COPY of ECG Blog #500 — Can You Solve this CASE?- EXTRA

=================================

NOTE: I started my ECG Blog in 2010 — and this is my 500th ECG Blog case! The reason I saved this case for #500 — is that it is challenging — but in the spirit of the great fictional detective Sherlock Holmes — logical deduction (which is what we often need to apply when solving a complex arrhythmia) allows us to arrive at the most plausible answer. Are YOU up for the challenge?

=================================

The ECG in Figure-1 is from an older patient who reports 2 syncopal episodes, but no chest pain. He is on a ß-blocker and a calcium-channel blocking agent.

QUESTIONS:

• What is the rhythm in Figure-1?
• What is the cause of this rhythm?
• What is the recommended treatment?

• Extra Credit: Can you explain each of the 10 beats?

Figure-1: The initial ECG in today's case — from an older patient with syncope, but no chest pain. (To improve visualization — I've digitized the original ECG using PMcardio).

My Initial Thoughts:

The history — and a 2-second look at this tracing gets us started!

• The patient is "older" — he/she presents with an obviously slow and not completely regular rhythm (overall heart rate under 50/minute) — and he/she is on rate-slowing medication ( = the ß-blocker — and perhaps also verapamil or diltiazem, which are the main rate-slowing calcium blocker medications).
• 
  
• PEARL #1: Given this history — if the very slow heart rate is not the result of rate-slowing medication — and acute ischemia/infarction, hypothyroidism and sleep apnea are not factors — then a component of SSS (Sick Sinus Syndrome) is probably operative (See ECG Video below in the ADDENDUM for review of the features of SSS). 

As to the Rhythm ...

The reason this case is so challenging — is that the P waves are tiny!

Take Another LOOK at the ECG in Figure-1:

• Focus on lead II — because this is the best lead to use when searching for sinus P waves (ie, If we see an upright P wave in lead II with similar P wave morphology in a number of beats — this probably reflects an underlying sinus rhythm).
• Are there any of the 10 beats in this tracing that we know are preceded by upright P waves in this lead II?
• Are there any P waves that we think may be conducting?
• Are there any P waves that we know are not conducting?
• 
  
• PEARL #2: The Sherlock Holmes principle that we apply for complex arrhythmia interpretation is simple: Start with what you know to be true. After this is established — we can work our way toward assessing those aspects of this complex tracing that we are not yet certain about.

=================================

What I Immediately Knew to be True:

Although tiny — I was quickly able in Figure-1 to identify a number of P waves. I have labeled what I quickly saw in Figure-2:

• The last 4 RED arrows in lead II are clearly highlighting sinus P waves (ie, Despite being of extremely low amplitude — all 4 of these P waves are upright and manifest the same P wave morphology).
• The PR interval preceding beats #7,8,9 is decreasing and different for each of these beats. We know the PR interval preceding beat #9 is too short to conduct.
• In addition — it is clear that the last RED arrow P wave in lead II can not be conducting, because it occurs after beat #10.
• Given that the PR interval preceding beats #7 and 8 is different (ie, The PR interval before beat #8 being a little bit shorter than the PR interval before beat #7) — this means that at most — only one of these P waves can be conducting (depending on what the “normal” PR interval for conduction is for this patient).

Armed with the knowledge that today’s ECG ends with 4 fairly regular sinus P waves ( = the last 4 RED arrows) — it seems logical to suspect that underlying sinus P waves may be present throughout this tracing. This puts us to the task of testing this hypothesis, keeping in mind how small sinus P waves are in this tracing.

• KEY Point: There is virtually no artifact on this tracing. As a result — even minor differences in morphology are most probably "real" — and likely to represent hidden atrial activity.
• With this in mind, as we look at the beginning of ECG #1 — it should be clear that the 1st RED arrow in lead II highlights a sinus P wave, albeit with a PR interval too short to conduct.
• 
  
• PEARL #3: Knowing what the P-P interval is from the last 4 RED arrow P waves in lead II — tells us approximately where to look for additional sinus P waves in the beginning of the lead II rhythm strip.
• For this reason — I thought the tiny distortion in the baseline seen immediately after beat #2 in lead II (ie, between the 2 RED arrows right after beat #2) most probably represents the 2nd sinus P wave in this tracing (albeit this P wave is partially hidden within the last part of the QRS complex before it).
• 
  
• PEARL #4: This is where the use of simultaneously-recorded leads is so useful for confirming our suspicion of additional atrial activity. Use of this concept allows me to confirm that the small upright deflection seen right after the QRS of beat #3 in lead II ( = the 3rd RED arrow in this lead) is real — because the vertical BLUE timeline below it highlights comparable small deflections at the same point in the cycle just after beat #3 in simultaneously-recorded leads V4,V5,V6.
• 
  
• An especially subtle distortion then appears near the beginning of the T wave of beat #4 in lead II (ie, between the 2 light BLUE arrows in this lead). Referral to the 2nd vertical BLUE timeline confirms that this subtle distortion of the T wave of beat #4 in lead II is indeed the 4th sinus P wave (because a comparable subtle distortion of the T wave of beat #4 occurs at the same point in lead V4).
• All that remains for us to do at this point — is to confirm where the 5th sinus P wave in lead II occurs (and the vertical RED timeline does this by highlighting a similar T wave distortion at the same point after beat #5 in lead V3).

Figure-2: I have labeled the sinus P waves that we have identified.

Which Beat in Figure-2 Occurs Earlier than Expected?

Now STEP BACK for a moment. Take a look at what we've established in Figure-2?

• We know that the rhythm is supraventricular (because the QRS is narrow in all leads throughout this tracing).
• There is a fairly regular atrial rhythm ( = the colored P waves in the lead II rhythm strip).
• Most of the 10 beats in this rhythm are not sinus-conducted. They can't be — because the PR intervals before beats #1 and #9 are too short to conduct — and the P waves closest to beats #2,3,4,5 and #10 all occur after the QRS. 
• This tells us: i) That there is AV dissociation for at least part of this tracing — because the P waves nearest to beats #1,2,3,4,5 and #9,10 are not related to their neighboring QRS complex; — and, ii) That these 7 beats (#1,2,3,4,5; and #9,10) — are all junctional escape beats occurring at an appropriate junctional escape rate of between 40-50/minute.
• Finally (as we step back a bit from this tracing) — We can see that the ventricular rhythm in Figure-2 is almost regular — with the exception of one beat.

QUESTION:

• Which beat in Figure-2 occurs earlier-than-expected?
• Why does this beat occur early?

ANSWER:

• Beat #6 in lead II clearly occurs earlier-than-expected. 
• 
  
• PEARL #5: When there is an underlying regular (or at least fairly regular) sinus rhythm, such that all sinus P waves are "on time" (as shown by the colored P wave arrows in Figure-2) — the finding of a beat that occurs earlier-than-expected strongly suggests that this beat is conducted. This tells us that beat #6 in Figure-2 is a "capture" beat that is being conducted by the "on time" sinus P wave in front of it!

=================================

Let's Magnify the Lead II Rhythm Strip:

At this point in our analysis — I'm going to magnify the lead II rhythm strip that we have been focusing on, as this will greatly facilitate our observations.

• I have done this in Figure-3 — in which I break up the 10-beat tracing from Figure-2 into 2 parts.

Figure-3: I've magnified the lead II rhythm strip from Figure-2.

Orient yourself to the rhythm in Figure-3:

• RED arrows highlight the underlying sinus bradycardia, with slight sinus arrhythmia.
• As described earlier — beats #1,2,3,4,5 are all junctional escape beats at a rate in the 40s — and, beat #6 represents a sinus-capture beat.
• The rhythm strip ends with 2 additional junctional escape beats ( = beats #9,10).
• This leaves us with beats #7,8 that we have not yet defined.

PEARL #6: If your goal is to confidently interpret complex arrhythmias — then the use of calipers is essential!

• Escape rhythms are usually regular (or at least almost regular). Awareness of this truism holds the key for determining which of the 2 remaining beats (#7 or #8) is sinus-conducted.

I illustrate this concept in Figure-4 — in which I show my measurements of each of the R-R intervals in today's tracing.

• QUESTION: What do these R-R interval measurements tell you about beats #7 and 8?

Figure-4: I've measured R-R intervals from Figure-3.

ANSWER:

• Note that the R-R interval preceding each of the junctional escape beats in Figure-4 is constant at 1480 milliseconds, with the exception of the slight variation (to 1460 msec.) preceding junctional beat #9.
• KEY Point: The R-R interval preceding beat #7 is shorter-than-expected ( = 1430 msec. — instead of 1480 msec.). This tells us that beat #7 is sinus-conducted — whereas beat #8 (which manifests a slightly shorter PR interval) is another junctional escape beat.

I illustrate the above findings schematically in Figure-5 — in which RED arrow P waves indicate sinus-conducted beats.

• YELLOW arrow P waves highlight "on-time" P waves that are not conducting.
• Note in Figure-5 that the PR interval preceding beat #7 is slightly more than 1 large box in duration — which tells us that there is 1st-degree AV block for this one "on-time" sinus P wave that is normally conducted to the ventricles.

Figure-5: RED arrows indicate sinus-conducted beats. YELLOW arrows highlight "on-time" P waves that are not conducting.

=================================

Laddergram Illustration:

For clarity of the above relationships — I add in Figure-6 my proposed laddergrams for today's tracing:

• XXXX

Figure-6: My proposed laddergrams for today's case.

XXXXXXXXX

So the reason that the P-P interval is not as regular as a "normal sinus rhythm" would be — is that we have sinus bradycardia and arrhythmia. Clinically — your patient is on 2 medications (ß-block and verapamil or diltiazem) that may each cause sinus brady and arrhythmia. Since your patient is 70 years old — we need to assess for SSS ( = Sick Sinus Syndrome) — but in order to diagnose SSS — we need to RULE OUT that the brady rhythm is being causes by rate-slowing medications — so we need to see the effect of tapering and stopping these to meds. You can only diagnose SSS after you rule out potentially other "fixable" causes of bradycardia — so rule out recent ischemia/infarction — hypothyroidism — sleep apnea — electrolyte disturbance — and rate-slowing medication. And if this degree of symptomatic bradycardia (Your patient is having syncopal episodes) — then a permanent pacemaker is needed. But it is possible that if you stop ß-blockers and Ca-blockers — that he will resume having a normal heart rate.

Now the "incubation period" for SSS is often very long (up to a decade or more! ) — and your patient might have subtle (preclinical) SSS that is being exacerbated by the drugs. So we would just have to see what happens when the drugs are slowly withdrawn (whether this may or may not be safe to do as an out-patient vs as an in-patient).

So the above is the clinical part of this case. The rhythm is VERY interesting — and a GREAT teaching case! 

To facilitate seeing the P waves — My Figure-5 magnifies leads I and II (the 2 lines here are continuous — as I broke them up to be able to magnify what we are looking at). Once you know where the P waves are — We can measure the preceding R-R intervals — which I have done in milliseconds. We know beats #1,2,3,4,9 and 10 are not conducted — because the P wave does not occur at a point where it can possibly conduct. Note that the R-R interval preceding all of these beats (except beat #9) by the identical preceding R-R interval of 1480 msec. — so this is the R-R interval of junctional escape beats. The R-R preceding beat #9 is close to this (1460 msec.) — and you can have slight variation in the junctional escape rate — but beat #7 is sinus-conducted (as the preceding R-R is less = 1430 msec. and the PR interval is longer than for all other beats except for the PR interval before beat #6.

But in my Figure-7 (which is the laddergram) — We can see that the reason the PR interval preceding beat #6 is longer than the PR interval before beat #7 is that junctional escape beat #5 exerts some degree of retrograde conduction, which delays sinus-conducted beat #6 a little (thereby resulting in a slightly longer PR interval by "concealed" conduction). 

BOTTOM LINE — The this rhythm is marked sinus bradycardia and arrhythmia — with resultant appropriate junctional escape. This is an "escape-capture" rhythm (with beats #6 and 7 being "captured" sinus conduction). And again — given symptoms of syncopal episodes — if discontinuing the ß-blocker and Ca-blocker does not result in normalization of the rate — then the patient will need a pacemaker.

XXXXXXXXX

=======================

abdallah sbai sassi <dr.abdallahsbaisassi@gmail.com>

Thanks for your insights regarding this EKG. Of course, you can use it for your blog — it would be my pleasure. My full name is Abdallah Sbai Sassi, from Rabat, Morocco — thank u again for your time.

Non-dihydropyridine (non-DHP) calcium channel blockers, specifically verapamil and diltiazem, are the primary calcium blockers that cause bradycardia by slowing the heart rate. While some dihydropyridine CCBs like amlodipine have been linked to bradycardia in rare cases, they are more often associated with reflex sinus tachycardia because they are more vascular-selective than dihydropyridines.

MY REPLY:

The reason this case is so challenging — is that the P waves are tiny. But if you use all 12 leads (as I show here in my Figure-2) — you can figure out where all of the P waves are (ie, the BLUE vertical lines show that in leads V3,V4 — there are in fact P waves in lead II at this precise moment). So if you look at lead II in this figure — you can see there is a fairly regular atrial rate — except for the early beat #6 (which as you correctly say is a "capture" beat = that is sinus-conducted).

So the reason that the P-P interval is not as regular as a "normal sinus rhythm" would be — is that we have sinus bradycardia and arrhythmia. Clinically — your patient is on 2 medications (ß-block and verapamil or diltiazem) that may each cause sinus brady and arrhythmia. Since your patient is 70 years old — we need to assess for SSS ( = Sick Sinus Syndrome) — but in order to diagnose SSS — we need to RULE OUT that the brady rhythm is being causes by rate-slowing medications — so we need to see the effect of tapering and stopping these to meds. You can only diagnose SSS after you rule out potentially other "fixable" causes of bradycardia — so rule out recent ischemia/infarction — hypothyroidism — sleep apnea — electrolyte disturbance — and rate-slowing medication. And if this degree of symptomatic bradycardia (Your patient is having syncopal episodes) — then a permanent pacemaker is needed. But it is possible that if you stop ß-blockers and Ca-blockers — that he will resume having a normal heart rate.

