Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. A patient with OMI can have a totally normal ECG!"

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Myocardial Infarction Chest Pain STEMI Blood Pressure 121

Dr. Smith's ECG Blog

JANUARY 10, 2020

He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain. Another similar case: Teenager with chest pain and slightly elevated troponin. I excerpted Figure-2 from Section 12 on Pericarditis , from my ECG-2014-ePub. Pericarditis?

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Chest Pain Pericarditis Ultrasound Download 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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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

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. Step 1 to missing posterior MI is relying on the STEMI criteria. But it is still STEMI negative. What do you think? A 15 lead ECG was done (below).

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Dr. Smith's ECG Blog

JANUARY 2, 2016

A middle aged male presented with chest pain. LVH and the diagnosis of STEMI - how should we apply the current guidelines? 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.

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Ischemia Chest Pain STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Context: a man in his 40s presented to the emergency department with 1 day of sudden onset chest pain. I sent this to our group without information and Dr. Smith responded: "Not OMI.

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Pericarditis Chest Pain Blog Aortic 95

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?

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Pericarditis Blog Chest Pain Coronary Angiogram 78

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. But the History in today's case was acute shortness of breath with dizziness and lightheadedness — and, essentially without chest pain!

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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. This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline."

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STEMI Chest Pain Ischemia Myocardial Infarction 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 70

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

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Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Thelin et al.

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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. OMI that are not STEMI can be very subtle and difficult to diagnose even though the findings are very specific. The patient was very agitated and could not hold still.

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Chest Pain Blog Ischemia STEMI 52

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. It was read by the treating physician and the overreading cardiologist as "Paced, no STEMI." Here is his triage ECG at time = 0: What do you think? (No How does the Queen of Hearts do? Lupu et al.

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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. His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI.

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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. Smith noted in his Learning Points about this Case that, “Many MIs do not have chest pain”.

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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. There is also much STE in V3-V6, especially V4-V6, that must be considered to be STEMI. Peak troponin was 3.21

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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. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What do you see?

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