Sunday, October 29, 2017

ECG Interpretation Review #143 (ECG Guru - Dawn Altman - Dr. Stephen Smith)

     One of the reasons why I have decreased the frequency of my own ECG Blog posts — is that for the past few years I have actively been commenting on Dawn Altman’s ECG Guru site — as well as on many of the wonderful ECG posts put forth by Dr. Steven Smith on his most excellent blog site. 

For those desirous of additional sources of detailed ECG commentary — I suggest you check out:
I’ve attached below links to more recent posts from both of these sites for which I’ve left detailed commentary. For anyone with a real “passion” for ECG/Arrhythmia interpretation — reading through these posts ought to keep you busy for a good while. Happy reading!
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Note: Below the Figure from Dawn’s most recent Instructors’Collection ECG. I’ve added my labels in Figure-1. Detailed commentary by me supplements Dawn’s initial interpretation. Enjoy!
Figure-1: ECG from a 75yo man with new chest pain. How would you interpret this ECG? What is the “culprit” artery? Do you need the bottom ECG to tell? And, WHAT is the rhythm?
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Figure-2: Addition of labels to Figure-1 (Please CLICK HERE for my detailed analysis of this case).
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For MECG Guru Comments:
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For My Comments on Dr. Steve Smith's Blog:
  • Chest Pain & Flu (STEMI vs Localized Myocarditis)  March 18, 2016 -
  • Acute Prox LAD Occlusion (RBBB/LAHB- Lambda) — March 21, 2016 -
  • Pathognomonic ECG (long QT, peaked T — Ca++) — March 24, 2016 -
  • Acute LMain Occlusion (ECG recognition) — March 26, 2016 -
  • Acute STEMI despite Permanent Pacing — April 2, 2016 -
  • Resuscitation Pearls / LCx vs RCA "Culprit" — April 17, 2016 -
  • DeWinter-like T waves — Should NOT be Missed! — April 20, 2016 -
  •    10 Examples to TEST Recognition (Ant. T Waves) — April 23, 2016 -
  •    10 Examples of Inferior Hyperacute T Waves — May 1, 2016 -
  • ECG Distinction between Acute Pvs Chronic RVH — May 27, 2016 -
  • Fusion, Capture beats: "2 Wrongs may make a Right" — June 3, 2016 -
  • RBBB and SElevation (new STEMI vs LAneurysm) — June 6, 2016 -
  • Hyperacute Inferior T Waves or Reciprocal SChanges — June 10, 2016 -
  • Anterior STEMI vs Benign Early Repolarization? — June 17, 2016 -
  • The Computer Missed WPW (re the Concertina Effect) — June 20, 2016 -
  • Terminal QRS Distortion with Acute LAD Occlusion — June 24, 2016 -
  • Acute Inferior STEMI — or IIt? — July 1, 2016 -
  • Acute Anterior Stemi, Saddleback, Early Repol? — July 8, 2016 -
  • Convex SElevation not due to STEMI — July 14, 2016 -
  • WCT in a 12-Year Old — July 20, 2016 -
  • ST Elevation in V1,V2 — RV MI, Brugada or Hyper-K ? — July 24, 2016 -
  • Bifascicular vs Trifascular Block / Acute Changes? — July 30, 2016 -
  • Proportionality of ST-T and the QRS (Ant. STEMI ) — August 5, 2016 -
  • Is this Brugada-1 or a Saddleback? (syncope) — August 10, 2016 -