Now the "incubation period" for SSS is often very long (up to a decade or more! ) — and your patient might have subtle (preclinical) SSS that is being exacerbated by the drugs. So we would just have to see what happens when the drugs are slowly withdrawn (whether this may or may not be safe to do as an out-patient vs as an in-patient).

So the above is the clinical part of this case. The rhythm is VERY interesting — and a GREAT teaching case! 

To facilitate seeing the P waves — My Figure-5 magnifies leads I and II (the 2 lines here are continuous — as I broke them up to be able to magnify what we are looking at). Once you know where the P waves are — We can measure the preceding R-R intervals — which I have done in milliseconds. We know beats #1,2,3,4,9 and 10 are not conducted — because the P wave does not occur at a point where it can possibly conduct. Note that the R-R interval preceding all of these beats (except beat #9) by the identical preceding R-R interval of 1480 msec. — so this is the R-R interval of junctional escape beats. The R-R preceding beat #9 is close to this (1460 msec.) — and you can have slight variation in the junctional escape rate — but beat #7 is sinus-conducted (as the preceding R-R is less = 1430 msec. and the PR interval is longer than for all other beats except for the PR interval before beat #6.

But in my Figure-7 (which is the laddergram) — We can see that the reason the PR interval preceding beat #6 is longer than the PR interval before beat #7 is that junctional escape beat #5 exerts some degree of retrograde conduction, which delays sinus-conducted beat #6 a little (thereby resulting in a slightly longer PR interval by "concealed" conduction). 

BOTTOM LINE — The this rhythm is marked sinus bradycardia and arrhythmia — with resultant appropriate junctional escape. This is an "escape-capture" rhythm (with beats #6 and 7 being "captured" sinus conduction). And again — given symptoms of syncopal episodes — if discontinuing the ß-blocker and Ca-blocker does not result in normalization of the rate — then the patient will need a pacemaker.

==================================

Acknowledgment: My appreciation to Abdallah Sbai Sassi (from Rabat, Morocco) for the case and this tracing.

==================================

 

==============================

Additional Relevant ECG Blog Posts to Today’s Case:

• ECG Blog #185 — Review of the Ps, Qs, 3R Approach for systematic rhythm interpretation.
• ECG Blog #188 — Reviews how to read and draw Laddergrams (with LINKS to more than 100 laddergram cases — many with step-by-step sequential illustration) — See the quick access LINK in the upper Menu on top of every page in this Blog!
• 
  
• ECG Blog #256 — Escape-Capture Bigeminy (with junctional escape and "capture" from retrograde conduction — with AUDIO Pearls on "Escape-Capture" and on "Sick Sinus Syndrome" plus Step-by-Step Laddergram).

Other Post with "Escape-Capture" Rhythms: 

• ECG Blog #349 — another example of Escape-Capture with Step-by-Step Laddergrams.

• ECG Blog #163 — Escape-Capture Bigeminy (with sinus bradycardia and resultant junctional escape — and possibly also with SA block).
• ECG Blog #315 — Escape-Capture Bigeminy (from marked sinus bradycardia).
• ECG Blog #144 — Escape-Capture Bigeminy (from 2nd-degree AV block of uncertain severity).

ADDENDUM:

• These 2 ECG Videos cover KEY concepts in today's case:

—  —

ECG Media PEARL #68 (6:15 minutes Audio) — Reviews the meaning of the term, "Escape-Capture" (this being a special form of bigeminal rhythm).

—  —

ECG Media PEARL #69 (2:45 minutes Audio) — Reviews the ECG findings of SSS = Sick Sinus Syndrome (excerpted from the Audio Pearl presented in Blog #252).

COPY of Blog #502 (Video) - Wellens' Syndrome?- COPY

XXXXXXX

Figure-1: The ECG in today's Case.

Below is the Video presentation of today's case:

==================================

Acknowledgment: My appreciation to Konstantin Тихонов (from Moscow, Russia) for the case and this tracing.

==================================

 

 

==================================

Related ECG Blog Posts to Today’s Case: 

• ECG Blog #205 — Reviews my Systematic Approach to 12-lead ECG Interpretation.
•  
• ECG Blog #209 and ECG Blog #254 and ECG Blog #309 — Review cases of marked LVH that result in similar ST-T wave changes as may be seen with Wellens' Syndrome. 
• ECG Blog #245 — Reviews my approach to the ECG diagnosis of LVH (outlined in Figures-3 and -4, and the subject of Audio Pearl MP-59 in Blog #245).
• 
  
• ECG Blog #320 — Reviews acute OMI of the 1st or 2nd Diagonal (presenting as Wellens' Syndrome).
• 
  
• ECG Blog #326 — Reviews a case of Wellens' Syndrome that was missed.
• ECG Blog #350 — another case of Wellens' Syndrome.
• 
  
• ECG Blog #337 — for Review of a case illustrating step-by-step clinical correlation between serial ECGs with symptom severity.
• 
  
• See the October 15, 2022 post (including My Comment at the bottom of the page) — for review and illustration of the concept of "Precordial Swirl" (due to proximal LAD OMI).

==================================

ADDENDUM (10/XXX/2025): I excerpted what follows below from My Comment in the August 12, 2022 post in Dr. Smith's ECG Blog).

==================================

The History of Wellens' Syndrome:

It's hard to believe that the original manuscript describing Wellens' Syndrome was published over 40 years ago! I thought it insightful to return to this original manuscript (de Zwaan, Bär & Wellens: Am Heart J 103: 7030-736, 1982):

• The authors (de Zwaan, Bär & Wellens) — studied 145 consecutive patients (mean age 58 years) admitted for chest pain, thought to be having an impending acute infarction (Patients with LBBB, RBBB, LVH or RVH were excluded). Of this group — 26/145 patients either had or developed within 24 hours after admission, a pattern of abnormal ST-T waves in the anterior chest leads without change in the QRS complex.
• I've reproduced (and adapted) in Figure-3 — prototypes of the 2 ECG Patterns seen in these 26 patients. Of note — all 26 patients manifested characteristic ST-T wave changes in leads V2 and V3.
• Most patients also showed characteristic changes in lead V4.
• Most patients showed some (but less) ST-T wave change in lead V1.
• In occasional patients — abnormal ST-T waves were also seen as lateral as in leads V5 and/or V6.
• 
  
• Half of the 26 patients manifested characteristic ST-T wave changes at the time of admission. The remaining 13/26 patients developed these changes within 24 hours after hospital admission.
• Serum markers for infarction (ie, CPK, SGOT, SLDH) were either normal or no more than minimally elevated

ECG Patterns of Wellens' Syndrome:

The 2 ECG Patterns observed in the 26 patients with characteristic ST-T wave changes are shown in Figure-3:

• Pattern A — was much less common in the study group (ie, seen in 4/26 patients). It featured an isoelectric or minimally elevated ST segment takeoff with straight or a coved (ie, "frowny"-configuration) ST segment, followed by a steep T wave descent from its peak until finishing with symmetric terminal T wave inversion.
• Pattern B — was far more common (ie, seen in 22/26 patients). It featured a coved ST segment, essentially without ST elevation — finishing with symmetric T wave inversion, that was often surprisingly deep.

Figure-3: The 2 ECG Patterns of Wellens' Syndrome — as reported in the original 1982 article (Figure adapted from de Zwaan, Bär & Wellens: Am Heart J 103:730-736, 1982).

ST-T Wave Evolution of Wellens' Syndrome:

I've reproduced (and adapted) in Figure-4 — representative sequential ECGs obtained from one of the patients in the original 1982 manuscript.

• The patient whose ECGs are shown in Figure-4 — is a 45-year old man who presented with ongoing chest pain for several weeks prior to admission. His initial ECG is shown in Panel A — and was unremarkable, with normal R wave progression. Serum markers were negative for infarction. Medical therapy with a ß-blocker and nitrates relieved all symptoms.
•  
• Panel B — was recorded 23 hours after admission when the patient was completely asymptomatic. This 2nd ECG shows characteristic ST-T wave changes similar to those shown for Pattern B in Figure-3 (ie, deep, symmetric T wave inversion in multiple chest leads — with steep T wave descent that is especially marked in lead V3).
• 
  
• Not shown in Figure-4 are subsequent ECGs obtained over the next 3 days — that showed a return to the "normal" appearance of this patient's initial ECG (that was shown in Panel A of Figure-4). During this time — this patient remained asymptomatic and was gradually increasing his activity level.
• 
  
• Panel C — was recorded ~5 days later, because the patient had a new attack of severe chest pain. As can be seen — there is loss of anterior forces (deep QS in lead V3) with marked anterior ST elevation consistent with an extensive STEMI. Unfortunately — this patient died within 12 hours of obtaining this tracing from cardiogenic shock. Autopsy revealed an extensive anteroseptal MI with complete coronary occlusion from fresh clot at the bifurcation between the LMain and proximal LAD.

Figure-4: Representative sequential ECGs from one of the patients in the original 1982 article. 
— Panel A: The initial ECG on admission to the hospital; 
— Panel B: The repeat ECG done 23 hours after A. The patient had no chest pain over these 23 hours. NOTE: 3 days after B — the ECG appearance of this patient closely resembled that seen in A ( = the initial tracing). 
— Panel C: 5 days later — the patient returned with a new attack of severe chest pain. As seen from this tracing (C) — this patient evolved a large anterior STEMI. He died within hours from cardiogenic shock (Figure adapted from de Zwaan, Bär & Wellens: Am Heart J 103:730-736, 1982 — See text).

==========================

Relevant Findings from the 1982 Article:

The ECG pattern known as Wellens' Syndrome was described over 40 years ago. Clinical findings derived from the original 1982 manuscript by de Zwaan, Bär & Wellens remain relevant today.

• One of the 2 ECG Patterns shown in Figure-3, in which there are characteristic anterior chest lead ST-T wave abnormalities — was seen in 18% of 145 patients admitted to the hospital for new or worsening cardiac chest pain.
• Variations in the appearance of these 2 ECG patterns may be seen among these patients admitted for chest pain. Serial ECGs do not show a change in QRS morphology (ie, no Q waves or QS complexes developed). Serum markers for infarction remained normal, or were no more than minimally elevated.
• Among the subgroup of these patients in this 1982 manuscript who did not undergo bypass surgery — 75% (12/16 patients) developed an extensive anterior STEMI from proximal LAD occlusion within 1-2 weeks after becoming pain-free.

LESSONS to Be Learned:

At the time the 1982 manuscript was written — the authors were uncertain about the mechanism responsible for the 2 ECG patterns of Wellens' Syndrome.

• We now know the mechanism. A high percentage of patients seen in the ED for new cardiac chest pain that then resolves — with development shortly thereafter of some form of the ECG patterns shown in Figure-1 — had recent coronary occlusion of the proximal LAD — that then spontaneously reopened.
• The reason Q waves do not develop on ECG and serum markers for infarction are normal (or at most, no more than minimally elevated) — is that the period of coronary occlusion is very brief. Myocardial injury is minimal (if there is any injury at all).
• BUT: What spontaneously occludes, and then spontaneously reopens — may continue with this cycle of occlusion — reopening — reocclusion — reopening — until eventually a final disposition is reached (ie, with the "culprit" vessel staying either open or closed).
• 
  
• Clinically: We can know whether the "culprit" artery is either open or closed by correlating serial ECGs with the patient's history of chest pain. For example — resolution of chest pain in association with reduction of ST elevation suggests that the "culprit" vessel has spontaneously reopened. And, if this is followed by return of chest pain in association with renewed ST elevation — the "culprit" artery has probably reclosed.
• The importance of recognizing Wellens' Syndrome — is that it tells us that timely cardiac cath will be essential IF we hope to prevent reclosure. In the de Zwaan, Bär & Wellens study — 75% of these pain-free patients with Wellens' ST-T wave changes went on to develop a large anterior STEMI within the ensuing 1-2 weeks if they were not treated.
• Thus, the goal of recognizing Wellens' Syndrome — is to intervene before significant myocardial damage occurs (ie, diagnostic criteria for this Syndrome require that anterior Q waves or QS complexes have not developed — and serum markers for infarction are no more than minimally elevated).
• It is not "Wellens' Syndrome" — IF the patient is having CP (Chest Pain) at the time one of the ECG patterns in Figure-3 are seen. Active CP suggests that the "culprit" artery is still occluded.
• Exclusions from the 1982 study were patients with LBBB, RBBB, LVH or RVH. While acute proximal LAD occlusion can of course occur in patients with conduction defects or chamber enlargement — Recognition of the patterns for Wellens' Syndrome is far more challenging when any of these ECG findings are present.
• Finally, a word about the 2 ECG Patterns in Figure-3. As suggested from data in the original 1982 manuscript, Pattern A — is far less common, but more specific for Wellens' Syndrome IF associated with the "right" history (ie, prior chest pain — that has now resolved at the time ST-T wave abnormalities appear).
• Unlike the example in Figure-3 — Pattern B may be limited to symmetric T wave inversion without the finding of steep T wave descent into terminal negativity in any lead. Deep, symmetric T wave inversion per se is seen in a number of other conditions, and is much less specific for Wellens' Syndrome.

In Conclusion: The 145 patients studied by de Zwaan, Bär & Wellens in 1982 continue to this day to provide clinical insight into the nature of Wellens' Syndrome.

 

EXTRA COPY- Dr. Smith ECG Blog- LINKS to My Comments (10-1.1-2025)

 

NOTE: Since end-May, 2018 — I have regularly written a "My Comment" feature on Dr. Smith's ECG Blog (with limited comments during 2021). 

