Dr. Smith's ECG Blog

DECEMBER 11, 2023

See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. This is different from nitroglycerin which produces vasodilation and can improve by pain improving myocardial perfusion. You do not need to be better than the Queen of Hearts at EKG to understand that refractory chest pain NEEDS CATH NOW.

Myocardial Infarction 123

Myocardial Infarction Chest Pain STEMI Blood Pressure 123

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. 2014 AHA/ACC guideline for the management of patients with non-ST elevation acute coronary syndromes.

STEMI 121

STEMI Chest Pain Myocardial Infarction Blog 121

Dr. Smith's ECG Blog

AUGUST 4, 2024

Context: a man in his 40s presented to the emergency department with 1 day of sudden onset chest pain. A DDENDUM ( 8/3/2024 ) : In the following 5 Figures — I post written summary from my ECG-2014-ePub on the ECG diagnosis of A cute P ericarditis. I sent this to our group without information and Dr. Smith responded: "Not OMI.

Pericarditis 116

Pericarditis Chest Pain Blog Aortic 116

Heart BMJ

AUGUST 26, 2024

Methods Patients with a first episode of acute pericarditis were consecutively enrolled between January 2014 and June 2022, and divided into four groups according to age (G1: 18–35 years; G2: 35–55 years; G3: 55–75 years; G4: >75 years). Results A total of 471 patients (median age 56.3 (IQR IQR 33–73) years, 32.3%

Pericarditis 52

Pericarditis Chest Pain Outcomes Atrial Fibrillation 52

Ken Grauer, MD

MARCH 18, 2023

The ECG in Figure-1 was obtained from a man in his mid-60s — who presented with new chest pain. The magnitude of ST-T wave change is maximal in lead V2 — with the insert in this lead showing a positive "Mirror" Test — that in this patient who presents with new chest pain, is diagnostic of acute posterior OMI — until proven otherwise.

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Blog Chest Pain STEMI Ischemia 78

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.

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

Dr. Smith's ECG Blog

JANUARY 2, 2016

A middle aged male presented with chest pain. Journal of Electrocardiology 47 (2014) 655–660. In LVH, T-wave inversions are usually much more assymetric , like these (Figure 2): Acute Chest pain, but baseline ECG. Here is another patient with severe LVH who presented with chest pain and ruled out for MI.

Ischemia 52

Ischemia Chest Pain STEMI Myocardial Infarction 52

Ken Grauer, MD

AUGUST 16, 2024

On occasion — such anterior lead ST elevation ( instead of T wave inversion ) can be seen with acute PE ( Zhan et al — Ann Noninvasive Electrocardiol 19(6):543-551, 2014 — and — Omar HR — Eur Heart J: Acute Cardiovascu Care (5(8): 579-586, 2016 ). Figure-8: Summary of KEY findings in the ECG diagnosis of acute PE ( from my ECG-2014-ePub ).

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Blog Tachycardia Cardiogenic Shock Pulmonary 156

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. The pain initially started the day prior to presentation. The ST elevation from today is ~0.2

Pericarditis 52

Pericarditis Chest Pain Stents Stent 52

Ken Grauer, MD

MARCH 7, 2023

But, in a patient who presents to the ED for new chest pain — seeing these subtle findings that are localized to leads V2- thru -V4 should at the least make you consider acute posterior OMI ( O cclusion-based MI ) — until you prove otherwise. To EMPHASIZE: These are subtle findings. What do YOU think?

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Blog Chest Pain STEMI Ischemia 78

Open Heart

JANUARY 30, 2024

Methods This study included consecutive patients with iSTEMI treated with percutaneous coronary intervention (PCI) between 1 January 2011 and 15 July 2019 at a single, tertiary referral centre.

STEMI 52

STEMI Hospital Chest Pain Outcomes 52

Ken Grauer, MD

FEBRUARY 24, 2023

. = M Y T houghts on the ECG in Figure-1: It's important to remember that the ECG in Figure-1 was obtained from a previously healthy 30-ish year old man who presented with an episode of vasovagal syncope — but there is no mention of chest pain in the history ! B OTTOM L ine : Need for Transfer to a PCI-capable Center?

Pericarditis 78

Pericarditis Blog Chest Pain Coronary Angiogram 78

Dr. Smith's ECG Blog

MARCH 8, 2021

He was a 30-something with chest pain. Echo immediate: 35% EF with anterior, septal, and apical wall motion abnormalities Echo convalescent, 2 months later: Better, with EF up to 45-50% I posted this in 2014: Is the LAD really completely occluded when there are de Winter's waves? Here is one case of a patient I saw.

