Paucis Verbis: AMI and ECG Geography

Sometimes a picture is worth MORE than a 1000 words. Such is the case of the above illustration that I saw on the Life In The Fast Lane blog. When I first saw it, I knew that I immediately had to find out who made the graphic. It turns out it is the multitalented Dr. Tor Ercleve, who is an emergency physician at Sir Charles Gairdner Hospital and an established medical illustrator.

ECG anatomy illustration AMI

This graphic demonstrates the EKG findings for the various types of acute MI’s as broken down by coronary vascular anatomy (right coronary artery, left circumflex artery, left anterior descending artery). This detailed illustration won’t be readable in print form but is great in digital format on your mobile device.

Thanks, Tor!


Go to ALiEM (PV) Cards for more resources.
By |2021-10-15T11:17:43-07:00Apr 8, 2011|ALiEM Cards, Cardiovascular, ECG|

Paucis Verbis: Right and posterior ECG leads

ECG EKG machine

A standard 12-lead ECG can be very telling for patients with chest pain or shortness of breath. A right ventricular (RV) and posterior wall infarct, however, can present very subtly. You can obtain special right-sided (V1R-V6R) and posterior leads (V7-V9), if you are concerned. What are the indications for obtaining right-sided and posterior ECG leads?

Go to the ALiEM Cards for more resources.

Addendum 3/11/11:

Right sided ECG leads (V1R-V6R) are positioned in a mirror image fashion from the standard 12-lead precordial leads.
Posterior ECG leads (V7-V9) are applied by moving V4-V6 in the posterior positions.

By |2021-10-16T19:28:52-07:00Mar 11, 2011|ALiEM Cards, ECG|

Paucis Verbis: Sgarbossa’s Criteria with LBBB


It is difficult to determine if a patient with a left bundle branch block (LBBB) has an acute myocardial infarction (AMI) because ST segments are “appropriately discordant” with the terminal portion of the QRS. That means if the QRS complex is negative (or downgoing), the ST segment normally will be positive (or elevated). Similarly if the QRS complex is positive (or upgoing), the ST segment will be negative (or depressed).

PV Card: Sgarbossa’s Criteria

In 1996, Sgarbossa et al looked through the GUSTO-1 trial patients with LBBB and AMI. They derived 3 criteria which may help diagnose the “hidden” AMI. The criteria are:

1. ST elevation ≥ 1 mm concordant with QRS complex (most predictive of AMI of the 3 criteria)
2. ST depression ≥ 1 mm in lead V1, V2, or V3
3. ST elevation ≥ 5 mm where discordant with QRS complex

Use these criteria with caution though. None of these criteria are perfect. They are to help you risk-stratify. For instance, criteria #3 (ST elevation ≥ 5 mm) can exist in asymptomatic patients with LBBB because of concurrent left ventricular hypertrophy and high voltages.

Thanks to Tom Bouthillet at for the useful illustration above.
Go to ALiEM (PV) Cards for more resources.
By |2021-10-17T09:25:38-07:00Nov 5, 2010|ALiEM Cards, Cardiovascular, ECG|

Paucis Verbis card: When murmurs need echo evaluation

Cardiac Echocardiography

Have you been in a situation where you are the first to detect a cardiac murmur in a patient? If you are hearing it in a busy, loud Emergency Department, I find that it’s at least a grade III.

Should you order an echocardiogram for further outpatient evaluation? It depends on the grade and characteristic of the murmur, in addition to the patient’s symptoms. For instance, all diastolic murmurs require an echo. There is a useful ACC/AHA algorithm which helps you decide.

PV Card: When Murmurs Need Echocardiography Evaluation

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Amy Kinard, an Emergency RN and aspiring Family Nurse Practitioner, for drafting this useful Paucis Verbis card for me during her studies. Keep the great ideas coming, everyone!


  1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523-e661. doi: 10.1161/circulationaha.108.190748
By |2021-10-18T10:05:29-07:00Sep 17, 2010|ALiEM Cards, Cardiovascular|

Paucis Verbis card: TIMI risk score

Chest PainHow do you risk-stratify undifferentiated chest pain patients in the Emergency Department? There are a multitude of causes for chest pain. We are always taught to think of the 5 big life-threats: ACS, PE, aortic dissection, tension pneumothorax, and pericardial tamponade.

So how do YOU risk-stratify your patients for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI)? STEMI’s are usually obvious. UA and NSTEMIs — not so much.

Fortunately a 2000 JAMA article and a followup Academic Emergency Medicine 2006 study have solidified the TIMI risk scoring system as a reasonable risk-stratification tool for all-comer ED patients with chest pain requiring an ECG.

Generally there is an upslope in risk at a TIMI score of 3 and greater.

PV Card: TIMI Risk Score

Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.


  1. Pollack C, Sites F, Shofer F, Sease K, Hollander J. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006;13(1):13-18. [PubMed]
  2. Antman E, Cohen M, Bernink P, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000;284(7):835-842. [PubMed]
By |2021-10-18T10:09:44-07:00Aug 27, 2010|ALiEM Cards, Cardiovascular|
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