  • Bidirectional VT vs AVNRT with Alternating RBBB? — August 25, 2016 -
  • RVH vs RBBB vs Both? — Acute PE? (large RV on Echo) — Sept. 1, 2016 -
  • Subtle LCOcclusion or Not? — Sept. 4, 2016 -
  • LAD Occlusion vs Early Repol (interpolated PVC) — Oct. 18, 2016 -
  • Right Precordial T Wave Inversion (benign) — Dec. 5, 2016 -
  • Changing ST Elevation Distribution (Spasm) — Dec. 7, 2016 -
  • Computer Reads "Non-specific" Abnormalities — Dec. 10, 2016 -
  • Cabrera Format at 50mm/sec (a patient with chest pain) — Dec. 29, 2016 -
  • LVH with Marked SDepression + Chest Pain — Jan. 6, 2017 - 
  • Wide Tachycardia with Cyanosis (VT vs SVT ...— Jan. 10, 2017 -
  • LBBB, Chest Pain and Evolving ST-T Changes — Jan. 20, 2017 -
  • Fast SVT in a Child (rate ~220/minute) — Jan. 22, 2017 -
  • Cocaine Overdose and Brugada ECG Pattern — Jan 25, 2017 - 
  • Group Beating & Hyperkalemia (Brugada Phenocopy) — Jan. 27, 2017 -
  • Use of the ECG with Severe DKA (U waves) — Feb. 2, 2017 -
  • Inferior MI, LVH or Both? (a patient with chest pain) — Feb. 5, 2017 -
  • ST Elevation, Neg Troponin but NOT Early Repol! — Feb. 10, 2017 -
  • Subtle Use of Smith-Sgarbossa Criteria with LBBB — Feb. 20, 2017 -
  • Unstable WCT not responding well to Cardioversion — Feb. 23, 2017 -
  • 40yo Man with Chest Pain and "Funny" ST-T Waves — March 1, 2017 -
  • Another 40yo Man with Chest Pain (recurring "theme" ) — March 3, 2017 -
  • Impending LAD Occlusion (recognizing subtle Wellens) — March 9, 2017 -
  • Do Computerized Interpretations Miss Acute STEMIs? — March 10, 2017 -
  •   — Related Post: EMS 12-Lead (on Triaging ED ECGs) — March 11, 2017 -
  • VT vs SVT with Aberration in a 20yo with DKA - March 17, 2017 -
  • T Peaking and "Pseudo-Infarction" with Dehydration - March 19, 2017 -
  • Alternating Fascicular Block Aberrancy (and LSFB! ) - March 31, 2017 -
  • RBBB with Transient ST Elevation (Rhythm?) - April 2, 2017 -
  • Acute or Recent Anterior MI vs LAneurysm? - April 21, 2017 -
  • 16yo Girl with Overdose: LBBB vs WPW? - April 23, 2017 -
  • 40yo Woman with Chest Pain (KEY subtle findings! ) - April 27, 2017 -
  • LVH Pseudo-Infarction Pattern vs Wellens? - May 3, 2017 - 
  • ST Elevation in V1,V2 in a Patient with LVH - May 6, 2017 -
  • TQRSD (Terminal QRS Distortion) - May 13, 2017 - 
  • Dialysis Patient with Bradycardia ... - May 18, 2017 -
  • Acute STEMI in a post-Op Paced Tracing - May 19, 2017 -
  • "Busy at Triage" (subtle-but-real LCx signs ... ) - May 26, 2017 -
  • Chest Pain, GE Reflux and Subtle ST-T Wave Changes - May 29, 2017 -
  • ST Elevation with Reciprocal Change due to ? (MI vs K+?) - June 1, 2017 - 
  • Peaked T Waves in 35yo with DKA/Something Else? June 17, 2017 -
  • Peaked T waves in a 20yo. Anything Else? - June 21, 2017 - 
  • Pulmonary Edema on Echo + Interesting ECG LVH - July 7, 2017 -
  • Subtle ECG Changes in an 82yo with Syncope - July 12, 2017 -
  • The Computer says, "AFib". Do you agree? - August 11, 2017 - 
  • Effect of Adenosine on this Rhythm? (AFlutter? ) - August 23, 2017 -
  • To Thrombolyse after 15 Hrs of Chest Pain? - Sept. 1, 2017 -