• Prior to May 24, 2018 — I frequently added comments as an avid reader to Dr. Smith's posts. CLICK HERE — for a link to those comments before 5/24/2018.
• I contributed to 310 posts up until I stopped in Dec., 2020. 
• From June, 2021 — through 6/17/2025 — I contributed to ~450 more posts ...
• From June 25, 2025 — thru 10/1/2025 when WordPress began:
•                                                     — I have now contributed ~488 more posts —
•    

===================================== 

For My Comments on Dr. Steve Smith's Blog (as Associate Editor):

• Cardiac Arrest/Abnl ECG (RVH/LVH-Katz-Wachtel) May 24, 2018 -
• Acute Posterior MI despite RBBB (posterior leads Not) May 26, 2018 -
• LIST: A Long QT/QU + U Waves (Drugs/Lytes/CNS)- May 27, 2018 -
• Paced ECG + Primary ST-T Changes! (Acute MI) May 29, 2018 - 
• Repost of 2015 WCT Rhythm: Is the QRS Wide??? May 30, 2018 -
• LBBB with LA-LL Lead Reversal + Suble ST Changes June 4, 2018 -
• Brady, Wide QRS, Pointed T, Hypotension (artifact) - June 6, 2018 - 
• Is the QRS really so Wide? (shark fin) - June 11, 2018 - 
• Inf. STEMI vs Constrict Pericarditis (Schamroth sign) June 17, 2018 -
• WPW or AIVR? Why AIVR? ( = Sinus Brady ...) - June 18, 2018 -
• What is Terminal QRS Distortion (Pericarditis @ Peril) June 20, 2018 -
• LBBB, modify Sgarbossa, Qualitative ST-T Changes June 22, 2018 -
• Does ECG help Manage Insulin Overdose? (low K+) June 24, 2018 -
• Early Repol vs OMI vs Pericard (AFib/Group Beating) June 26, 2018 -
• Wellens' Syndrome + Change in Serial Tracings! - June 28, 2018 -
• Type 1 MI with a Normal Cath (isolated high lateral MI) - July 1, 2018 - 
• Use of Terminal QRS Distortion to make Diagnosis! - July 3, 2018 -
• Slow AFib + Syncope (about Sick Sinus Syndrome!) - July 5, 2018 -
• 
  
• When Should the OMI Dx have Been Made? - July 8, 2018 -
• Inf. OMI + RV MI (Hyperacute ST-T / Mirror-Image) - July 11, 2018 -
•    — Also — ischemia-induced J-waves (My July 11 Comment)
• 
  
