tag:blogger.com,1999:blog-3364570834099131201.post8161968114465813350..comments2024-03-23T08:57:50.965-04:00Comments on ECG Interpretation: ECG Blog #17 — A Patient with a Pacer and CPECG Interpretationhttp://www.blogger.com/profile/02309020028961384995noreply@blogger.comBlogger15125tag:blogger.com,1999:blog-3364570834099131201.post-77350853696134387652023-03-09T20:36:01.192-05:002023-03-09T20:36:01.192-05:00@ Teodor — THANK YOU for your comments. I agree wi...@ Teodor — THANK YOU for your comments. I agree with you completely that we just cannot be sure what is going on ... The T wave inversion could be ischemic — it could reflect reperfusion T waves following an event — or it could be "memory" T wave inversion as you say! Clinical correlation (and ideally comparison with prior tracings) would be needed to know more. THANKS again for your comment! — :)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-83133149452450463482023-03-07T14:53:45.163-05:002023-03-07T14:53:45.163-05:00Dear Ken, this is a wonderful ECG as usual. I have...Dear Ken, this is a wonderful ECG as usual. I have an interesting differential that should be discussed - how about memory T wave inversion if the patient had a high pacing burden? How about LV strain pattern? Of course, one should assume the worst when treating such patients with chest pain, but on this ECG, for me, the T and ST are not convincing for ischemia. Teodor Serbannoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-84510979484071577822021-04-19T20:22:02.463-04:002021-04-19T20:22:02.463-04:00My pleasure — :)My pleasure — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-61218281082745006942021-04-19T12:06:36.046-04:002021-04-19T12:06:36.046-04:00thank you very much.
thank you very much.<br />Anonymoushttps://www.blogger.com/profile/05783612323573432898noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-65532360446130899822017-07-29T18:12:31.167-04:002017-07-29T18:12:31.167-04:00@ Tamás — Thank you for your comment. What we both...@ Tamás — Thank you for your comment. What we both DO agree on, is that in a patient with chest discomfort, this ECG IS of concern for ongoing ischemia. That said, to me ( = my opinion) — there is no ST elevation in spontaneous beats seen in either lead aVF or in the long lead II. As I show by the BLUE circles in Figure 2, there ARE ST-T waves that are of concern in spontaneous beats — but this is not ST elevation. As to the paced beats — I do not think the ST-T waves that we see are in any way definitive of acute injury. MOST of the time with paced beats, you will not see definitive changes. Sometimes you can — but given how terribly wide the paced QRS complexes are, to me ( = my opinion) the shape of the ST-T waves in the paced beats is just NOT definitive. I say this despite the fact that I'm often the first to point out subtle (ischemic)paced beat ST-T wave changes of concern in ECG internet forums. But in my opinion, this is not one of those times. Thanks again for your comment — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-37116733401665138722017-07-10T15:52:15.245-04:002017-07-10T15:52:15.245-04:00In my opinion, the ST-segments of the spontaneous ...In my opinion, the ST-segments of the spontaneous beats suggest a tiny-tiny STE in aVF and II (+ negT), although there are no q-waves. In addition, pacemaker beats in inferior leads may also suggest STEMI, however, they do not fulfill the Scarbossa criteria. Strengthening my hypothesis, there are small STD in V5-6 as contralateral alterations. + The patient is complaining of chest pain (although atypical). Do you disagree?Tamashttps://www.blogger.com/profile/17527272487002525211noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-7884334581564509542016-04-13T00:52:14.040-04:002016-04-13T00:52:14.040-04:00Thanks! Thanks! Anonymoushttps://www.blogger.com/profile/10222616342277768927noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-90775232702929915172016-04-12T19:22:34.751-04:002016-04-12T19:22:34.751-04:00Excellent question Niko. Opinions on the answer va...Excellent question Niko. Opinions on the answer vary. There are those who say that Sgarbossa criteria may be applied to paced tracings. In my opinion — that is an extrapolation that is not well validated. I honestly don't see how it could be "validated" — since there are so many different types/sites for pacing, that doing a controlled, prospective study would be exceedingly difficult (to say the least). On the other hand — assessment of QRST morphology can at times be helpful with pacer tracings — and when you see clear ST elevation that shouldn't be in certain leads, the ECG of paced beats can even be diagnostic. In my opinion — this is not one of those times ... The ST-T waves in leads V2,V3 for the paced beats in Figure 1 is suspicious, but to me, just not diagnostic of acute stemi given paced etiology. On the other hand, ischemic-looking ST-T waves in spontaneous beats support that there is ischemia, though the findings are again not diagnostic of acute ongoing stemi in my opinion. Thanks for your interest!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-57642324370704580792016-04-12T12:26:00.468-04:002016-04-12T12:26:00.468-04:00Great ECG as always Ken!