  • DeWinter T Waves / AIVR - Sept. 24, 2017 - 
  • A 30yo Woman with Chest Pain. Is her ECG Normal? - Sept 30, 2017 -
  • VT or Supraventricular with LBBB? - Oct. 14, 2017 -
  • Syncope in an Elderly Man ( ? Wellens ? Oct. 25, 2017 -
  • Chest Pain but a Non-Diagnostic ECG ... Nov. 1, 2017 -
  • How to Convince the Cardiologist ??? - Nov. 6, 2017 -  
  • Chest Pain & a "Normal ECG" by Computer Report - Nov. 10, 2017 - 
  • 50yo with Chest Pain (Concept of "Competing Conditions") - Nov 15, 2017 - 
  • 30yo with Chest Pain and this ECG (S1Q3T3; IRBBB,ST) - Nov. 22, 2017 - 
  • About the QTc Interval (Using the Rule of Thumb for QTc) - Nov. 24, 2017 - 
  • RBBB, Missed Occlusion on ECG, What is the Rhythm? - Nov 25, 2017 - 
  • Subtle Abnormality in a 54yo with Chest Pain - Nov. 27, 2017 - 
  • Post Cardiac Arrest ECG (Acute MI vs something else?) - Nov. 30, 2017 
  • Why the Inf. ST Depression? What's the Rhythm? - Dec. 1, 2017
  • 30yo with Pulmonary Hypertension and this ECG - Dec. 13, 2017 -
  • Challenging Wide Rhythm (Syncopal patient) - Dec. 16, 2017 -
  • Wellens' ST-T Waves or Something Else? - Dec. 18, 2017 -
  • Serial Tracings tell the Tale (Cancellation Effect) - Dec. 23, 2017 -
  • Not a "STEMI", but NOT Normal! (Ed Burns, LITFL) - Dec. 27, 2017 -
  • Subtle Findings in a Patient with Chest Pain - Dec. 29, 2017 -
  • There is nothing subtle about this ... Right? - Jan. 2, 2018 - 
  • Acute MI or Something Else? - Jan. 5, 2018 -
  • SElevation: STEMI vs Early Repol vs Pericarditis? - Jan. 8, 2018 -
  • Use of Terminal QRS Distortion (acute stemi- AIVR) - Jan. 11, 2018 -
  • Chest Pain and ST Elevation (old inf MI? Pericarditis?) - Jan. 17, 2018 -
  • Repolarization Variant? LVH? and/or Acute STEMI? - Jan. 24, 2018 -
  • STEMI? Need for Acute Cath? — or Not? - Jan. 26, 2018 - 
  • The Importance of Comparison Tracings (subtle! ) - Jan. 28, 2018 -
  • Artifact in a Dialysis Patient (Not hyperacute ST-T ! ) - Jan. 30, 2018 -
  • Subtle Changes in a Patient with CP (but no doubts! ) - Feb. 1, 2018 - 
  • Acute LCOcclusion despite Non-Diagnostic ECG! — Feb. 5, 2018 -
  • Cardiac Trauma — Now ST Elevation (on Pericarditis) — Feb. 7, 2018 -
  • LBBB + CP — Is there Acute Coronary Occlusion? - Feb. 11, 2018 - 
  • Subtle Abnormality (in leads III,T inversion in aVL) - Feb. 15, 2018 -
  • What's the Temperature? (from an unresponsive woman) - Feb. 19, 2018 -
  • Hyperacute ST-T Waves in an evolving STEMI - Feb. 22, 2018 -
  • RBBB with Subtle Ischemic Changes ... - Feb. 24, 2018 -
  • Diffuse SDepression + SElevation in aVR - Feb. 28, 2018 -
  • Anterior ST Elevation: To Activate or Not? - March 5, 2018 -
  • Alcohol Withdrawal + a very Long QTc - March 8, 2018 -
  • Seizure + a somewhat long QTc Interval - March 9, 2018 - 
  • A Pattern To Recognize! ( = Acute PE! ) - March 12, 2018 -
  • LBBB Criteria Redefined? Acute STEMI? - March 14, 2018 -
  • Not Wellens, but V1,V2 Too High on Chest March 16, 2018 -
  • STEMI vs Pericarditis/Early Repol - May 14, 2011/March 18, 2018 -
  • SVT & Retrograde Atrial Activity (AVNRT vs AVRT?) - March 20, 2018 -