• Acute High Lat. OMI (only seen in aVL) - July 13, 2018 -
• Recognizing LQTS (Long QT Syndrome) on ECG - July 17, 2018 -
• Sodium-Channel Blockade on ECG (Long QTc) - July 20, 2018 -
• Findings of Hypokalemia - and — Anything Else? - July 22, 2018 -
• Findings of Hyperkalemia (Eiffel Tower/Rhabdo) - July 24, 2018 -
• ST Elevation? (Acute PE/Simultaneous Leads) - July 26, 2018 -
• Paramedic recognize subtle OMI (V1,2 malposition) - July 28, 2018 - 
• Limb Lead and Chest Lead Misplaced (Recognize!) - July 29, 2018 -
• CP in 30yo f (Subtle Abns in 11/12 leads/Compare) - July 31, 2018 -
• A Regular SVT — How to Diagnose AFlutter? - August 3, 2018 -
• A Regular WCT with an LBBB-like Pattern ... - August 5, 2018 -
• A 13yo with SOB (WPW - arrhythmias - localization) - August 7, 2018 -
• Lots of ST Elev.: Repol vs STEMI? (mirror-image) - August 9, 2018 -
• Acute LMain Occlusion! — a subtle initial tracing - August 30, 2018 -
• 2 Occlusions (Less good ECG interpretation ... ) - Sept. 2, 2018 -
• Reverse Takotsubo and an Unusual ECG - Sept. 4, 2018 -
• Subtle Post-Lat OMI (LCx) + VT with AV Diss/Capture - Sept. 7, 2018 -
• 50yo Woman with CP & "Normal" Triage Tracings - Sept. 11, 2018 -
• Acute PE (ECG & Echo findings) - Sept. 12, 2018 -
• Idiopathic VT — Fascicular VT (See My Comment) - Sept. 14, 2018 -
• Subtle Serial ECG Changes in a 30yo with CP - Sept. 15, 2018 -
• Hyperacute T Waves (The Wrong Question was Asked) - Sept. 20, 2018 - 
• AFlutter with subtle Anterior STEMI (Use calipers! ) - Sept. 24, 2018 -
• Cabrera Format - 50mm/second speed - Chest Pain ... - Sept. 26, 2018 -
• Dialysis Patient — "Pseudonormalization" ST-T Waves - Sept. 29, 2018 - 
• Giant T Waves / Origin of an Atrial Rhythm - October 1, 2018 - 
• Paced ECG with Acute Anterior STEMI (Sgarbossa) - October 3, 2018 - 
• Subtle Acute High-Lat STEMI (aVL-mirror image) - October 6, 2018 - 
• Acute STEMI diagnosed ONLY by PVC Morphology - October 8, 2018 - 
• Another Invalid Study on Triage ECGs in the ED - October 9, 2018 - 
• Subtle OMI in a Triage ECG (PR vs TP Baseline) - October 14, 2018 - 
• Anterior MI + PVCs (Subtle rhythm-junctional escape) - Oct. 19, 2018 - 
• 80yo man with sudden PEA (no clear "culprit" on ECG) - Oct. 22, 2018 -
• Normal Troponin & Acute Occlusion (ischemic J waves) - Oct. 24, 2018 - 
• Inf. ST Elev but No MI! (ST straightened- a "normal" ST) - Oct. 27, 2018 - 
• Diffuse ST Dep/ST Elev in aVR (Recognize this pattern! ) - Oct. 31, 2018 - 
• Q waves in V1,V2 = Septal MI? (or V1/V2 Misplacement?) - Nov. 4, 2018 - 
• Recognition of a Long QTc (Assessing the QTc- LIST ) - Nov. 7, 2018 - 
• A Case-Based Study of Pacer Malfunction (bradycardia) - Nov. 9, 2018 - 
• 2 ECGs Texted to Dr. Meyers (Acute STEMI or not?) - Nov. 12, 2018 - 
• Serial ECG Changes over 10 tracings in Acute STEMI - Nov. 15, 2018 - 
• Hyperacute T waves - new LAHB + Inf. Q waves = OMI - Nov. 18, 2018 -
• RBBB + Chest Pain: New vs Old? - Nov. 21, 2018 - 
• Acute STEMI missed by the Computer - Nov. 21, 2018 -
• Are these Hyperacute T waves? (Computer says stemi) - Nov. 24, 2018 - 
• Regular SVT at 200/min. + acute STEMI? (Semantics) - Nov. 26, 2018 - 
• ST Elev. in V1,V2 — STEMI? Brugada-2? (or leads?) - Nov. 28, 2018 - 
• Shock, LVH and/or Diffuse Subendocardial Ischemia - Nov. 30, 2018 -
• 2 ECGs without a History: Acute Changes or Not? - Dec. 5, 2018 - 
• Not Bigeminy — But a Problem with K+ & Ca++ (DKA) - Dec. 11, 2018 - 
• Can this be Wellens' Syndrome without an Infarct? - Dec. 14, 2018 -
• A Regular WCT: VT vs AFlutter + Flecainide Toxicity? - Dec. 16, 2018 - 
• The Computer Called this Normal (Subtle STEMI ) - Dec. 19, 2018 - 
• Subtle ST-T wave changes (Normal vs Flat ST segment) - Dec. 24, 2018 - 
• ST Elevation in V1-3: Ant MI vs "Strain" (ECG Dx of LVH)- Dec 27, 2018 - 
• ST Elevation in V3: Is it Normal? (More on ECG Dx LVH) - Dec. 29, 2018 - 
• Benign T Wave? Hypertrophic CardioMyopathy? - Jan. 2, 2019 -  
• "Who Done It? = HyperKalemia + HypoCalcemia - Jan. 3, 2019 - Jan 7 -
• Dynamic ST-T Wave Changes (Myocarditis, LVH) - Jan. 9, 2019 -
• Isolated RV MI + unusual pointed ischemic T waves - Jan. 11, 2019 -
• Bradycardia & AV Block from Hyper-K (Rhythm Pearls) - Jan. 13, 2019 - 
• The Regular WCT: VT vs SVT with Aberrancy? - Jan 24, 2019 - 
• Junctional vs Low Atrial Rhythm? (neg P  or part QRS?) - Jan. 28, 2019 - 
• Hyperthermia and ST Elevation in V1,V2 (Brugada-1) - Jan. 30, 2019 - 
• Diffuse ST Dep/ST Elev in aVR not due to CAD (low K+) - Feb. 2, 2019 - 
• Subtle OMI diagnosis by ECG Comparison (pos Trop) - Feb. 5, 2019 - 
• Right-Sided HF and an SVT (Why is this AFlutter?) - Feb. 9, 2019 -
• RVH - IRBBB: Is Ant T Inversion New or Old? - Feb. 12, 2019 - 
• How Long Will You Wait for OMI to become STEMI? - Feb. 16, 2019 - 
• Coved ST Elevation in Chest Leads: Acute or Not? - Feb. 18, 2019 - 
• Cardiac Arrest, ROSC and now RBBB? (very wide! ) - Feb. 28, 2019 - 
• LVH, diffuse ST dep/ST elev in aVR (Sickle Cell ) - March 2, 2019 - 
• Monitor Leads for ST Elevation? (Filter Settings! ) - March 4, 2019 -
• Recognizing abnormal ST elevation in V1,V2 - March 6, 2019 - 
• Subtle Acute MI (Is complex A or B in aVL correct?) - March 8, 2019 - 
• Resp. Failure + a "Normal" Computer ECG ("smiley" ) - March 11, 2019 - 
• What is the Rhythm? (2 Regular WCTs vs 1 Rhythm?) - March 13, 2019 - 
• The SHAPE in lead V2 — Acute OMI - March 15, 2019 - 
• Acute OMI Dx'd by Speckle Echo (an unusual IVCD) - March 18, 2019 - 
• Electrolytes — Pathognomonic ECG (hypoCa/hyperK) - March 19, 2019 - 
• Junctional Escape (Laddergram)/SubEndo Ischemia - March 26, 2019 -
• Subtle High-Lat OMI + 3 False Pos (ST elev in aVL) - March 29, 2019 -  
• 3 ECG shown to Dr. Meyers (To Activate Cath Lab? ) - March 31, 2019 - 
• Acute LAD Occlusion in an Elderly Patient - April 3, 2019 - 
• ECG Findings & Clinical Diagnosis of Acute PE - April 5, 2019 - 
• A Pt with Abdominal Pain and LBBB (qualitatively + ) - April 7, 2019 -
• Acute OMI missed because it wasn't a "STEMI" - April 12, 2019 - 
• Type 2 MI + Myocardial Bridging + Tachy/ST Elev - April 15, 2019 - 
• Acute Pericarditis or a Repolarization Variant ECG? - April 19, 2019 -
• OMI despite no STEMI ( + V2 lead malposition) - April 20, 2019 - 
• CP & ST Depression only in leads I and aVL ... - April 22, 2019 -
• A WCT Rhythm with Alternating Wide-Narrow Beats - April 23, 2019 - 
• Dx of Acute STEMI despite being a Paced Tracing - April 25, 2019 - 
• Terminal QRS Distortion (T-QRS-D) - LVH Voltage - April 27, 2019 - 
• LBBB vs WPW (LBBB criteria- All about WPW) - April 30, 2019 - 
• Tachyarrhythmias: Use of Monitor vs a 12-Lead ECG - May 1, 2019 - 
• De Winter T Waves (Typical & Atypical Features) - May 2, 2019 - 
• Brugada ECG Patterns vs Acute Anterior STEMI - May 6, 2019 - 
• Don't Overlook this OMI (Be Systematic/Computer Use) - May 7, 2019 - 
• Another Anterior OMI/Not Repol (the Visual Picture) - May 11, 2019 - 
• Chest Pain in a Pt with a Paced Rhythm (2:1 ATach?) - May 13, 2019 - 
• Peaked T Waves despite serum K+ = 2.4 mEq/L - May 15, 2019 -
• LVH and/or Acute OMI (Nit-Picking Serial Tracings/LVH) - May 19, 2019 - 
• LBBB: Recognizing Acute OMI (Smith-Mod-Sgarbossa) - May 24, 2019 - 
• Acute Ant. OMI (What will the Cardiologist do Next Time?) May 26, 2019 - 
• A Complex ECG and No Clinical Info (Laddergram) - May 28, 2019 - 
• Superimposed Changes on Prior Antero-Lat STEMI? - June 2, 2019 - 
• Cardiologist & Computer said "Normal" (acute OMI) - June 4, 2019 -  
• Is ST-T wave SHAPE normal? (Cath lab activation? ) - June 7, 2019 -
• How Not to Miss WPW (Reviews My Approach) - June 8, 2019 - 
• Hyperacute T Waves (on way down) - Computer - June 9, 2019 - 
• 20yo with Chest Pain: Early Repol or Something Else?- June 11, 2019 - 
• A Patient with SOB (Systematic-LVH-QTc-hyper-K+) - June 15, 2019 - 
• Dr. Smith's 3- and 4-Variable Formula (Ant STEMI? ) - June 17, 2019 - 
• Repolarization Variants vs LVH-HCM-STEMI? (blacks) - June 20, 2019 - 
• "Smiley"-shape ST Elevation (Using this Concept! ) - June 22, 2019 - 
• Very Subtle Inferior Lead ST-T Wave Change - June 23, 2019 -
• Quick Recognition of Acute Proximal LAD Occlusion - June 26, 2019 -
• A System needed to pick up all Findings! (Inf OMI ) - June 28, 2019 - 
• 2 Cases of RBBB (My Approach for ECG Dx of BBB) - July 1, 2019 - 
• CP Onset 24-48 Hrs Ago (2 Post MIs- Correlate to Hx) - July 5, 2019 - 
• Subtle-but-definite acute LAD OMI (artifact! ) - July 11, 2019 - 
• ST Elevation only in V6/Recip in V1 (LCx-Post MI ) - July 15, 2019 - 
• Doubling Size of Complexes Facilitates OMI Dx! - July 17, 2019 - 
• Subtle LAD OMI: New vs Old? (Brugada-like) - July 19, 2019 - 
• Acute MYOCARDITIS vs OMI vs Repol (Serial Tracings) - July 21, 2019 - 
• The ECG was Correct; Cath was Not! (Late-Cycle PVCs)- Aug. 13, 2019 - 
• 5 Cardiologists say No STEMI — Is in an OMI? - August 15, 2019 - 
• CP in a 50yo with a "Normal" ECG — Or an OMI? - August 18, 2019 - 
• Evidence of Acute OMI on this Pacer Tracing? - August 20, 2019 - 
• Are these Hyperacute T Waves? - August 26, 2019 - 
• Short QTc Syndrome vs Hyperkalemic T Waves - Sept. 2, 2019 - 
• Recognize this ECG? (HyperK- Brugada Phenocopy) - Sept. 8, 2019 - 
• Non-Cardiac Ischemia on ECG (+ a few questions) - Sept. 12, 2019 - 
• Troponin Trajectory: New Ant MI vs LV Aneurysm? - Sept. 17, 2019 - 
• When the QRS is Wide — the J-Point will Hide! (VSD) - Sept. 20, 2019 - 
• Why do beats "A" and "B" look so different? (artifact) - Sept. 22, 2019 - 
• 7 mm of ST Elevation with LBBB = Acute? What Else? - Sept. 25, 2019 - 
• Acute MI diagnosis by Chest CT (+ suble ECG/Artifact) - Sept. 27, 2019 - 
• Subtle Inf. OMI / MAT at normal Rate - Sept. 30, 2019 - 
• ST Depression in a 30yo (Atrial Repol Wave/Tachycardia) - Oct. 2, 2019 - 
• Shark Fin Morphology (Don't Forget to look for P waves! ) - Oct. 4, 2019 - 
• Interplay between Post MI and acute RV MI! - Oct. 9, 2019 - 
• Do You Understand these T Wave Inversions? - Oct. 10, 2019 - 
• Regular SVT (AVRT — 30yo with WPW — Mgmt) - Oct. 16, 2019 - 
• Acute Inf-Lat OMI (QS inf leads-Tall R V1-Silent MI ) - Oct. 20, 2019 - 
• Causes of ST Depression ("scooped" ST/Dig/LIST ) - Oct. 21, 2019 - 
• SCAD (Spontaneous Coronary Artery Dissection) - 30f - Oct. 24, 2019 - 
• Look at All ECGs done Serially! (Subtle clues! ) - Nov. 1, 2019 - 
• Diffuse Subendocardial Ischemia (not always cardiac! ) - Nov. 3, 2019 - 
• Vagotonic AFib in 30yo (The RATE of AFib - D.D.) - Nov 5, 2019 - 
• Subtle Changes = an ECG non-diagnostic of OMI (Lytics?) - Nov. 8, 2019 - 
• What is this SVT @ 150/min? (AFlutter — MY POST ) - Nov. 12, 2019 -
• Repolarization Variants vs Acute OMI (T-QRS-D) - Nov. 14, 2019 - 
• Seizures — Review of HypoKalemia - Nov. 18, 2019 - 
• CP in a 30yo — Acute OMI? (Serial ECGs) - Nov. 20, 2019 -
• Cardiac Arrest — Shark Fin/ Osborn Waves/ Low Atrial - Nov. 22, 2019 -  
• Is there Global ST Depression? — or Atrial Flutter? - Nov. 26, 2019 - 
• Acute Pancreatitis/LVH and Repol vs Acute OMI? - Nov. 27, 2019 - 
• Distinguishing New vs Old MI (vs superimposed MI) - Nov. 29, 2019 - 
• A 30yo woman with Fever-Induced Brugada-1? - Dec. 5, 2019 - 
• CO Poisoning — Prox LAD Occlusion (T-QRS-D ) - Dec. 9, 2019 - 
• Acute Myocarditis vs Repol vs OMI (Serial ECGs) - Dec. 10, 2019 - 
• Acute PERICARDITIS (detailed discussion! ) - Dec. 13, 2019 - 
• Acute OMI despite LBBB (Smith-Sgarbossa- subtle! ) - Dec. 16, 2019 - 
• More on HypoKalemia - Dec. 18, 2019 - 
• A Regular WCT (Wide-Complex Tachycardia) - Dec. 23, 2019 - 
• Don't Overlook AFlutter! (Regular SVT at ~150/minute) - Dec. 24, 2019 - 
• Mobitz II in an Asymptomatic 80yo (AV Blocks) - January 1, 2020 -  
• Hypothermia with Osborn Waves! - Jan. 2, 2020 - 
• MAT - the Computer - Aberrant Conduction (Ashman) - Jan. 5, 2020 - 
• Crochetage Sign — Is there an ASD? - Jan. 8, 2020 - 
• Acute Pericarditis (Myocarditis)? Acute OMI? Repol? - Jan. 10, 2020 - 
• Acute MI + Post-Infarction Pericarditis (Review) - Jan. 14, 2020 - 
• Acute LMain Occlusion (ECG Recognition) - Jan. 16, 2020 - 
• Acute Inf OMI (Complex Rhythms-Ladder-Mobitz I ) - Jan 19, 2020 - 
• RBBB + 1° ST-T changes/AFib + AV Block (SSS? ) - Jan 22, 2020 - 
• "Shark Fin" / Myocardial "Stunning" ==> Low Voltage - Jan. 24, 2020 - 
• Hyperkalemia (Ventricular Escape - ECG Changes) - Jan. 26, 2020 - 
• 20-ish yo with Chest Pain (distal LAD OMI - subtle) - Jan. 29, 2020 - 
• Hx of Stents with Chest Pain (RBBB-Fragmentation) - Jan. 31, 2020 - 
• 7 Tracings: Which 3 have Acute Inferior OMI? - Feb. 2, 2020 - 
• Cardiology would Not Cath this Patient! (Ant. OMI ) - Feb 4, 2020 -
• ST Elevation in V1,V2 — due to LVH (not ACS) - Feb. 6, 2020 -  
• Ischemia vs Lead Misplacement (How to Recognize) - Feb. 11, 2020 - 
• A 50s Man with "Gas Pain" (Early LAD Occlusion) - Feb. 14, 2020 -
• HypoThermia — Shark Fin (Causes of Myocarditis) - Feb. 16, 2020 -
• 32yo with CP — Hyperacute T waves MISSED - Feb. 18, 2020 - 
• What are these Wide Complexes (AV Diss- AIVR) - Feb. 20, 2020 -  
• Anterior T Inversion (Not Wellens- PE vs Ischemia) - Feb. 28, 2020 -
• A Man in his 60s with CP (Subtle OMI) - March 2, 2020 - 
• Sinus Tach with a VERY Long PR Interval - March 4, 2020 - 
• ATach vs AVNRT of the Fast-Slow Type - March 6, 2020 - 
• ST Elevation in aVR (Coronary Occlusion?/SVT? ) - March 9, 2020 -
• A Scenario to Recognize (Irregular WCT-AFib/WPW) - March 12, 2020 - 
• 32yo with CP (LA-RA Lead Reversal + acute OMI) - March 18, 2020 - 
• 50ish yo with ETOH Ketoacidosis (Takotsubo CMP) - March 25, 2020 - 
• 30yo with CP (Tom Fiero case- acute OMI missed) - March 29, 2020 -   
• PVCs and AV Block? (NOT! - Interpolated- My Case) - April 9, 2020 -   
• Man in 60s (RBBB Basics-Hemiblocks-Acute OMI) - April 13, 2020 -  
• Differential Diagnosis of a Regular WCT (VT/LPHB) - April 15, 2020 -  
• Acute OMI not seen on ECG (subtle V1 ST elev) - April 20, 2020 - 
• Why 3 QRS Morphologies? (Rate-Related BBB) - April 22, 2020 -  
• Is it VT or SVT with Aberrancy? (MY Case! ) - May 5, 2020 - 
• Ant. ST Dep: Post MI or Subendocardial Ischemia? - April 24, 2020 -  
• "Shark Fin" with Twist (pseudo-MI- Hyper-K+ ) - April 25, 2020 - 
• Cardiac Arrest- Torsades vs PMVT (bizarre PVCs) - April 29, 2020 - 
• A 20yo with Vomiting (low K+ - Causes of Long QT) - May 3, 2020 - 
• ECG from a Study (Normal variant - Gestalt! ) - May 7, 2020 -
• The Many Faces of HypoKalemia! (Table-K+ ) - May 9, 2020 - 
• 50yo/SOB/Covid-19 (Indeterminate Axis-MyoCard) - May 11, 2020 -  
• Diffuse Subendocardial Ischemia (Normal Echo! ) - May 13, 2020 -
• Cardiac Arrest/ECMO — Shark Fin (rhythm-Type II MI) - May 19, 2020 - 
• AV Block & Something Else? (Ladder! - MY Case) - May 16, 2020 - 
• Subtle AFlutter (looks like sinus tach-MY Case) - May 22, 2020 -
• Syncope- Long 1st Deg. (AV Diss vs 3rd- P or U-wave?) - May 24, 2020 - 
• Early Repol vs Acute OMI (GOOD- R/O acute OMI ) - May 26, 2020 - 
• A Different Kind of WCT (Pleomorphic VT ) - June 1, 2020 -  
• SVT at 160 — then 240/minute (AVNRT-Adenosine) - May 31, 2020 -  
• What is the Culprit Artery? (prox LAD vs RCA/RV MI ) - June 6, 2020 - 
• Emery Phenomenon = (Pseudo-MI from neg P in lead II ) - June 3, 2020 - 
• A Fast Regular WCT/BBB-Reentry VT (at ~268/minute! ) - June 9, 2020 - 
• A 50-something man (SUBTLE MI !!! ) - June 12, 2020 -  
• Drug O/D with Fascinating Arrhythmia (Ladder! ) - June 13, 2020 - 
• Man in 60s — ROSC, Hyperacute T Waves (lad omi) - June 15, 2020 - 
• LVH causing ST Elevation in V1,V2 (not a STEMI!- LVH) - June 20, 2020 - 
• GIANT T Waves (Table) - HypoKalemia - June 22, 2020 -  
• Intermittent Wide QRS - No Hx (RBBB-MY Case) - June 25, 2020 - 
• Severe HyperNatremia (also hyper/hypo-Ca++ ) - July 1, 2020 - 
• A 60-something man (AFib/Ashman phenomenon) - June 17, 2020 - 
• Resuscitation ECGs are Often Bizarre (Spiked Helmet) - June 28, 2020 -  
• Trauma & blood Transfusions (hypo-Ca++/hyper-K+ ) - July 3, 2020 - 
• An Elderly Man with Hiatal Hernia (ischemic ST-T/new AFib) - July 7, 2020 - 
• Subacute MI (MI of ? Age/Dating MI - ongoing CP-for Cath) - July 9, 2020 -
• 20yo with Syncope (Pericarditis - Pericardial Tamponade) - July 12, 2020 -  
• CP — RBBB — Subendocardial Ischemia (No Cath Lab!) - July 15, 2020 -  
• Subtle Inferior/RV MI (Acute RV MI- Right-sided leads) - July 19, 2020 - 
• Interesting Troponins (Dynamic ST-T Wave Changes) - July 21, 2020 -  
• New Dyspnea (RA-LL Lead Reversal- USE! ) - July 28, 2020 - 
• 50yo man — de Winter-like OMI (late-cycle PVCs) - July 26, 2020 -  
• The OMI Manifesto (Summary) - July 31, 2020 - 
• Subtle OMI from France (Computer) - August 1, 2020 - 
• 40yo man — another OMI (STEMI-neg- Greece) - August 4, 2020 -  
• Middle-aged woman (OMI not Pericard- Q wave size) - August 8, 2020 - 
• VERDICT Trial (Use of CT Angiography for NSTE-ACS) - August 8, 2020 -  
• 4 Tachyarrhythmias in a Man with CP - August 13, 2020 -
• 35yo (MY Case - Ladder! - Mobitz I-Phase 4- RHYTHM) - August 17, 2020 -  
• Pseudo-Wellens' Syndrome (Why it is not Wellens! ) - August 19, 2020 - 
• Dynamic ST-T Change (Repolarization Variant) - August 21, 2020 -  
• Acute OMI + RBBB/LAHB (Cardiology oversight! ) - August 24, 2020 -
• Low Voltage, Cardiogenic Shock & Subtle OMI - August 28, 2020 - 
• 31yo with HTN + ST Elev/T Inversion (but not OMI) - August 30, 2020 -
• 21yof with SOB,exertional syncope (ECG Dx of RVH!) - Sept. 1, 2020 - 
• The OMI Manifesto (17 minutes — Dr. Meyers) - Sept. 3, 2020 -
• HyperKalemia (serial ECGs - Brugada Phenocopy) - Sept. 5, 2020 -
• SVT at 257/minute (Idiopathic VT- Fascicular/RVOT VT) - Sept. 7, 2020 -
• AV Wenckebach (Dual AV Pathways- Laddergram) - Sept. 9, 2020 - 
• An 18yo with CP (ST/T Ratio - Pericarditis vs Repol) - Sept. 11, 2020 -
• Acute Inf-Post-Lat OMI (Mirror- Fig of OMI Findings) - Sept. 13, 2020 - 
• 58yo with False Positive OMI (Repolarization Variant) - Sept. 15, 2020 -
• 60yo with LBBB + Acute OMI (MY Case) - Sept. 17, 2020 -
• Cardiac Arrest with Neg initial Troponin - Sept. 19, 2020 -
• Cardiologists limited by STEMI Criteria (Mirror- Post MI) - Sept 21, 2020 - 
• Prominent J (Osborn) Waves as Sign of Acute OMI - Sept. 23, 2020 -
• Cardiac Arrest/Massive PE (Not Complete AV Block) - Sept. 24, 2020 -
• 40-yo with Irreg. Rhythm (MY Case- Runs of PACs-Ladder) - Sept. 26, 2020 -
• Another Post MI missed by Cards (Mirror- Hyper-K+) - Sept. 28, 2020 - 
• Missed OMI (Subtle Posterior MI- LCx OMI ) - October 2, 2020 -
• Partially Paced ECG with Inf-Post-Lat OMI - October 5, 2020 -
• Is this Wellens' Syndrome (LVH - AV Diss- Ladder) - October 9, 2020 -   
• The Posterior Paradox (Post MI- Mirror- Silent MI) - October 11, 2020 -
• Serial ECGs = a STEMI that Resolves (11/12 leads) - October 14, 2020 -
• Covid with a Regular WCT ( Not VT but ARTIFACT) - October 17, 2020 -   
• Brooks: PACER ECG that is Acute OMI (My Comment) - October 19, 2020 - 
• HyperKalemia — Advanced Points (My Comment !!! ) - October 21, 2020 - 
• 40-yo with CP (Repol vs LVH vs Subtle Ant. OMI !!!) - October 23, 2020 -
• Shark Tooth "Silent Ischemia" + VT (Cabrera Format) - October 26, 2020 -
•    — MY Review on Cabrera format — GOOD on Coronary Spasm —
• 
  