Chest Pain 52

Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

But the History in today's case was acute shortness of breath with dizziness and lightheadedness — and, essentially without chest pain! Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

Cardiogenic Shock 127

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 127

Dr. Smith's ECG Blog

MARCH 11, 2019

Here is data from a study we published in 2014 for type II NonSTEMI: Sandoval Y. At some point he returned with chest pain, and all these findings were put into place. Many MI do not have chest pain 4. Of this group (ie, which is comprised of >1/4 of all MIs ) — about HALF have NO chest pain at all.

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 18, 2013

This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion. Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain. Ann Emerg Med 1998;31(1):3-11. Wang T, Zhang M, Fu Y, et al. Marti D et al.

STEMI 52

STEMI Chest Pain Myocardial Infarction Webinar 52

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

OCTOBER 13, 2023

She was hemodynamically stable — and did not have chest pain, lightheadedness or syncope. Section 2F ( 6 pages = the " short " Answer ) from my ECG-2014 Pocket Brain book provides quick written review of the AV Blocks ( This is a free download ). QUESTIONS: HOW would you interpret the rhythm in Figure-1 ? Is a pacemaker needed?

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Blog Arrhythmia Bradycardia Download 159

Dr. Smith's ECG Blog

MARCH 6, 2019

A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath. J of National Association of EMS Physicians 2014. E CG # 1 was obtained in the referral hospital, approximately 2 hours after the onset of chest pain. Meisel et al.

STEMI 52

STEMI Chest Pain Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

A 40-something woman with diabetes and peripheral vascular disease who frequently needs the ED for chronic pain called 911 for sudden severe chest pain. Figure-1: Illustration of the rational for the Mirror Test ( Figure excerpted from Grauer K: ECG-2014 Pocket Brain ePub ).

Chest Pain 52

Chest Pain Blog Ischemia STEMI 52

Ken Grauer, MD

JANUARY 5, 2024

Section 2F ( 6 pages = the " short " Answer ) from my ECG-2014 Pocket Brain book provides quick written review of the AV Blocks. PEARL # 1 ( Advanced Point ): The fact that the QRS complex is narrow, with at least some P waves — and a pattern suggesting group beating — should clue us into: i ) The possibility of Wenckebach conduction! —

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Blog Chest Pain Arrhythmia 176

Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain.

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

JULY 1, 2019

Case 2: sent by Dr. James Alva A man in his 50s with diabetes, hypertension, and hyperlipidemia presented to the ED with chest pain and shortness of breath off and on over the past three days, with associated vomiting. M y T HOUGHTS on E CG # 1 — The patient in Case #1 was a 60-something woman with acute dyspnea, but no chest pain.

Chest Pain 52

Chest Pain Ischemia STEMI Blog 52

Dr. Smith's ECG Blog

FEBRUARY 12, 2023

There was no chest pain. Acute posterior OMI would be a prime concern for the ECG in Figure-1 — IF the patient presented with cardiac-sounding chest pain. But today's patient had no chest pain. I was worried that the ST depression and T-wave inversion in V2 and V3 might be posterior OMI.

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Pulmonary Chest Pain Hypertension Tricuspid 40

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.

Ischemia 52

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

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. 10 The 2014 ACC/AHA guidelines for the Management of Patients with Valvular Heart Disease , referencing this article, gives this recommendation: "CLASS IIb 1.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

JULY 19, 2024

Written by Pendell Meyers, with edits by Smith A man in his 80s presented with acute chest pain and normal vital signs. We need more such ECGs for training but we are constantly working on the algorithm and one day it will make this diagnosis. == But isn't ongoing chest pain in NSTEMI a guideline indication for emergent angiography?

Chest Pain 115

Chest Pain Myocardial Infarction Pacemaker STEMI 115

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was NOT high sensitivity troponin, but we know from a couple studies that, even using hs-cTnI, Unstable angina still exists: These two slides come from my recent lecture on high sensitivity troponin : Slide 23 in the lecture. Thelin et al.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Case 1: 20-something woman with chest pain Case 2: 50-something man with chest pain Case 1 A 20-something yo woman presented in the middle of the night with severe crushing chest pain. History Patient complains of a 24-hours of chest pain of sudden onset, sharp in nature. Denies SOB.

Chest Pain 105

Chest Pain STEMI Aortic Ultrasound 105

Dr. Smith's ECG Blog

MARCH 9, 2025

A 62 year old man with hyperlipidemia presented to a rural emergency department with 7 hours of 3/10 chest pain. Figure-2: Illustration of the rational for the Mirror Test ( Figure excerpted from Grauer K: ECG-2014 Pocket Brain ePub ). =

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Ischemia Blog STEMI Coronary Angiogram 88

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

MARCH 8, 2025

He had no chest pain, dyspnea, or any other anginal equivalent, and his vital signs were normal. Note characteristic ballooning of the apex and hypercontractility of the base during cardiac cath ( Figure excerpted from Grauer K: ECG-2014- Expanded ePub, KG/EKG Press ). = Journal of Geriatric Cardiology , 19 (6). Virmani, R., &

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Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75