Dr. Smith's ECG Blog

JUNE 1, 2022

A 40-something male with no previous cardiac disease presented with chest pain. The pain continued and the first high sensitivity troponin I returned at 105 ng/L Another ECG was recorded: The ST segment in aVF has flattened a bit, revealing that there is some STD in addition to the non-specific findings in III and aVL.

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Chest Pain STEMI Myocardial Infarction Bradycardia 52

Ken Grauer, MD

FEBRUARY 3, 2024

As discussed in detail in ECG Blog #228 — this seemingly qualifies as a “ Silent ” MI ( Approximately half of those MIs not accompanied by CP — have some other associated symptom such as syncope, which substitutes as a “chest pain equivalent” ).

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Blog Cardiac Arrest STEMI Plaque 163

Ken Grauer, MD

APRIL 23, 2023

No chest pain. In a previously healthy adolescent ( who is 15 years old in today's case ) — the presentation of an acute febrile illness that is without a complaint of chest pain, is highly unlikely to be due to an acute MI. He was hemodynamically stable. How would YOU interpret the ECG in Figure-1 ?

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Blog Chest Pain Arrhythmia Download 78

Ken Grauer, MD

JULY 22, 2023

Although this " Imbalance " of precordial T waves is not see n very often — in the “right” clinical setting, it has been associated with recent OMI ( O cclusion-based MI ) , most often from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM — and ECG Blog #350 ).

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Blog Chest Pain STEMI AFIB 78

Ken Grauer, MD

OCTOBER 13, 2023

She was hemodynamically stable — and did not have chest pain, lightheadedness or syncope. Section 20 ( 54 pages = the " long " Answer ) from my ACLS-2013-Arrhythmias Expanded Version provides detailed discussion of WHAT the AV Blocks are — and what they are not ! QUESTIONS: HOW would you interpret the rhythm in Figure-1 ?

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Blog Arrhythmia Bradycardia Download 159

Dr. Smith's ECG Blog

OCTOBER 8, 2018

I have enclosed the ECG from a 50-something year old male who complained of chest pain. Steffen wrote: " I remembered the ECG from your blog titled: "STEMI Seen Best in PVC, Diagnosed by Medic, Ignored by Physician" from 2013. I was on scene at his working place (in Germany physicians are on the Emergency vehicles).

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STEMI Chest Pain Blog Atherosclerosis 52

Ken Grauer, MD

JANUARY 5, 2024

and , ii ) That we need to carefully inquire about recent chest pain, paying special attention to the rest of this 12-lead ECG ( looking carefully for signs of acute or recent infarction — because AV Wenckebach is common with acute inferior MI ).

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Blog Chest Pain Arrhythmia 176

Dr. Smith's ECG Blog

MAY 6, 2018

This 50-something otherwise healthy male presented with one hour of epigastric and lower chest pain. One of our fine interns, Daniel Lee, who is also an ECG whiz, found this paper from 2013 and brought it to my attention: The delayed activation wave in non-ST-elevation myocardial infarction.

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STEMI Chest Pain Myocardial Infarction Stents 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest.

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Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. He described it as "10/10" intensity, radiating across his chest from right to left. This is written by Willy Frick, an amazing cardiology fellow in St.

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Plaque Angina Blog Stent 126

Ken Grauer, MD

FEBRUARY 13, 2023

The ECG in Figure-1 was obtained from an older woman — who presented with chest pain and palpitations over the previous hour. She had a history of hypertension, and was on medication for this — but she was otherwise healthy. BP = 140/90 mm Hg in association with the rhythm in Figure-1. How would YOU interpret the rhythm in Figure-1 ?

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Blog Arrhythmia Exercise Chest Pain 78

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

Written by Pendell Meyers, few edits by Smith A man in his 60s with history of stroke and hypertension but no known heart disease presented with chest pain that started on the morning of presentation at around 8am. Here is his triage ECG when he presented at 1657: What do you think?

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STEMI Chest Pain Myocardial Infarction Document 52

Dr. Smith's ECG Blog

MARCH 22, 2022

P.S.: Note that in today's case — the brief description of the chest pain history in this teenager does not sound convincing for an acute cardiac event. But eliciting both a personal and family History on such patients ( inquiring about syncope-presyncope, or malignant arrhythmia symptoms ) — is essential for optimal management.

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Blog Chest Pain Ischemia Arrhythmia 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia.

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Ischemia STEMI Stenosis Chest Pain 52

Ken Grauer, MD

OCTOBER 27, 2023

Given the history of dyspnea on exertion over a several week period ( but no mention of chest pain ) — and — the finding of deep, symmetric T wave inversion in the anterior leads ( as per Pearl #2 ) — it is possible that the onset of her symptoms is the result of a "Silent MI" ( See ECG Blog #228 for more on "Silent" MI ).

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Blog Pacemaker Bradycardia Arrhythmia 101

Ken Grauer, MD

APRIL 29, 2023

Although this " Imbalance " of precordial T waves is not seen very often — in the “right” clinical setting, it has been associated with recent OMI ( O cclusion-based MI ) from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM — and ECG Blog #350 ).

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Blog Chest Pain STEMI Ischemia 78

Dr. Smith's ECG Blog

DECEMBER 12, 2022

This " imbalance of precordial T waves" is not seen very often — and in the “right” clinical setting, has been associated with recent OMI from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM ).