• Septal OMI? (Saddleback- Many ECG Findings) - October 28, 2020 -
• 60-yo with Weakness (My Comment- HyperCalcemia) - October 30, 2020 - 
• An ECG without History is Mystery (Wellens! ) - November 6, 2020 -  
• This can be Taught: Qualitative Approach to ECGs (OMI) - Nov. 8, 2020 -  
• A 30-something Man - CP - Artifact-D.Richley-Christopher- Nov. 10, 2020 -  
• Extreme SHOCK + COVID (Low Voltage - RA artifact) - Nov. 12, 2020 -
• ATach with Block - Dig Toxicity (My Comment- Ladder) - Nov. 24, 2020 -
• Amyloid with Slow AFlutter vs ATach & 2:1 Block - Nov. 15, 2020 - 
• Anterior ST Elevation (LVH) + LA-LL Lead Reversal - Nov. 19, 2020 -
• VFib/ subtle OMI-TABLE! (Inter-Intra Observ Variability) - Nov. 17, 2020 - 
• Resident not Faculty saw OMI (Lead aVL- Coronary Circ.) - Nov. 21, 2020 -
• 49yo-Serial ECGs-Wellens Syndrome (My LAST Comment) - Dec. 4, 2020 -

 

I Resumed MY Commentary after June, 2021:

• Acute prox. RCA Occlusion (2nd-Degree- LADDERGRAM) - Jun. 17, 2021 -
• A Child with Biphasic T Waves in Leads V1,V2 - July 10, 20201 -
• AV Block? Echo beats?  — No, Interpolated PVCs - July 16, 2021 -
• AV Block that "doesn't obey the rules" (Hyperkalemia) - October 16, 2021 -
• PEA Arrest & AV Blocks (subtle 2:1; dual-level Wencke) - October 27, 2021 -
• WCT Case: 1 VT site, but Changing QRS Morphology! - Nov. 6, 2021 -
• LA-RA Lead Reversal misdiagnosed as acute OMI - Nov. 27, 2021 -
• Large Ta Wave simulates Ischemic ST Depression - Dec. 9, 2021 -
• Detection of Posterior OMI (Use of Mirror Test! ) - January 3, 2022 -
• Giant T-Wave Syndrome (LVH-Apical HCM) - January 8, 2022 -
• Marked ST Abnormality = CNS/OMI/Takotsubo? - January 14, 2022 -
• Other ECG Findings of Life-Threatening Hyper-K+ - January 16, 2022 -
• Subtle ECG Signs of acute OMI in LBBB — January 31, 2022 -
• This ECG Interpreted by Computer as Normal (OMI) — Feb. 4, 2022 -
• Hypothermia to 18°C (with huge Osborn Waves) — Feb. 8, 2022 -
• Jessie McLaren: 6 serial ECGs (subtle OMI- Mirror! ) — Feb. 10, 2022 -
• Use of the Term, "Diffuse"? (Inf-Ant-Lat OMI) — February 12, 2022 -
• 40yo woman with RVOT VT (MY Comment) — February 14, 2022 -
• CO Poisoning (J-Point vs Terminal QRS Distortion) — Feb. 18, 2022 -
• 40yo man with CP- OMI ECG Signs- LA-LL Reversal — Feb. 22, 2022 -
• Subtle Post. OMI- Technically Inadequate ECG! — Feb. 25, 2022 -
• 40yo with worrisome ST Elevation but Tachycardia! — March 3, 2022 - 
• 80yo woman with SOB — All about RVH! — March 6, 2022 - 
• Memorize those Squiggly Lines (11/12 leads- OMI! )- March 9, 2022 -
• Pendell: 60m-Seizure ( vs Vent. Standstill/Mobitz I) - March 14, 2022 -
• SSmith: Giant U-Waves ( + LVH,RAA,RVH- HypoK )- March 18, 2022 -
• SSmith: I was reading ECGs (3:1 AFlutter/Computer)- March 20, 2022 -
• Pendell: Pathognomonic (BTWI & ER-ST Variation! ) - March 22, 2022 -
•        (also shows benign T wave notching! )
• 
  
• SSmith (Deep): Subtle OMI-VT Criteria- Low Voltage - March 23, 2022 -
• SSmith (Deep): Evidence of OMI? (T-Imbalance V1-V6) - March 26, 2022 -
• Pendell: Woman 50s-SOB-large Acute PE (QR in V1) - March 28, 2022 -
• JesseM: LBBB + OMI (SSmith on Modified Sgarbossa!)- March 31, 2022 -
• Pendell: Man in 50s — Asymptomatic VT! for ? duration - April 2, 2022 -
• Diffuse ST Depression in 35yo with Chest Pain and WPW - April 5, 2022 -
• SSmith: Will Cath tell if ECG is OMI? (subtle - RBBB)- April 11, 2022 -
• Pendell: Man in 50s: CP-serial ECGs-DELAY for OMI - April 13, 2022 -
• Pendell: Woman-30s: CP- ST elev in V2-OMI-FLAG/AIVR - April 8, 2022 -
• SSmith: Ant. ST Elevate? (V1,V2- LVH-Brugada-2-K=6.1)- April 17, 2022 -
• SSmith: ST Elev./Dep. on a Monitor? (Filter Settings)- April 20, 2022 -
• JesseM: CP, Normal ECG- OMI missed (ETT, History)- April 22, 2022 -
• Pendell-Magnus: WPW (AFib @250 -AVRT-Cabrera)- April 24, 2022 -
• SSmith: RBBB/LAHB- Abnl ST-T Waves (Me on BBB)- April 26, 2022 -
• Pendell-Goss: 40m-RUQ Pain- Acute PE (My Table)- April 28, 2022 -
• Pendell: Man-40s (ME-subtle 2:1 Block-PM Cardio App)- May 1, 2022 -
• JesseM: Posterior OMI-Mirror (Low voltage/Technical) - May 3, 2022 -
• Pendell: Confusing (LA-RA Reversal-Brugada-Hyper-K)- May 5, 2022 -
• SSmith: Unstable Angina Exists (ME on Atypical CP) - May 8, 2022 -
• Pendell: Quiz Post — OMI or Nl? (S.African Flag Sign) - May 11, 2022 -
• SSmith: 30yo (Regular WCT-AVRT-vs- Idiopathic VT)- May 14, 2022 -
• Pendell: Asthma- BTWI vs Wellens (Trop p-running-WAP)- May 19, 2022 -
• JesseM: Quiz — Inf ST Elev- Omi? (Early Repol- ME) - May 23, 2022 -
• SSmith: CP + Troponin-Myocarditis (LA-LL Reversal)- May 24, 2022 -
• Pendell: Back to Basics-OMI (SA Block-Leads III,aVF) - May 25, 2022 -
• SSmith: Does single Troponin R/O? (LA-LL Reversal)- May 27, 2022 -
• SSmith: Occlusion MI? (T-Imbalance V1-V6- OMI? ) - June 1, 2022 -
• JesseM: Acute OMI on ECG but not on Cath (MINOCA)- June 5, 2022 -
• Pendell: GSW-Heart (Traumatic Pericarditis- Review!)- June 8, 2022 -
• SSmith: Acute OMI vs Acute Pericarditis - June 11, 2022 -
• Pendell: 30yo with CP/AS (Subtle ECG OMI- LVH) - June 17, 2022 -
• JesseM: LVH and repeated ED Visits for Chest Pain - June 20, 2022 -
• SSmith: LBBB with marked ST-T wave changes! - June 23, 2022 -
• Pendell: LVH-difficult ECG; Need to Repeat the ECG!- June 25, 2022 -
• SSmith: PseudoNormalization-Wellens-Serial ECGs- June 29, 2022 -
• SSmith: Unstable Angina-2 (ME-Diastolic Dysfunction)- July 2, 2022 -
• SSmith: The ECG Must be at Right Time (Subtle OMI)- July 4, 2022 -
• Pendell: Instant "Easy Save" (deWinter T-waves) - July 11, 2022 -
• Pendell: Not Convinced of STEMI (890-Cath-Osborn)- July 13, 2022 -
• SSmith: Middle-aged Male with GERD (subtle OMI) - July 16, 2022 -
• JesseM: 90yo-CP,RBBB-STEMI Neg (Location-Shape)- July 18, 2022 -
•    — Shape - Proportion & Location !!! (to assess for OMI) —
• 
  
• Pendell: 40yo Woman - Nausea - Reverse Takotsubo - July 21, 2022 -
• Pendell: Covid-pos: Myocarditis vs Acute OMI - July 25, 2022 -
• JesseM: How to Assess for OMI with marked LVH? - July 29, 2022 -
• — Shape - Proportion & Location !!! (to assess for OMI) —
• 
  
• Pendell: Man 60s — LBBB-subtle OMI (Qualitative) - August 1, 2022 -
• SSmith: Serial ECGs-Ant. OMI (Pacer- Laddergram) - August 3, 2022 -
• Pendell: Multi-Chest Trauma (Me) Cardiac Contusion - August 6, 2022 -
• SSmith: Wellens' Syndrome (Me)- (may mimic Inferior MI) Aug. 12, 2022 -
• Pendell: Woman 30s — CP, LVH and OMI (Tall T waves) August 15, 2022 -
• SSmith: Rapid AFib not Post OMI (Me) LA-RA Reversal!- Aug. 17, 2022 -
•    — Links to other Lead Reversals on Dr. Smith's Blog!  
• 
  
• JesseM: 60yo-Sepsis-Wellens? (Infarction-Type 1,2 MIs! ) - Aug. 19, 2022 -
• SSmith: Very Fast SVT (Adenosine-induced RBBB) - August 23, 2022 -
• Pendell: Tapping Artifact (Me) - Einthoven's Triangle - August 26, 2022 -
• SSmith: Unstable Angina/HS Troponin (Me)- Hyper-K+ - Sept. 5, 2022 -
• Pendell: 2 Patients with CP (Which has acute OMI? ) September 9, 2022 -
• Pendell: Man 60s — LBBB-OMI-Sgarbossa-Qualitative- Sept. 11, 2022 -
• JesseM: CP, high Trop (STEMI vs OMI-diagnostic PVC) Sept. 13, 2022 -
• SSmith: Woman Agitated (Takotsubo-Giant T-waves)- Sept. 19, 2022 -
• SSmith: Post Leads = False Reassurance (Mirror Test) - Sept. 21, 2022 -
• Pendell: 50m-CP- Early deWinter T-wave Pattern (Me) - Sept. 22, 2022 -
• Emre Aslanger: (Prox LAD OMI- Misdiagnosed) - September 25, 2022 -
• SSmith: All Changes from LVH? (LVH vs Acute OMI) - Sept. 30, 2022 -
• Pendell: CP 1 day after Nl Stress Test (ME-Rhythm! ) - Oct. 3, 2022 -
• SSmith: Activate the Cath Lab? (LVH-V1,V2-BTWI- Me!) Oct. 6, 2022 -
•                        (Great TABLE  on Nl Variant ST Elev/T inv. )
• 
  
• Pendell: Cardiac Arrest & STE (Acute PE on ECG) - October 10, 2022 -
• JesseM: Acute Post OMI despite WPW! - October 13, 2022 -
• Pendell-SSmith: Precordial Swirl (vs LVH-"Strain") - October 15, 2022 -
• SSmith: Is there T-QRS-D (Terminal-QRS-Distortion)? October 17, 2022 -
• SSmith: Problematic Pacer? (Sensing? - Pacing?) - October 19, 2022 -
• Pendell: The Rhythm? (VT ARTIFACT- RA Electrode)  October 21, 2022 -
• SSmith: REPOST (3/28/2017) Serial T-waves-OMI - October 23, 2022 -
• Pendell: The Rhythm? (Reentry SVT- RP' interval) October 25, 2022 -
• SSmith: Abused Medic (Pacer- ST Elevation-OMI) - October 28, 2022 - 
• SSmith: was "Reading EKGs" (Swirl vs LVH- T-QRS-D) November 1, 2022 -
• JesseM: 90yo with CP-Ab Pain (Diffuse Subendo Isch) November 4, 2022 -
• SSmith: Bizarre ECG (Pulse-Tap Artifact-V1,V2- ME) November 8, 2022 -
• Pendell: Elderly Woman (Simult. Leads-OMI-RBBB/LAHB) Nov. 11, 2022 -
• Emre Aslanger: Sometimes STEMI not Enough - November 13, 2022 -
• Pendell: Mistaken Ventricular Bigeminy (vs WPW) November 19, 2022 -
• Pendell: 70m CP — Subtle OMI (KEY is lead V3) - November 23, 2022 -
• SSmith: ST V1,V2-Trop 6500 (Brugada-Car Contusion) - Nov. 25, 2022 -
• Pendell: 20f - Pericardial Effusion/Low Voltage) - November 28, 2022 -
• SSmith: ED MD "Nothing much" (MINOCA- OMI) - November 30, 2022 -
• SSmith: Hyperacute T waves? (Pulse-Tap Artifact!) December 5, 2022 -
• JesseM: 65yo-Syncope (subtle- "Silent" OMI) - December 6, 2022 -
• SSmith: 60yo-Shock- Unusual "hyperacute" -RAD ECG- Dec. 10, 2022 -
• Pendell: On its Way from OMI to Reperfusion - December 12, 2022 -
• Pendell: Marked LVH and acute LAD OMI - December 14, 2022 -
• SSmith: WPW - Huge Delta Waves! (OMI?-DRichley) - Dec. 16, 2022 -
• Pendell: 70yo "Eye-Catching" ECG (Aortic Dissection) - Dec. 18, 2022 -
• Emre Aslanger: OMI (V1,V2,V3 off- post leads) - December 18, 2022 -
• Emre Aslanger: OMI vs STEMI Philosophy in Action! - Dec. 22, 2022 -
• SSmith: 30-something (subtle KEY Findings-OMI- ME) Dec. 23, 2022 -
• SSmith: A diagnostic OMI that may look "nonspecific" - Jan. 2, 2023 -
• Pendell: 50s,f- An OMI with Delay of Cath - January 6, 2023 -
• Pendell: A Teenage Male with CP (OMI in Young Pts) Jan. 9, 2023 -
• Pendell: 2 ECGs — Repol or OMI? (S. African Flag) January 12, 2023 -
• SSmith: Subtle OMI (LA-LL - V1,V2 - Serial ECGs-OMI) Jan 15, 2023 -
•    — (This post published again on June 25, 2024 ! ) —
• 
  
