Dr. Smith's ECG Blog

JUNE 17, 2018

A middle-aged patient with lung cancer had presented to clinic complaining of generalized malaise, cough, and chest pain. Symptoms other than chest pain (malaise, cough in a cancer patient) 2. Inclusion criteria were chest pain, at least 2 serial cTnI in 24 hours, sinus rhythm , and at least 1 ECG.

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Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 5, 2024

The patient presented due to chest pain that was typical in nature, retrosternal and radiating to the left arm and neck. He denied any exertional chest pain. It is unclear if the patient was pain free at this time. He has a medical hx notable for hypertension, hyperlipidemia and previous tobacco use disorder.

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Chest Pain Blog Cardiac Arrest Cardiomyopathy 122

Dr. Smith's ECG Blog

JANUARY 15, 2024

They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They described the chest pain as severe, crushing, and non-radiating. Altogether, this strongly suggests inferolateral OMI, particularly in a patient with acute chest pain.

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Chest Pain Blog Arrhythmia Critical Care 64

Dr. Smith's ECG Blog

OCTOBER 24, 2019

[link] A 30 year-old woman was brought to the ED with chest pain. She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying "I'm just an anxious person." A similar episode had occurred a week earlier during labor.

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Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

MARCH 27, 2023

My Comment by K EN G RAUER, MD ( 2/22 /2023 ): = Today’s case is an important one, because as per Dr. Smith ( in this patient with new chest pain ) — “The initial ECG is diagnostic of infero-postero OMI.” Also ( as per Dr. Smith ) — there is subtle-but-real ST depression in chest leads V2-thru-V5.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

JANUARY 17, 2023

A 60 year old with chest pain presented to the ED. In this case, lead I does not look bizarre, but all other leads do. == N OTE : The reasons I especially liked today's case are: i ) The patient presented with chest pain — so the importance of distinguishing artifact from reality can not be overstated! —

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Chest Pain Physiology Blog Electrophysiology 52

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

SEPTEMBER 30, 2019

Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Written by Jesse McLaren Two 70 year olds had acute chest pain with nausea and shortness of breath, and called paramedics. Eur Heart J 2018 4. Today's patient is a 70-year old adult who called EMS because of new-onset chest pain , associated with nausea and shortness of breath. Who needs the cath lab? Lemkes et al.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JUNE 28, 2018

He had suffered a couple bouts of typical chest pain in the last 24 hours. This ECG (ECG #3) was recorded immediately after the last episode of pain spontaneously resolved. The pain had lasted about one hour. Case A 40-something male presented to triage. There are classic Wellens' waves in V2-V5.

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Chest Pain Myocardial Infarction STEMI Article 52

Ken Grauer, MD

DECEMBER 8, 2023

For full discussion of this case — See ECG Blog #292 — == The 2 ECGs shown in Figure-1 were obtained from a man in his 30s — who presented to the ED ( E mergency D epartment ) with chest pain that began several hours earlier. ECG #2 was recorded 1 hour after ECG #1. Initial troponin was negative.

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Blog Chest Pain STEMI Ischemia 163

Dr. Smith's ECG Blog

NOVEMBER 4, 2018

A middle-aged woman presented with chest pain. American Journal of Emergency Medicine 36(5):865-870; May 2018. My Comment, by K EN G RAUER, MD ( 11/4/2018 ): = Important post by Dr. Smith regarding recognition of chest lead misplacement of leads V1 and V2. 27, 2018 blog post ).

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Chest Pain Anatomy Echocardiogram Blog 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? Meyers, Weingart and Smith in their 2018 OMI Manifesto. I like to start my ECG assessment in patients with new chest pain by looking for at least 1 or 2 leads that I know are definitely abnormal. This was sent to me by a friend.

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Chest Pain STEMI Blog Academic 52

DAIC

MAY 8, 2024

5 Revascularization to improve blood flow to the heart has been shown to reduce mortality in stable chest pain patients. 5 Revascularization to improve blood flow to the heart has been shown to reduce mortality in stable chest pain patients. European Journal of Vascular and Endovascular Surgery, vol. 301–302, [link].

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Coronary Artery Disease Chest Pain Ischemia Myocardial Infarction 111

Circulation: Cardiovascular Quality & Outcomes

FEBRUARY 3, 2025

BACKGROUND:The PRECISE (Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization) demonstrated that a precision diagnostic strategy reduced the primary composite of death, nonfatal myocardial infarction, or catheterization without obstructive coronary artery disease by 65% in patients with nonacute chest pain (..)

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Chest Pain Outcomes Coronary Artery Disease Myocardial Infarction 40

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. The following ECG was obtained.

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Chest Pain Myocardial Infarction Blog Stent 131

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.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Ken Grauer, MD

SEPTEMBER 22, 2023

Impression: In this middle-aged man with palpitations and dyspnea, but no chest pain — I suspect that the T wave peaking and slight, upward-sloping chest lead ST elevation represent a repolarization variant. The July 29, 2018 post ( LA-RA reversal ). The November 4, 2018 post ( Leads V1,V2 misplacement ).

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Blog Chest Pain Bradycardia Physiology 176

Dr. Smith's ECG Blog

MARCH 27, 2025

After only 90 minutes of chest pain, the first troponin was unsurprisingly in the normal range at 11ng/L (normal <26 in males and <16 in females), so the emergency physician waited for repeat troponin. Chest pain still persists. Paged cardiology 0800: patient complains of chest pain. Cardiology aware.

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STEMI Chest Pain Pericarditis Ischemia 80

Dr. Smith's ECG Blog

SEPTEMBER 11, 2018

many readers of this blog). -- Comment by K EN G RAUER, MD ( 9/11/2018 ): -- The lesson in this case relates to the recognition of subtle abnormalities that typically go undetected by the computerized interpretation — and which also may be overlooked by clinicians in the setting of a busy ED.