Aren't v1 and v2 pace...Great ECG as always Ken!<br />Aren't v1 and v2 paced beats meeting the sgarbossa criteria for STEMI?<br />Thanks,<br />Niko GAnonymoushttps://www.blogger.com/profile/10222616342277768927noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-79764740255046063412016-04-12T12:25:08.194-04:002016-04-12T12:25:08.194-04:00Great ECG as always!
Aren't v1 and v2 paced be...Great ECG as always!<br />Aren't v1 and v2 paced beats meeting the Sgarbossa Criteria?<br />Thanks,<br />Niko GAnonymoushttps://www.blogger.com/profile/10222616342277768927noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-26146581452234299272011-12-18T20:39:22.484-05:002011-12-18T20:39:22.484-05:00I will share by paraphrasing this comment just rec...I will share by paraphrasing this comment just received from Dr. Ekaterina Pervova of Moscow, Russia: "I have a comment. I think we should talk to doctors about the impossibility of interpreting ST-T wave changes on the ECG in non-paced beats as indicative of myocardial ischemia. ECG changes such as these should be interpreted as the phenomenon of ECG "Cardiac memory" (in Russia, this is called "ECG phenomenon Chattergjee"). Rather than risk false diagnosis of acute MI in a paced ECG - the physician should take into account the tracing with the history of chest pain - and reserve final diagnosis for confirmatory tests (cardiac enzymes, echocardiography, coronary angiography, etc.). THANK YOU Dr. Pervova for your excellent comment! I should have been a little less definitive in my statements ... Your point is well taken that pacing may affect the reliability of ECG interpretation of non-paced beats in assessing for ischemia - BUT while clearly not definitive - in a patient like this one with chest discomfort - finding the ST segment shape as is seen in a number of leads on this tracing (in conjunction with the small but real q wave and T inversion in the lead II rhythm strip) I believe should certainly at least raise the question of acute ischemia/recent infarction. I agree completely with you that definitive tests (troponins and probably cath) will ultimately be needed for confirmation - Ken Grauer, MD (12-18-2011).ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-81456279084264468892011-06-21T17:29:45.918-04:002011-06-21T17:29:45.918-04:00It was very helpful , thank you very muchIt was very helpful <a href="http://emedicalguide.co.cc/index.php?topic=2.msg8" rel="nofollow">,</a> thank you very muchAnonymoushttps://www.blogger.com/profile/17104832142688186011noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-53056089693044630362011-03-18T09:27:25.223-04:002011-03-18T09:27:25.223-04:00Agreed, after identifying paced complexes my first...Agreed, after identifying paced complexes my first task is usually to find non-paced complexes (if any). I always enjoy fusion complexes, reminds me of studying superimposition of waves in physics and analog signal processing.Christopherhttps://www.blogger.com/profile/11415988855392944633noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-69730142046006500202011-03-18T07:10:08.908-04:002011-03-18T07:10:08.908-04:00YES - The ST-T wave changes in V1,V2,V3 paced beat...YES - The ST-T wave changes in V1,V2,V3 paced beats are eye-catching (these are the paced beats corresponding to [above] beat #6 in the Lead II Rhythm Strip). That said - these are PACED beats. The QRS is wide because of the ventricular origin of these paced beats - and interpretation of ST-T wave morphology is unfortunately not reliable. Although possible (on rare occasions) to gain insight about ischemia/infarction from paced beats - in the overwhelming majority of cases, you cannot draw reliable conclusions. The point of this tracing is to highlight how looking for non-paced beats may provide information about ischemia/infarction on a paced tracing (BLUE Ovals). The fusion beat (BLUE oval in V3) is particularly interesting - in that the shallow T wave inversion represents fusion of ST elevation and T wave peaking from the paced beat - and symmetric T inversion of the spontaneous beat ... THANKS for your Comment Christopher! - Ken Grauer, MDECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-24701180202103761962011-03-17T18:07:41.509-04:002011-03-17T18:07:41.509-04:00The T-wave changes in V1 and V2's paced beats ...The T-wave changes in V1 and V2's paced beats are also concerning. They do not appear to have the appropriate discordance. Although, without seeing the patient's "resting" 12-lead, it is difficult to say exactly what I'm seeing in those leads.Christopherhttps://www.blogger.com/profile/11415988855392944633noreply@blogger.com