• SSmith: Pulse-Tap Artifact (Links to other artifact) - January 17, 2023 -
• JesseM: Hypothermia-Hypothyroid-Coma (BRogers) Jan. 21, 2023 - 
• Alex Bracey: The Hint from the ICD (Mirror Test-OMI) - Jan. 23, 2023 -
• KG: MY CASE — A Long AV Wenckebach Cycle - Jan. 26, 2023 -
• Pendell: CP in Middle-Aged F (Missed Acute OMI!) - Jan. 28, 2023 -
• JesseM: Dueling OMIs (ME: Not to Miss this OMI) - Feb. 1, 2023 -
• SSmith: Repost from 2020 (EMS ECG-Voltage cut! ) - Feb. 4, 2023 -
• Pendell: 60s Man/CP (I review why OMI missed!) - Feb. 6, 2023 -
• SSmith: What is ECG Diagnosis? (deWinter T-waves) Feb. 10, 2023 -
• SSmith: What Going On in V2,V3? (subtle RVH! ) - Feb. 12, 2023 -
• JesseM: Two 70s with CP (subtle OMI Findings) - Feb. 13, 2023 -
• SSmith: CP & Many C/O (short QTc- Hyper-Ca++) - Feb. 17, 2023 -
• Pendell: Man 40s, Ab Pain (Emery Phenomenon) - Feb. 23, 2023 -
• SSmith: Hyperacute T waves (Me) Hyper-K PEARLS) - Feb. 27, 2023 -
• Pendell: Anaphylax-CP-Diffuse Subendo Ischemia - March 1, 2023 -
• SSmith: CP & SOB — S1Q3T3 & Acute PE Dx - March 4, 2023 -
• SSmith: What to Think of ECG? (Me- Lots on OMI) - March 6, 2023 -
• Pendell: Man in his 50s (OMI-TQRSD- Errors !!!) - March 9, 2023 -
• SSmith: CP-Wellens on EMS ECG (Me- OMI) - March 13, 2023 -
• SSmith: Strange about this PAF? ( = Slow AFib) - March 15, 2023 -
• Pendell: 50yof with CP (Pulse-Tap Artifact) - March 17, 2023 -
• SSmith: 50yom with CP (Not a "Non-STEMI" !) - March 19, 2023 -
• Pendell: Teaching Others (Post OMI- Mirror) - March 21, 2023 -
• JesseM: OMI sent Home (SSmith on Troponin) - March 24, 2023 -
• SSmith: 40yo-OMI Delay (Mirror-leads III-aVL-RV) - March 27, 2023 -
• KG-SSmith: Puzzling rhythm? (MY Case- Mobitz I)- March 30, 2023 -
• SSmith: a STEMI-neg OMI (the PM Cardio APP) - March 31, 2023 -
•      — Great example of T-QRS-D in my comment …
• 
  
• SSmith: the PM Cardio APP (No OMI-abnl ECG-LVH) - April 2, 2023 -
• JesseM: 70yo- OMI Delay (ME details Why OMI) - April 4, 2023 -
• SSmith: Wenckebach + RBBB/LAHB (Trifascicular?) - April 6, 2023 -
• Pendell: OMI with flat ST-T waves & CP Hx - April 9, 2023 -
• Pendell: Man 60s: LVH-Strain vs Ant. OMI (Lead V4) - April 14, 2023 -
• Pendell: Compare Case #1 & 2 (LVH Fake-deWinter) - April 17, 2023 -
• JesseM: 50yo- "normal" ECG (Must correlate CP! ) - April 21, 2023 -
• SSmith: 25ish with CP (Myocarditis- Cardiac MRI) - April 25, 2023 -
• SSmith: 50yo CP (Post. OMI-Mirror - MY LINKS) - April 29, 2023 -
• Pendell: 60f- large T waves (subtle AFlutter- ME! ) - May 1, 2023 -
• KG-SSmith: An Unusual Bradycardia (MY Case) - May 5, 2023 -
• Pendell: 70m-CP (Pacer ECG - obvious STEMI) - May 8, 2023 -
• SSmith: 30f-Atypical CP-Neg CTCA (Wellens- ME!) - May 10, 2023 -
• SSmith: Strange ECG? (Missed LA-RA Reversal! ) - May 13, 2023 -
•     — Initially missed the LA-RA Reversal/Nl variant ST elev./T inv. —  
• 
  
• Pendell: 30s-m-CP (Not OMI - Pericarditis? - ME! ) - May 16, 2023 -
• SSmith: 45-m-jaw pain (OMI from Hx + ECG - ME! ) - May 18, 2023 -
• SSmith: Elder fall (Flecainide Toxicity-Wide QRS) - May 21, 2023 -
• Pendell: 40s,m-CP (OMI- Ignore Computer-V1,V6) - May 23, 2023 -
• SSmith: 20s-m (Verapamil OD-Laddergram-Mobitz I)- May 26, 2023 -
• SSmith: 50s- (RV MI-Shock- LA-RA Lead Reversal) - May 30, 2023 -
• SSmith: 67f- Acute Prox LAD OMI missed!-deWinter- May 31, 2023 -
• Pendell: 30s - Regular WCT- ARVC (not RVOT VT! ) - June 3, 2023 -
• SSmith: 40yo- Cardiology & computer missed OMI! - June 5, 2023 -
• SSmith: 50f- CP-Peaked T Waves- Not OMI! (V1,V2) - June 6, 2023 -
• 
  
•                         — I was on vacation ...  —
• 
  
• SSmith: DKA-Cardiomyopathy (Pt in a regular WCT) - June 23, 2023 -
• KG: MY CASE: Isorhythmic AV Dissociation/PACs - June 26, 2023 -
• SSmith: Young man Regular WCT (Antidromic AVRT) June 28, 2023 -
• SSmith: Texted 2 serial ECGs (Dynamic Repol/BTWI) - June 30, 2023 -
•      — for referencing Repol Variants showing "dynamic" change! —
• 
  
• SSmith: Texted Pt with CP (Bizarre ECG ==> HCM?) - July 5, 2023 -
• SSmith: Texted 80yo-CP-SOB-QOH (RVH-post MI?) - July 7, 2023 -
• SSmith: 60yo with CP (WHY it's Not OMI despite V3) - July 10, 2023 -
• SSmith: Reading ECGs (Pseudonormalization- OMI!) - July 12, 2023 -
• SSmith: 40yo-VFib (Post-ROSC ECGs- à la Shark Fin)- July 14, 2023 -
• KG: MY CASE (+SSmith)To Try Adenosine? (Sinus Tach) July 19, 2023 -
• Pendell: 70yo m-Syncope,Fever (Brugada Phenocopy) - July 22, 2023 - 
• SSmith: Mimic-Vertigo (ME - History needed for Interp! ) July 26, 2023 -
• SSmith: Inf. ST Dep (Amphetamines- Type II MI- LVH) - July 27, 2023 -
• Pendell: Post OMI (subtle Mobitz I — Ladder-PEARLS!) July 30, 2023 -
• MHellerman: OMI Pocket Guide (https://omiguide.org/)- Aug. 3, 2023 -
• SSmith: 1 Hour Lecture — Acute OMI by Dr. Smith! - August 6, 2023 -
• JesseM: 14 hrs of CP: Reperfusion T-waves (PVC ST) - Aug. 10, 2023 -
• Pendell: Subtle AFlutter-RVH (ME- Reg SVT-qR in V1) - Aug. 14, 2023 -
• JesseM: 75yo-No CP (Silent MI- OMI- 5 Problems-ME) - Aug. 19, 2023 -
• Pendell: 70f-CP-wax-waning (ME- Recognizing OMI) - Aug. 30, 2023 -
•       NOTE: I added Laddergrams re the Group Beating! — 
• 
  
• SSmith: 50s-CP- subtle OMI (ME- Lead V1 ST elev.) - Sept. 1, 2023 -
• SSmith: 50s-CP-OMI-890 (ME- Lead aVL T wave) - September 3, 2023 -
• SSmith: Artifact + computer neg — ME = acute OMI! - Sept. 5, 2023 -
• JesseM: 50yo in Remote place (OMI- Cards missed) - Sept. 8, 2023 -
• Pendell: Judge for Yourself (ME - OMI not NSTEMI) - Sept. 10, 2023 -
• SSmith: 40yo-Nonspecific Sx (short QTc- Hyper-Ca++) Sept. 12, 2023 -
• SSmith: 60yo - APTA (Arterial Pulse Tap Artifact) - September 15, 2023 -
• MagnusN: Acute Prox. RCA OMI (RV MI- Echo) - September 17, 2023 -
• SSmith: Regular WCT (AV Dissociation-Fusion) - September 20, 2023 -
• SSmith: Repol T Waves vs OMI (1 or 2 abnormal leads)- Sept. 22, 2023 -
• MagnusN: OMI-ECG Dx (not Morphine) the Problem - Sept. 24, 2023 -
• SSmith: Which Pt has More Severe CP? (OMI? )- September 26, 2023 -
• MagnusN: Shark Fin — then VT, AVRT (ME-Rhythm) - Sept. 27, 2023 -
• Pendell: Ectopic ATach — Emery — SVT Dx - September 29, 2023 -
• Pendell: Repost — Acute OMI that was Missed (ME !) - October 1, 2023 -
• MagnusN: Rhythm (AIVR usurps Mobitz I - LADDER)- October 3, 2023 -
• SSmith: "Culprit" Artery? (ME - on unusual deWinter) - Oct. 6, 2023 -
• MagnusN: Which Patient(s) Need Immediate Cath? - October 8, 2023 -
• MagnusN: What Scenario BEST? (ME-Takotsubo) - October 12, 2023 -
• SSmith: Was texted this ECG (ME- Subtle OMI ) - October 13, 2023 -
• Pendell: Did You See? (ME- Low Voltage-subtle OMI) Oct. 16, 2023 -
• SSmith: Repost- Oct. 13 (ME- Why QOH was Wrong) - Oct. 17, 2023 -
• MagnusN: 20yof — Takotsubo- (ME - Torsades !!! ) - October 18, 2023 -
• JesseM: 4 ECGs — Computer missed OMI !!! - October 19, 2023 -
• SSmith: 70m with Resp. Distress (ME — SVT vs VT)- October 21, 2023 -
• AlexBracey: Electrical & T-Wave Alternans (ME) - October 23, 2023 -
• Pendell: ETOH-Cipro-Lytes (ME- LIST- long QTc!) - October 25, 2023 -
• SSmith: AI YouTube Video (Drs. Kashou & Herman) - Oct. 26, 2023 -
• SSmith: 20ish HCM (Hypertrophic CardioMyopathy) - October 28, 2023 -
• SSmith: NSTEMI a Useless Term! (Lead V2 is KEY- ME)- Oct. 30, 2023 -
• SSmith: RBBB with ST up in V2 - ME (Need Info! ) - November 1, 2023 -
• SSmith: Man 70s — Died (deWinter T-Waves- LBBB) - Nov. 3, 2023 -
• MagnusN: Wide QRS Similar to Prior (ME- paced OMI) - Nov. 5, 2023 -
• SSmith: Intermittent LBBB (Memory vs Ichemia) - November 9, 2023 -
• SSmith: 90yo-CVA (bizarre ECG- not OMI, not Mobitz I)- Nov. 11, 2023 -
• SSmith: 62yo-CP (Serial and Old ECG invaluable! ) November 13, 2023 -
• SSmith: 70f-CP (Pos. Trop- Neg. Cath- MINOCA- ME! ) - Nov. 16, 2023 -
• SSmith: Dyspnea (RBBB- not PE but LV Aneurysm) - Nov. 18, 2023 -
• SSmith: 63m-DKA,Dyspnea (Aslanger's Pattern- ME! ) - Nov. 22, 2023 -
• JesseM: 45yo-CP (Serial ECG Changes but No OMI! ) - Nov. 27, 2023 -
• Pendell: 2 Similar ECGs (LVH-"Swirl"- Truncation- ME!)- Nov. 29, 2023 -
• AlexBracey: Teen with CP (OMI vs Myocarditis- Peds MI)- Dec. 5, 2023 -
• SSmith: LINK to WEBINAR on Acute OMI (My Comment)- Dec. 5, 2023 -
•   My Retrospective Comment on June 18, 2013 post (Dec. 6, 2023) -
• 
  
