- Hyperacute T-waves are often the first manifestation of complete vessel occlusion; they are wide, bulky and prominent.
- Hyperacute T-waves are not necessarily tall, and small T-waves can still be hyperacute when paired with a low-amplitude QRS complex.
- De Winter T-waves represent LAD occlusion (a STEMI equivalent) requiring immediate revascularization.
- Previously inverted T-waves can appear normal and upright in the setting of acute vessel occlusion. This is known as pseudonormalization.
- The tall T-waves associated with hyperkalemia are sharp, pointy, symmetric, and have a narrow base.
- When in doubt, get serial ECGs (every 15 minutes) and use adjunctive information.
Heart Blocks: A Primer
- Heart blocks can be a sign of underlying pathology such as MI, Lyme disease, myocarditis, structural heart disease, pulmonary embolism, autoimmune disease, electrolyte disturbances, medication side effects, Lenegre’s or Lev’s disease, increased vagal tone, or could be a normal variant.
- Treatment with Atropine is indicated in bradycardic, symptomatic and/or unstable patients with a 1st or 2nd-degree Mobitz type 1 AV block. It is unlikely to be effective in high-grade blocks as the block is usually below the AV node. Atropine can still be used as a temporizing measure while setting up for transcutaneous pacing and/or transvenous pacemaker placement in high-grade blocks
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The Heart Score
- The risk of ACS in patients with negative biomarkers and normal ECGs approaches 0.2%.
- Prior risk scores, such as TIMI and GRACE, provide little, if any benefit, in risk stratification for ED chest pain patients.
- The HEART score and pathway can risk stratify patients into three separate categories: low (0-3), moderate (4-6), and high score (> 7).
- Low-risk patients on the HEART pathway demonstrate likelihood of ACS that approaches < 1%, and it is easy to use in the ED.
- Risk factors, history, ECG, troponin, follow up, gestalt, patients with points 3 or 4, and research design are areas of potential weakness.
- Further improvement of the HEART pathway at this time is difficult, but in patients at moderate risk, CCTA may hold promise for evaluation of risk. This requires further study.
Effects of Electrolytes on ECG
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Chest Pain in Atrial Fibrillation
The STEMI ECG Assessment
This ECG assessment is designed to evaluate your ability to use simply the 12-Lead ECG to make the diagnosis of a coronary artery occlusion. It uses a standardized list of 36 ECG’s from McCabe JM, et al. Physician Accuracy in Interpreting Potential ST-Segment Elevation Myocardial Infarction Electrocardiograms. J Am Heart Assoc. 2013;2:e000268.