line-height: normal;"><br /></span></p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/300/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Circumflex Occlusion with Posterior-lateral M.I. 1/5</option><option value="40">Give Circumflex Occlusion with Posterior-lateral M.I. 2/5</option><option value="60">Give Circumflex Occlusion with Posterior-lateral M.I. 3/5</option><option value="80">Give Circumflex Occlusion with Posterior-lateral M.I. 4/5</option><option value="100" selected="selected">Give Circumflex Occlusion with Posterior-lateral M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-O0LICD7KHa7L6N9yD4rzLZ4b-QZ0CHFvatXjNyqd4Qc" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/posterior-wall-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Posterior wall M.I.</a></div><div class="field-item odd"><a href="/ecg/lateral-wall-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Lateral wall M.I.</a></div><div class="field-item even"><a href="/ecg/circumflex-occlusion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Circumflex occlusion</a></div><div class="field-item odd"><a href="/ecg/stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">STEMI</a></div><div class="field-item even"><a href="/ecg/myocardial-infarction" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Myocardial infarction</a></div><div class="field-item odd"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div><div class="field-item even"><a href="/ecg/st-elevation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST elevation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fcircumflex-occlusion-posterior-lateral-mi&amp;title=Circumflex%20Occlusion%20with%20Posterior-lateral%20%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 12 Mar 2015 19:00:10 +0000 Dawn 627 at https://www.ecgguru.com https://www.ecgguru.com/ecg/circumflex-occlusion-posterior-lateral-mi#comments ECG Basics: Sinus Pause / Sinus Arrest https://www.ecgguru.com/ecg/ecg-basics-sinus-pause-sinus-arrest <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-sinus-pause-sinus-arrest"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/123%20Sinus%20arrest.jpg" width="1800" height="357" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This example of sinus arrest, also called sinus pause, shows a spontaneous return to sinus rhythm. &nbsp;There are many mechanisms by which pauses can occur on the ECG. One concept for beginner students to grasp is that, if the pause contains the equivalent of regular R-to-R intervals, and the first complex after the pause is "on time", &nbsp;we can expect that the sinus node kept firing, but did not penetrate the atria (exit block). If the pause is irregular in length, with the first beat after the pause seeming to come in randomly, we can call this sinus arrest or pause, understanding that there are many different mechanisms that can be at work here. Because what little we can see of the underlying sinus rhythm is irregular, or speeding up, we cannot discern absolutely that this is sinus arrest.&nbsp;</p><p>The bottom line for the patient, and for any level practitioner, is, "how is the patient tolerating this pause, and what does it mean to the patient's overall prognosis? &nbsp;In the short term, the patient may require emergency pacing while the cause of the dysfunction is investigated. If pauses are long enough to lower cardiac output, they can cause fainting. More than a few automobile accidents have happened as a result of this type of dysrhythmia.&nbsp;</p><p>For more advanced students, this short rhythm strip (Lead II) reveals sloping ST depression, and indicates the urgent need for a 12-lead ECG and other tests.&nbsp;</p><p>&nbsp;</p><p>&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/300/feed" method="post" id="fivestar-custom-widget--5" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--10" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give ECG Basics: Sinus Pause / Sinus Arrest 1/5</option><option value="40">Give ECG Basics: Sinus Pause / Sinus Arrest 2/5</option><option value="60">Give ECG Basics: Sinus Pause / Sinus Arrest 3/5</option><option value="80">Give ECG Basics: Sinus Pause / Sinus Arrest 4/5</option><option value="100" selected="selected">Give ECG Basics: Sinus Pause / Sinus Arrest 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.1</span></span> <span class="total-votes">(<span >8</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-rH9P-XbplE1srMr7Kils6MoJzsK-lufv3JAAdVPTQ0c" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item odd"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item even"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/sinus-arrest" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus arrest</a></div><div class="field-item even"><a href="/ecg/sinus-pause" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus pause</a></div><div class="field-item odd"><a href="/ecg/st-depression" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ST depression</a></div><div class="field-item even"><a href="/ecg/sinus-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus block</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-pause-sinus-arrest&amp;title=ECG%20Basics%3A%20%20Sinus%20Pause%20%2F%20Sinus%20Arrest%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 12 Dec 2013 17:03:41 +0000 Dawn 525 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-pause-sinus-arrest#comments