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Chest Pain STEMI Blog 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

Arch Cardiovasc Dis 2013 Khan AR et al. Smith : this proves my impression that the inferior T-waves on the first ECG are hyperacute. JAHA 2022 Grosmaitre P et al. Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments.

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STEMI Myocardial Infarction Chest Pain Angina 40

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. N Engl J Med 2003; 348:1756-1763, 5/1/2013. This was contributed by some folks at Wake Forest: Jason Stopyra, Shannon Mumma, Sean O'Rourke, and Brian Hiestand.

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Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? 2013 Sep;26(9):965-1012.e15. She was noted to be tachycardic and her heart sounds were distant on physical exam. She had a normal respiratory effort, and her lungs were clear to auscultation bilaterally. 2013.06.023.

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Tachycardia Pericarditis Ultrasound Blood Pressure 40

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. Only 5-18% of ED patients with chest pain have a myocardial infarction of any kind. Is it Brugada pattern?

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Triage ECG: What do you think? This is diagnostic of proximal LAD occlusion. This is a huge anterolateral OMI. I cannot be anything else.

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

JULY 22, 2023

He denied chest pain or shortness of breath. In the clinical context of weakness and fever, without chest pain or shortness of breath, the likelihood of Brugada pattern is obviously much higher. Today's patient presented with acute weakness, syncope and fever, but no chest pain or shortness of breath.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

BoardVitals - Cardiovascular

JANUARY 18, 2021

Other trials that evaluated this subject were the WOEST trial (2013), Pioneer AF-PCI trial (2016), and ISAR-TRIPLE (2015). ACS QID 3103 A 64 year old Caucasian male with a history of extensive tobacco use, hypertension, hyperlipidemia, and obesity presents with acute onset chest pain. Incorrect Answers: A and E. Question 2.

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Bicuspid/Mitral Atrial Fibrillation Chest Pain STEMI 52

Dr. Smith's ECG Blog

MAY 5, 2022

He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. He complained of generalized weakness and left lower extremity numbness. What is it?

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Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

His comments/questions are inserted below the ECG: A 50-something woman presented with 3 days of intermittent chest pain that became worse on the day of presentation, with diaphoresis and radiation to the left arm, as well as abdominal pain. American heart journal 2010;160:995-1003,e1-8. O'Gara PT, Kushner FG, Ascheim DD, et al.

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Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

It was from a patient with chest pain: Note the obvious Brugada pattern. This definition was changed following an expert consensus panel in 2013 — so that at the present time, all that is needed to diagnose Brugada Syndrome is a spontaneous or induced Brugada-1 ECG pattern, without need for additional criteria.

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Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 24, 2017

Am J Cardiol 12(9):1379-1383; Nov 2013. the optimum QT correction formula for patients with chest pain was found to be unique for each individual ; it is a correction factor that can be calculated real-time for each patient by taking multiple measurements over a range of heart rates. Musat DL et al.

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Bradycardia Article Atrial Fibrillation Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 9, 2025

A 26 year old male presented with syncope and chest pain. No signs of OMI" The chest pain resolved after some time, and another ECG was recorded: The ST Elevation is nearly gone. Syncope was sudden and without prodrome, and resulted in head trauma with a scalp laceration. Smith : I recognize this as a STEMI mimic.

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Chest Pain Ischemia Dysrhythmia Arrhythmia 106

Dr. Smith's ECG Blog

APRIL 13, 2025

A man in his early 30s was walking when he developed central chest pain which was non-radiating, then had a syncopal event with bowel incontinence, and when he woke up he had ongoing chest pain. Notes never having symptoms like this before, pain is so severe its causing SOB. He called 911.

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Chest Pain Embolism STEMI Plaque 83

Ken Grauer, MD

MARCH 8, 2025

The ECG in Figure-1 was obtained from a middle-aged man who presents to the ED ( E mergency D epartment ) with 6 hours of chest pain. Figure-1: The initial ECG in today's case obtained from a middle-aged man with 6 hours of chest pain. ( He is hemodynamically stable.

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Blog STEMI Download Chest Pain 105

Dr. Smith's ECG Blog

APRIL 9, 2025

A middle-age woman with no previous cardiac history called 911 for chest pain. This was her prehospital ECG: What do you think? There is sinus rhythm with RBBB and obvious LAD OMI (proximal LAD occlusion): hyperacute T-waves in I, aVL and minimal STE in V1, V2.

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Defibrillator Cardiac Arrest Myocardial Infarction STEMI 63

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

Scenario 1 : The patient presents with 24 hours of substernal chest pain. Ninety percent of patients with reperfusion attained a maximum T wave negativity of 3 mm or more within 48 hours after the onset of chest pain in the lead that initially displayed the greatest ST segment elevation. Below is his presentation ECG.

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Chest Pain Pericarditis Myocardial Infarction Dementia 88

Dr. Smith's ECG Blog

MARCH 8, 2025

He had no chest pain, dyspnea, or any other anginal equivalent, and his vital signs were normal. The cardiologist thought she had stent thrombosis which is possible, but I do not necessarily think is sufficient to explain her complete hemodynamic collapse. SanzRuiz, R., Solis, J., & & FernndezAvils, F. link] Bai, J.,

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Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 74