  • You had 2 Hours to Save this Patient (missed STEMI ) - March 24, 2018 -
  • Tale of 2 STEMIs- Step-by-Step (computer report) - March 27, 2018 -
  • NOT an OMI despite HUGE Anterior S Waves! (Superb! ) - April 4, 2018 -
  • Regular Wide Tachycardia due to HyperKalemia! - April 6, 2018 - 
  • ST Elevation + Hyperthyroidism + LVH + Repol April 9, 2018 - 
  • U Wave Inversion — Clinical Significance ... - April 14, 2018 -
  • RBBB with HyperKalemia — Anything Else? - April 16, 2018 -
  • Pseudonormalization of ST-T wave and QRS changes - April 20, 2018 -
  • Subtle Hyperkalemia on Serial ECG Findings ... April 22, 2018 -
  • Isolated ST Elevation in aVL (cardiac spasm) - April 23, 2018 -
  • Cardiac Arrest / "Shark Fin" SElevation (Me on ETT ) - April 25, 2018 -
  • Abnormal T (U) Waves in an Alcoholic - May 4, 2018 -
  • Fascicular VT vs Bundle Branch Reentrant VT - May 8, 2018 -
  • ADissociation in a Young Man (AV block? ) - May 11, 2018 -
  • Isolated Posterior STEMI (Mirror Test - LCx) - May 19, 2018 -
  • Cardiac Arrest and an Abnormal 12-Lead (RVH/LVH) - 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 Wave Changes! (Acute MI) - May 29, 2018 - 
  • Repost of this 2015 WCT Rhythm: Ithe QRS Wide??? - May 30, 2018 -
  • LBBB with LA-LLead Reversal + Suble ST Changes - June 4, 2018 -
  • Bradycardia, Wide QRS, Pointed T, Hypotension (artifact) - June 6, 2018 - 
  • Is the QRS really so Wide? (shark fin) - June 11, 2018 - 
  • Inf. STEMI vs Constrictive 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, modified Sgarbossa, Qualitative ST-T Changes - June 22, 2018 -
  • Does this ECG help Manage Insulin Overdose? (low K+) - June 24, 2018 -
  • Early Repol vs OMI vs Pericarditis (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 the Diagnosis! - July 3, 2018 -
  • Slower-than-Expected AFib + Syncope (about SSS!) - July 5, 2018 -
  • When Should the OMI Dx have Been Made? - July 8, 2018 -
  • Acute 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 -
  • ECG Findings of Hypokalemia — and — Anything Else? - July 22, 2018 -
  • ECG Findings of Hyperkalemia (Eiffel Tower/Rhabdo) - July 24, 2018 -
  • Is there ST Elevation? (Acute PE/Simultaneous Leads) - July 26, 2018 -
  • Paramedic recognition of subtle OMI (V1,2 malposition) - July 28, 2018 - 
  • Limb Lead and Chest Lead Misplacement (Recognition!) - July 29, 2018 -
  • CP in 30yo Woman (Subtle Abns in 11/12 leads/Compare) - July 31, 2018 -
  • Regular SVT — How to Diagnose AFlutter? - August 3, 2018 -
  • Regular WCT with an LBBB-like Pattern ... August 5, 2018 -
  • A 13yo with SOB (WPW - arrhythmias - localization) - August 7, 2018 -
  • Lots of SElevation: Repol vs STEMI? ("mirror-image"August 9, 2018 -
  • Acute LMain Occlusion! — and a subtle initial tracing ... - August 30, 2018 -
  • 2 Occlusions (Good and less good ECG interpretation ... ) - Sept. 2, 2018 -
  • Reverse Takotsubo and an Unusual ECG - Sept. 4, 2018 -
  • Subtle Post-Lat OMI (LCx) + Vwith ADiss/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 -
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