• WillyFrick: SCAD- LAD OMI (ME — 5 Serial ECGs) - December 7, 2023 -
• SSmith: 50yo-Syncope-No CP (Acute OMI mimic! ) - December 9, 2023 -
• WFrick: 70sf — intermittent CP (ME - Correlate Sx-ECG!) - Dec. 11, 2023 -
• SSmith: The Proportionality Concept (Low Voltage- ME! ) Dec. 13, 2023 -
• MagnusN: Suble OMI (Cabrera- ST Elev. only in aVL) December 16, 2023 -
• WFrick: T-QRS-D — MINOCA — Comparing ECGs-ME! - Dec. 19, 2023 -
• SSmith: Is there an OMI on this ECG? (LCx OMI- ME! ) - Dec. 22, 2023 -
• Pendell: Palpitations 20f (AFlutter @200/min- Schamroth) - Dec. 24, 2023 -
• SSmith: HOCM getting an Angiogram (ME- Apical HCM) - Dec. 26, 2023 -
• WFrick: False Reassurance from Repol. (ME- I see OMI! ) - Dec. 27, 2023 -
• JesseM: CP but "No Ischemic Changes" (ME- subtle OMI) - Dec. 30, 2023 -
• EAslanger: Use of Cannon Waves to diagnose VT-(ME!)- January 1, 2024 -
• Pendell: EMS told "No STEMI" (ME- comparing ECGs) - January 3, 2024 -
• WFrick: 3 Normal Troponins-CATH films! (ME- Morphine)- January 5, 2024 -
•                                    —  —  —  —  —  —  —  —  —   
• WFrick: RA-LL Lead — ME - LIST of Reversals - Artifacts - Jan. 6, 2024 -
•                                    —  —  —  —  —  —  —  —  —  
• SSmith: 40yof with CP & SOB (ME- acute PE ECG Dx) - January 8, 2024 -
• MagnusN: How to Manage this Pt? (ME- on Why VT!) - January 10, 2024 -
• WFrick: Atrial Pacing Troubleshooting (ME- FILTERs) - January 13, 2024 -
• WFrick: Noisy, Low Amplitude ECG (ME- ARTIFACT) - January 15, 2024 -
• JesseM: 2 Patients with CP (ME- My ECG "Mantras") - January 17, 2024 -
• Pendell: 30yom- CP dx'd as NSTEMI (ME- deWinter) - January 20, 2024 -
• MagnusN: "Slow- then Fast ..." (ME- Mobitz I vs II-Ladder)- Jan. 23, 2024 -
• SSmith: CP with LVH and known CAD (multivessel CAD) - Jan. 25, 2024 -
• JesseM: Should this "Nl" ECG Wait? (ME- definite OMI)- January 27, 2024 -
• SSmith: CP in 40yom (Benign Saddleback vs OMI?) - January 29, 2024 -
• SSmith: LV Aneurysm vs NOMI (ME- I can't be sure! ) January 31, 2024 -
• Pendell: What is this? (ME- Huge Osborn Waves!) - February 2, 2024 -
• SSmith: To implement QOH? (ME- OMI-Reperfusion) - February 4, 2024 -
• Pendell: Teenager trauma (ME- Cardiac Contusion) - February 6, 2024 -
•                                   —  —  —  —  —  —  —  —  —
• WFrick: Dyspnea in 90f (ME- PTA, Pacer- ARTIFACT) February 18, 2024 -
•                                   —  —  —  —  —  —  —  —  —
• SSmith: 10 OMI Cases Computer Called Normal (ME! ) - March 4, 2024 -
• SSmith: Irregular AIVR in GSW (Group Beating in AIVR! )- March 7, 2024 -
• 
  
• WFrick: Precordial Swirl (Fascicular Escape- Ladder) - March 22, 2024 - 
• MagnusN: VT in Patient with ARVD (ME- Epsilon waves) March 24, 2024 -
• SSmith quotes ME: Regular WCT that is not VT! - March 28, 2024 -
• Pendell: Another acute Post. OMI missed! (ME- Mirror)- March 31, 2024 -
• MagnusN: CP in Young Man (Acute Myocarditis-Cabrera)- April 11, 2024 -
• SSmith: RBBB/LPHB ( ME 11/12 leads = acute LAD OMI )- April 16, 2024 -
• JesseM: 70m-Bayes Theory= Hx is KEY (ME-PVC = OMI) - April 19, 2024 -
• SSmith: CP resolved: Need Cath? (ME- Wellens' Type A) - April 22, 2024 -
• Pendell: Outperform STEMI Criteria (ME- within seconds!)- April 27, 2024 -
• SSmith: What is the Rhythm? (ME- Hyper-K -neg T wave) April 30, 2024 -
• SSmith: Shock/Nasty ECG (LMain- Shark Fin- Rhythm?) - May 3, 2024 -
• SSmith: Young Man (orthodromic AVRT- AFib-WPW- ME) - May 8, 2024 -
• SSmith: Why in Shock? (RV MI-OMI- AIVR- 10-sec. Dx-ME) May 10, 2024 -
• Pendell: 60m- LAD OMI (Artifact-Filter- subtle ECG- ME) - May 18, 2024 -
• JesseM: OMI missed by Cards (3rd-deg to subtle Mobitz I ) May 27, 2024 -
• Pendell: 2 Patients — Neither is an OMI (I wasn't certain! ) - May 29, 2024 -
• MagnusN: Not OMI — but instead RVH! (ME) — May 31, 2024 -
• SSmith: 2 OMIs that were missed! (ME — AFlutter-Ladder)- June 3, 2024 -
• Magnus: Nl Cath and CP (MINOCA- vagotonic block) - June 5, 2024 -
• JesseM: Serial ECGs: What Sequence? (ME- Correlate!) - June 7, 2024 -
• SSmith:  Marked Hyper-K+ (ME- Is ECG #2 ARTIFACT? ) - June 10, 2024 -
• Pendell: OMI Missed (ME — Repol Mimic- Why OMI) - June 11, 2024 -
• SSmith: Malpractice on OMI missed! (ME- on Why/QOH)- June 13, 2024 -
• WFrick: Telemetry ARTIFACT !!! (ME - LIST !!! ) — June 15, 2024 -
• Pendell: Deadly Triage ECG Missed (ME- acute PE Table) - June 17, 2024 -
• SSmith: 82yo with pacer, shock (ME- Pt had Pericarditis!) - June 19, 2024 -
• SSmith: What to do for this Regular WCT (long RP' ?) - June 21, 2024 -
• W.Frick: VFib-Need an ICD? (ME- similar to Wellens? ) - June 23, 2024 -
• SSmith: Subtle OMI (LA-LL - V1,V2 - Serial ECGs-OMI) - June 25, 2024 -
•    — (This post previously published on Jan 15, 2023 ! ) —
• 
  
• Pendell: Syncopes, Pacer (ME- Complex AV Block) - June 27, 2024 -
• SSmith: Cardiac Arrest (LBBB/OMI- Pt needs Cath/PCI) - June 29, 2024 -
• WFrick: OMI in a Pt with Seizures? (ME- Bayes Theorem) - July 2, 2024 -
• SSmith: Reg WCT with 2:1 (ME- AFlutter-calipers-Dig) - July 5, 2024 -
• JesseM: Shows 2 Cases (ME- STEMI vs OMI Paradigm) - July 7, 2024 -
• Pendell: Precordial Swirl after VFib 890 (ME- on Swirl ) - July 9, 2024 -
• SSmith: Hans H Case — Bad Outcome (ME- Fam Med- OMI) July 11, 2024 -
• Pendell: 2 Cases of "Swirl" (ME- Deep Dive on 2 Cases) - July 14, 2024 -
• SSmith: 81m with CP — pseudo-ST elev. is 2:1 SVT- ME - July 16, 2024 -
• Pendell: 80m, Paced (ME- What Kind of Pacing? - OMI?) - July 19, 2024 -
• Magnus: Incessant VT (ME- LMCA on ECG; Quinidine) - July 21, 2024 -
• SSmith: EMS OMI not Seen (ME- Serial Comparison! ) - July 23, 2024 -
• KG: My 4 ECG/Rhythm Podcasts (for Anthony Kashou) - July 24, 2024 -
• SSmith: 890 from Drug O/D (ME- DSI- 2-Step ECG Interp) - July 25, 2024 -
• Magnus: Crochetage Sign- significant ASD (ME- Bayes) - July 28, 2024 -
• SSmith: 2 ECGs — Is there acute OMI? (ME- deep dive! ) - July 30, 2024 -
• WFrick: Ant. ST Elevation — Surprise Cath! (ME- RV MI) - August 2, 2024 -
• Pendell: What does this ECG show? (ME- Pericarditis! ) - August 4, 2024 -
• Magnus: 3 Pre-Hospital ECGs (ME- OMI-LBBB-Myocard)- August 6, 2024 -
• WFrick: 46m with CP (ME- OMI on AIVR, LADDER) - August 9, 2024 -
• JesseM: 75yo EMS-Acute LAD OMI (ME- Rhythm, OMI)- August 11, 2024 -
• WFrick: Disappearing P waves? (ME- SA Block, LADDER) Aug. 14, 2024 -
• Pendell: CP and a rare combination (ME- acute OMI-WPW) Aug. 16, 2024 -
• Pendell: Back to Basics (Pacemaker Malfunction- ME) - August 19, 2024 -
• SSmith: 69yo- CP- Sam Ghali (ME- RBBB,CABG- OMI)- August 20, 2024 -
• Magnus: Bizarre wide QRS (ME- Brugada-1; PMVT) - August 23, 2024 -
• SSmith: RUQ Pain- acute OMI- Tall R in V2; Women- ME- Aug. 26, 2024 -
• Magnus: "Seizures" in 30f (ME- QTc- long QT LIST! )- September 2, 2024 -
•     — Torsades de Pointes (How to spell? )
• 
  
• Magnus: Ventricular Septal Rupture (ME- "Silent" MI) - Sept. 5, 2024 -
• SSmith: 70m- Wellens' Syndrome (ME- Compare ECGs)- Sept. 7, 2024 -
• WFrick: LAD OMI- Cath films! (ME- Precordial Swirl)- September 9, 2024 -
• SSmith: Syncope-CPR (LV Aneurysm vs LAD OMI) September 11, 2024 -
• Pendell: RBBB- acute LAD OMI (ME- on Serial ECGs) - Sept. 13, 2024 -
• Magnus: Pause-dependent Torsades (ME- Ashman)- Sept. 16, 2024 -
• SSmith: Neg Cath-no R/O OMI-IVUS (ME- Spasm? )- September 18, 2024 -
• SSmith: Syncope during Exercise (ME- SVT at 280/min) - Sept. 20, 2024 -
• WFrick: ST Elevation in III,aVR,V1 (ME - Acute PE)- September 23, 2024 -
• Hans/SSmith: Cardiologys says "Normal" (ME- Errors! ) - Sept. 25, 2024 -
• JesseM: 45yo woman (ME- hyperacute T, OMI - SCAD) - Sept. 27, 2024 -
• SSmith: 50yo VFib (ME- Predict "culprit" not academic) - Sept 29, 2024 -
• KG: MY CASE: (VT in a Sick Patient? = Sinus Tach) - October 1, 2024 -
• SSmith: CP in a 30yo m (Looks like no OMI = "Fake" ) - October 3, 2024 -
• SSmith: Belgium Case (ME- acute Post-Lat OMI) - October 6, 2024 -
• SSmith: How Terrible Not to Recognize OMI (ME- Ant OMI)- Oct. 8, 2024 -
• Pendell: If QOH was available (ME- interplay Post-RV OMI) - Oct. 10, 2024 -
• BNichols: 91m (ME- No OMI-Osborn-flat II- RA-RL Reversal) Oct. 12, 2024 -
• SSmith: Which of 2 Patients Need Cath? (ME- OMI or Not?) - Oct. 15, 2024 -
• JesseM: CP & RBBB - OMI? (ME- ST segment baseline?) - Oct. 17, 2024 -
• Magnus: ME- DSI evolves to complete LMain Occlusion! - Oct. 20, 2024 -
• SSmith: Dr. Peyronie-FR. (ME-Repeat the ECG-acute OMI)- Oct. 22, 2024 -
• Pendell: Computer misses long QTc (ME- flat long QTc-QU)- Oct. 24, 2024 -
• SSmith: Prehosp Activation — Deactivated! (ME- acute OMI)- Oct. 27, 2024 -
• Magnus: 6 Patients with CP + Saddleback STE- OMI? (ME) Oct. 30, 2024 -
• SSmith: Thrombolytic to Treat this NSTEMI (ME-Rhythm-OMI) Nov. 1, 2024 -
• Magnus: NSVT-Echo Beats-Retrograde (ME-LADDER) November 4, 2024 -
• Magnus: Baseline Wander/Artifact (ME-acute OMI-Artifact!) - Nov. 8, 2024 - 
• Pendell: 70f awakened from Sleep (Test recognizing OMI!)- Nov. 10, 2024 -
• WFrick: How Dangerous this ECG? (Mobitz I vs Mobitz II?) Nov. 12, 2024 -
• SSmith: Prehosp Cath Lab Activation (ME- Missed OMI !!! ) Nov. 14, 2024 -
• WFrick: Simulates BTWI (ME- OMI - not BTWI- 9 Criteria) - Nov. 17, 2024 -
• SSmith: Will Smoot Case (ME- acute OMI; Cards missed!)- Nov. 19, 2024 -
• Pendell: 40f with SOB/CP (ME- acute PE; ant. T inversion) Nov. 21, 2024 -
• SSmith: APTA + very high Trop (ME- Artifact; PVC = OMI) - Nov. 23, 2024 -
• SSmith: 30 Examples- HYPERACUTE T waves (ME!) November 27, 2024 -
• WFrick: Recent MI at Other Facility (ME- subtle new OMI) - Nov. 29, 2024 -
• JesseM: 4 Patients with Inf. STE- OMI? (My Opinion)- December 1, 2024 -
• SSmith: 10 Serial ECGs (ME- subtle OMI- Mobitz I; not II)- Dec. 3, 2024 -
• SSmith: Deflating T Waves (ME- amazing evolution!)- December 6, 2024 -
• Pendell: Older woman-CP (ME- OMI, interesting ECG) December 10, 2024 -
• Magnus and ME — WPW with rapid AFib! (IV Amio) - December 13, 2024 -
• SSmith: CT- Dissect Aneurysm (ME- HT crisis/ Ant. STEMI)- Dec. 16, 2024 -
• WFrick: Chest Pain & Rapid Pacing (ME- Pacing!-LADDER)- Dec. 20, 2024 -
• WFrick: How Good Your Memory? (subtle OMI- 3/13/2024) - Dec. 22, 2024 -
• WFrick: Comfortable with Transcutaneous Pacing? (ACLS) Dec. 24, 2024 -
• WFrick: Palpitations in Cardiology Clinic (ME- VT/AV Diss) - Dec. 27, 2024 -
• SSmith: Dizziness in 40yo (Hyperacute T Waves? Not! ) - Dec. 29, 2024 -
• Pendell: DSI in pt. with CP- Aslanger? (ME- DSI Causes) - Dec. 31, 2024 -
• SSmith: Sepsis, LBBB-Torsades (ME- QTc- wide QRS?)- January 2, 2025 -
• WillyF: 60yo CP OMI with AIVR (ME- LADDER; Fusion) - January 5, 2025 -
•     — includes example of “wrong-vessel PCI” (importance of ECG !!!) —
•  
• Arron Pearce — Excel QTc Calculator (for wide QRS) - January 8, 2025 -
• SSmith: 26yo- Syncope, CP, ST Elev (ME- Repol Changes)- Jan. 9, 2025 -
  