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Chest Pain Critical Care Blog Stents 52

Dr. Smith's ECG Blog

MAY 7, 2024

A 30-something presented with chest pain, palpitations, and SOB. This finding is typical for a post-ablation memory T wave pattern — which is often considered evidence of a successful ablation ( Silverman et al — J Investig Med: Jan, 2018 ). He has had similar symptoms for 4 years, but has never been evaluated.

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Atrial Fibrillation AFIB Ablation Chest Pain 130

Dr. Smith's ECG Blog

AUGUST 3, 2018

In the evening, a middle-aged man complained of chest pain at the nursing home. His chest pain was vague. He mentioned "cancer" and "chest". Nurses found him with a BP of 50/30 and heart rate of 130 and called EMS. He was awake, with a pulse of 130 and BP of 50/30. Fluids were started.

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Chest Pain Tachycardia Atrial Flutter Ultrasound 40

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

He reports significant chest pain at the base of his scapula on the right side along with new shortness of breath. Eur Heart J 2018. Wellen's waves indicate that, when the patient was having chest pain, there was occlusion. See these casese (and I have many others): First ED ECG is Wellens' (pain free).

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Chest Pain Myocardial Infarction STEMI Pericarditis 116

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. Echo showed new anterior regional wall motion abnormality and decrease EF from 60% to 45%.

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STEMI Chest Pain Myocardial Infarction Blog 121

Ken Grauer, MD

DECEMBER 15, 2023

ECG #2 was actually done first, at the time the EMS unit arrived on the scene ( at which time the patient was having severe chest pain ). The July 31, 2018 post in Dr. Smith's ECG Blog ( Please scroll down to the bottom of the page to see My Comment ). Figure-2: Comparison between the 2 ECGs recorded in today's case.

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Blog STEMI Ischemia Chest Pain 151

Dr. Smith's ECG Blog

OCTOBER 10, 2024

Written by Pendell Meyers A man in his early sixties with no significant medical history (including a "negative cardiac workup a few years ago" for unclear indication) called 911 for acute chest pain constantly for the past 5 hours. However, this patient has active chest pain, and thus this this is inferior-posterior OMI.

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Chest Pain STEMI Blog Stenosis 108

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

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The above said — in today's patient with a convincing history of chest pain, this initial ECG in Figure-1 was all that was needed for prompt diagnosis of acute postero-lateral OMI. Here is that ECG: Original ECG What do you think?

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Hospital Chest Pain Blog Pulmonary 77

Ken Grauer, MD

AUGUST 16, 2024

Today’s patient presented to the ED not only with chest pain — but also with shortness of breath , therefore with a history potentially consistent with the diagnosis. Excellent review of diagnostic testing for acute PE ( Moore et al — Cardiovasc Diagn Ther 8(3):225-243, 2018 ).

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Blog Tachycardia Cardiogenic Shock Pulmonary 156

Dr. Smith's ECG Blog

OCTOBER 9, 2018

October 2018. We record ECGs in triage on every patient with chest pain, and some other indications, and this amounts to 8000 ECGs in triage each year, costing at most $200,000 (8000 x $20.00). A patient with chest pain: See the computer analysis. This paper was just published: Noll S.

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Chest Pain STEMI Cardiac Arrest Blog 52

Ken Grauer, MD

OCTOBER 21, 2023

Having looked for negative U waves in patients with chest pain over a period of decades — I'll emphasize that this is not a common finding. PEARL # 4: When the ECG changes evolve in a way that corresponds to the coming and going of chest pain symptoms — this is important information. BLUE arrows in Figure-2 ).

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Blog Chest Pain Ischemia STEMI 98

Ken Grauer, MD

APRIL 5, 2024

For additional examples of this phenomenon whereby automatic truncation of an EMS ECG may mistakenly result in LVH serving to mimi c ischemia — Check out My Comment at the bottom of the page of the following posts in Dr. Smith's ECG Blog — the November 29, 2023 post — June 20, 2020 — March 31, 2019 — March 29, 2019 — and t he December 27, 2018 post.

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Blog Ischemia Chest Pain Hypertension 94

DAIC

JANUARY 25, 2024

More than 8 million Americans visit hospital emergency departments experiencing chest pain every year. “In the future, patients with coronary inflammation can be identified by the CaRi-Heart technology and treated by our FDA -approved LODOCO 0.5 mg tablets.”

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Heart attacks Heart Attack Technology Cardiovascular Disease 110

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. As I illustrated in detail in My Comment of the October 3, 2018 post of Dr. Smith's ECG Blog — I favor a qualitative approach based on shape. The question is, does she need to go urgently to the cath lab or can she wait.

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Chest Pain Pacemaker Ischemia Stent 111

Ken Grauer, MD

JANUARY 13, 2024

On the other hand — the ST elevation seen in lead V1 is perfectly consistent with LVH and LV "strain" ( ie, The shape of this ST-T wave in lead V1, in association with the deep S wave in this lead — is a mirror-image opposite picture of the typical expected appearance of LVH with "strain" in a lateral chest lead ).

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Blog Ischemia AFIB Hypertension 159

DAIC

MAY 2, 2024

This causes angina, a type of chest pain which is characterized as refractory angina when this pain cannot be controlled by a combination of optimal medical therapy, angioplasty or bypass surgery, and is estimated to impact 600,000 to 1.8 million patients in the United States.

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Ischemia Angina Heart Failure Outcomes 95

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). She has no chest symptoms. What is the diagnosis?

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Chest Pain Blog Thrombosis Hospital 116