• Pendell: Must Recognize! (LAD OMI- shark fin Technique)- Jan 11, 2025 -
• SSmith: 50yo- CP, Pneumonia (ME- Brugada Phenocopy) - Jan. 13, 2025 -
• SSmith-Hans Helseth: What is a "Normal" ECG? (OMI ) - Jan. 15, 2025 -
• SSmith: South African Flag Sign (reperfusion T waves) - Jan. 18, 2025 -
• SSmith: Type II MI or STEMI? (ME-Rhythm? -LBBB-OMI) - Jan. 21, 2025 -
• Hans: 76m- LBBB and Acute STEMI (ME- qualitative)- January 23, 2025 -
• WillyF: 52m- CP (ME- OMI missed! - Precordial Swirl)- January 24, 2025 -
•      — SSmith gives data as to Harm from Waiting with OMIs! —
• 
  
• Magnus and ME: AFlutter- 1:1-Flec (Dual-Level LADDER)- Jan. 26, 2025 -
• Hans Helseth: 34yo with CP (ME- OMI missed! - Delay) - January 28, 2025 -
• Magnus: "Must Know" ECG = deWinter T-Waves (ME) - January 31, 2025 -
• Pendell: 60s man-VFib in ED (ME - LVH- Lead Overlap)- February 2, 2025 -
• WillyF: Syncope & a short Pause (ME- PAVB, Pacing)- February 4, 2025 -
• Magnus: 50yo unusual idiopathic VT? (ME- Review) - February 6, 2025 -
• JesseM: NSTEMI vs Reperfused (ME- missed Findings!) - Feb. 8, 2025 -
• JesseM: To treat 80yo with K+ = 6.2? (ME- ECG-HyperK+)- Feb. 10, 2025 -
• WillyF: Psych. of Acute MI (ME- LVH,"strain"-not OMI)- February 12, 2025 -
• Pendell: 30m with "burning" pain (ME- not OMI; rSR's' V1)- Feb. 14, 2025 -
• WillyF: Is it Pericarditis? (ME- acute OMI- Errors ... )- February 16, 2025 -
• WillyF: subtle Hyperkalemia (ME- low Ca++/Lessons!) - Feb. 18, 2025 -
• SSmith: PEA Arrest — acute MI Mimic (ME-ECG in SAH)- Feb. 20, 2025 -
• Magnus: 85yo- SOB (ME- post-MI Pericarditis- Rupture) - Feb. 26, 2025 -
• SSmith: "Pay Now or Pay Later" (ME-OMI missed/Errors)- March 1, 2025 -
• Hans Helseth: OMI missed! (ME- Inf-Post OMI missed!) - March 3, 2025 -
• Pendell: What is the Rhythm? (ME- I review WCT = VT !) - March 6, 2025 -
• WillyF: 60f- MVA, hubby died (ME- Broken-Heart CM) - March 8, 2025 -
• Hans Helseth: Cards overlooks (ME- isolated post OMI)- March 10, 2025 -
• JesseM: 50yo- new CP (ME- What is "normal" ECG?) - March 12, 2025 -
• Magnus: CP-OMI (ME- serial ECGs- Don't Give MS! ) - March 14, 2025 -
• WillyF: 60s man (ME- multiple Errors-OMI- GREAT! ) - March 17, 2025 -
•        — Cath not impressive (Need intravscular imaging! )
• 
  
• JesseM: 84yo (ME- post. OMI not NSTEMI- Mirror ) - March 19, 2025 -
• Pendell: 40m- CP (ME- OMI missed- "good chart") - March 23, 2025 -
• WillyF: Localize the "Culprit"? (ME-Basics-Artifact-OMI)- March 25, 2025 -
• SSmith: Missed, even in Retrospect (ME-Compare ECGs) March 27, 2025 -
• WillyF: ST Dep on ECG? (ME- Spasm? When to Cath?) March 30, 2025 -
• SSmith: Wellens' not Repol! (ME- 30yo aa male!) - April 2, 2025 -
• JesseM: Refractory CP (ME- multiple Errors!- LAD OMI) - April 4, 2025 -
• SSmith: Katie B Case — Shock (ME- missed Rhythms) - April 6, 2025 -
• SSmith: Ant. STEMI-VFib (ME- R-on-T, RBBB,Lidocaine)- April 9, 2025 -
• SSmith: We must Advocate for Our Pt (ME- post. OMI) - April 11, 2025 -
• SSmith: Young man with MINOCA (ME-EMS ECGs-OMI )- April 13, 2025 -
• Pendell: 40f, CP (ME- OMI, Rhythm?- RA-RL- Rhythm?)- April 16, 2025 -
• 
  
• Hans Helseth: 84yo- missed OMI (Me-Masquerade (MBBB)
•      — Rhythm with PVCs, Fusion - PVC with ST Elev - April 18, 2025 -
• Pendell: Elderly Pt (ME- Alternans- Pericard Effusion)- April 21, 2025 -
• Hans Helseth: 59m- Hypothermia (ME- ECG-shivering)- April25, 2025 -
• SSmith: Repost- 3/28/2017 (ME- LAD OMI-Hyeracute) - April 27, 2025 -
• Hans Helseth; Junctional Tach vs slow AVNRT- ME) - April 30, 2025 -
• SSmith: Drew's Case (ME- OMI-Great on Serial ECGs!) - May 2, 2025 -
• Hans: "Nl" ECG- persistent CP (ME- Is ECG "Normal"?) - May 4, 2025 -
• SSmith: Seizures & Tachy (ME- Na-Channel Blockade) - May 6, 2025 -
• SSmith: 70m with Fall, Hip Fx- No CP (ME- "Silent" MI) - May 8, 2025 -
• SSmith: Repost from 6/23/2014 (ME- Inf OMI-LADDER) May 10, 2025 -
• Pendell: 60sw — CP (ME- RBBB-LAD OMI, not WPW!)- May 13, 2025 -
• Magnus: Young Male- Pathologic ECG (ME- on BTWI) - May 15, 2025 -
• SSmith: CP; Neg hs-Troponin (ME- ECG not "Normal")- May 17, 2025 -
• Mark Hellerman: Spot this ECG Finding? (ME- LVH, OMI)- May 19, 2025 -
• Magnus: subtle S. African Flag (ME- Effect of Artifact! ) May 21, 2025 -
•     (Great Refs by SSmith on benefits of EARLY vs late PCI !!! )
• 
  
• WillyF: AFlutter + Dual-Level Wenckebach-LADDER) - May 24, 2025 -
• WillyF: 90m-Shoulder Pain (ME- OMI- Lessons re ETT!)- May 26, 2025 -
• SSmith: 30f- obvious missed OMI (ME- prox. LAD OMI) - June 5, 2025 -
• SSmith: Known HOCM- new CP! (ME- OMI despite LVH!)- June 7, 2025 -
• WillyF (Evan's Case): 41m (ME- OMI, unclear details) - June 10, 2025 -
•       — has LINKS to "magic" leads III-aVL reciprocal relationship —
• SSmith: 60m-CABG- new CP (ME- fast Dx of post. OMI)- June 12, 2025 -
• Pendell: 50f- sudden CP (ME- pure Pericarditis- ECGs!)- June 15, 2025 -
• WillyF: 40s man- Anteroseptal ST Elev (ME- acute RV MI)- June 17, 2025 -
• 
  
• 
  
• = = = = = = = = = = = = = = = = = =
•   — TRANSITION to the WORDPRESS SITE (6/23/2025) —
• = = = = = = = = = = = = = = = = = =
• SSmith: Excellent OMI Care (ME- acute prox. LAD OMI) - June 25, 2025 -
• SSmith: Emily Dawra Case (ME- Precordial "Swirl" ) - June 27, 2025 -
• JesseM: 65yo-CP in Dialysis (ME- Aslanger's, IVCD, and
•      use of simultaneously-recorded leads for Rhythm) - June 29, 2025 -
• WillyF: 40s man-10/10 CP (ME- "Swirl"- dynamic ST-T) - July 1, 2025 -
• Magnus: Dx after 20 Years!- not Sz! (ME- CPVT, WPW) - July 3, 2025 -
• SSmith: Regular WCT — (ME- RVOT VT- Idiopathic VT) - July 5, 2025 -
• JesseM: 75yo: 6 Reasons "Not to Cath" (ME-OMI missed) July 7, 2025 -
•     — Great REF for nl 1st, 2nd Trop; STEMI sensitivity- "dynamic"
• 
  
• Pendell: 40m EMS OMI (ME- lead V3 hyperacute-OMI) - July 9, 2025 -
• Magnus: 70f — Long QT Synd (ME- QTc-T/U Alternans) July 12, 2025 -
• Pendell: EMS very wide QRS (ME- HyperK+ ) - July 14, 2025 -
• Emerson Floyd: Acute OMI in a "STEMI World" (ME- OMI)- July 16, 2025 -
• SSmith: An OMI that is a STEMI! (ME- Oversights! ) - July 19, 2025 -
• SSmith: CP and a Fast Rhythm (ME- WCT, Abnl ECG!) - July 21, 2025 -
• Pendell: CP & ST Elev-Cath Lab? (ME- Artifact LIST) - July 23, 2025 -
• SSmith: 70f — CP, ST Elev. (ME- RBBB- needs Cath! ) - July 26, 2025 -
• Magnus: Can You Guess Dx? No Hx. (ME- acute PE! ) - July 28, 2025 -
• Magnus: 87m with CP (ME- acute OMI should see!) - July 30, 2025 -
• SSmith: Cody Pinnow- ETTs (ME- OMI not recognized)- August 1, 2025 -
• SSmith: Accuracy of Cath Lab Activation (ME- QOH)- August 3, 2025 -
• SSmith: Will Smoot case- Neg 1st Trop (ME- acute OMI) - Aug. 5, 2005 -
• Magnus: 35f — post-ROSC ECG (ME-Shark-Fin - VFib) - Aug. 8, 2025 -
• JesseM: 75yom- new CP (ME- OMI-"Swirl"-new RBBB) - Aug. 10, 2025 -
• SSmith: 30m- agitated (ME- regular SVT = Sinus Tach! ) - Aug. 13, 2025 -
• SSmith: 40sm- Cough,SOB,CP (ME- hyperacute? No ) - Aug. 15, 2025 -
• Pendell: 60sm- Acute CP: Swirl? (ME- Nl cath; HCM? ) - Aug. 18, 2025 -
• SSmith: VFib Arrest-HyperK+ (ME- HyperK masks OMI)- Aug. 22, 2025 -
• SSmith: New CP in 15yo (abnl ECG- Trop 11,000- Dx?)- Aug. 25, 2025 -
• SSmith: Severe CP, 50sw (Wellens'-like ECG; Nl Trop) - Sept. 5, 2025 -
• Magnus: 80m- CP, LBBB (ME — acute OMI! ) - September 8, 2025 -
• SSmith: 89w-CP radiating to Back (Aortic Dissect-OMI)- Sept. 10, 2025 -
• Emerson Floyd: 80m- 5 Lessons (ME- prox LAD OMI) - Sept. 13, 2025 -
•                     — LA-RA Lead Reversal ... —
• 
  
• SSmith: Brady Preg ECG (ME-RBBB/LAHB-acute OMI) - Sept. 15, 2025 -
• WillyF: 60sm — Is this Real or a "Fake"? (ME- not OMI)- Sept. 18, 2025 -
• SSmith: 70sm- SOB: Can AI make Dx? (ME- AFlutter) - Sept. 21, 2025 -
• SSmith: 21m- "Viral Syndrome" (ME- ECG = Acute PE!)- Sept. 23, 2025 -
• WillyF: Rapid SVT- Dx? (ME- 1:1 AFlutter/Flec/Adeno) - Sept. 26, 2025 -
• Pendell: 30sm - recurrent Pericarditis! - (ME- Review) - Sept. 28, 2025 -
• Magnus: 90m- new CP (ME- deWinter-RBBB-compare) - Oct. 1, 2025 -
• Magnus: 77m- Apical HCM with minimal Voltage- ME) - Aug. XX, 2025 -
• Magnus: 87f- Pacer Troubleshooting (ME- Pacer/Filter) - Aug. XX, 2025 -
• 
  
• WillyF: Emergent Cath (ME-"magic" leads III-aVL- OMI) June XX, 2025 -
•       — monomorphic VT usually due to "scar" (not ischemic!) —
• 
  
• SSmith: 50f- Some OMIs are Atypical (ME- bizarre ECG)- May XX, 2025 -
•  — This was Dx'd as no ischemia. Can be a big problem! NOT Yet! —
• 
  
• SSmith: 34 wks Pregnant (ME- ECG Dx/Rx of new AFib) May XX, 2025 -
• 
  
•       

  

NOT USING (12/8/2024):

• SSmith: REPOST (6/17/2016) Truncated EMS ECG - Sept. XXX, 2022 -
• 
  
•               

 

-------------------------------------------