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.

Blog 138

Blog Chest Pain STEMI Ischemia 138

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

Blog 100

Blog Chest Pain Ischemia STEMI 100

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 ). ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL ( featured in Audio Pearl #2 in this blog post ).

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Blog STEMI Ischemia Chest Pain 128

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. ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. Many health care providers will simply not attempt to assess ischemia in the presence of a wide QRS.

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Chest Pain Ischemia Pacemaker Stents 104

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. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI.

STEMI 121

STEMI Chest Pain Myocardial Infarction Stent 121

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

JULY 16, 2024

This is the prehospital ECG from an 81 year old man with acute chest pain. The PEARL is that recognition of a longer-than-expected P wave in a supraventricular tachycardia should bring to mind the “Bix Rule” ( See My Comment at the bottom of the page in the August 3, 2018 post in Dr. Smith's ECG Blog ). Would you give lytics?

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Atrial Flutter Chest Pain Tachycardia Arrhythmia 61

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. Anything more on history? J Electrocardiol 2013;46:240-8 2.

Ischemia 52

Ischemia STEMI Stenosis Coronary Artery Disease 52

Dr. Paddy Barrett

AUGUST 1, 2023

Share Chest Pain Symptoms There is no role for CT Calcium Scoring in the setting of someone with chest pain symptoms suspected to be from a narrowed coronary artery. Regardless, if you present with chest pain and get a stress test instead of a CTCA, you are arguably getting an inferior test. I would say yes.

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Coronary Angiogram Plaque Coronary Artery Disease Chest Pain 52

Dr. Smith's ECG Blog

MARCH 27, 2023

--The STD in V2-V6 might be interpreted as subendocardial ischemia, but with the inferior STE, it is far more likely to represent posterior OMI. Here is the history: A 40-something male had intermittent chest discomfort until 90 minutes prior to presentation, when it became constant. At 100 minutes, the above ECG was recorded.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Paddy Barrett

NOVEMBER 28, 2023

Ischemia Trial In an attempt to clarify this question, a similar trial was done called the Ischemia Trial, which had important differences to the Courage trial but again tried to answer a similar question 3. But what about those with symptoms such as chest pain or shortness of breath as a result of their coronary artery disease?

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Stents Stent Heart attacks Heart Attack 52

Dr. Smith's ECG Blog

DECEMBER 19, 2018

A middle-aged woman had an acute onset of chest pain and dyspnea. The pain had almost resolved by the time an ECG was obtained in the ED: Here is the computer diagnosis What do you think? This confirms that there were dynamic signs of ischemia on the initial ECG. The ST depression in aVL is also resolved.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Paddy Barrett

DECEMBER 5, 2023

Whether stenting a narrowed coronary artery improves symptoms such as chest pain (angina) or shortness of breath is a very different question. Subscribe now 1 ISCHEMIA Research Group. 2018 Jan 6;391(10115):31-40. What About Symptoms? This is not about making you live longer; it is about making you feel better.

Stents 59

Stents Stent Angina Heart attacks 59

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). Later on during the night of his admission he had a short episode of chest pain that resolved with sublingual nitroglycerin. His vitals were initially normal.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? ST depression. Myocardial Contusion?

Tachycardia 110

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 110

Dr. Smith's ECG Blog

NOVEMBER 24, 2018

If it is a chest pain patient, I would get a formal echo and serial ECGs. There were no others: Notice the similarities to the ECG above, confirming that they are baseline Then he sent the clinical history, which was of a malfunctioning ICD, but without any chest pain or SOB. And look for an old EKG."

Chest Pain 52

Chest Pain Exercise Myocardial Infarction Ischemia 52

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This is the initial ECG: The QRS is widened with a regular cadence, and there are no discernable P waves.

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Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Case An elderly patient had acute chest pain and 911 was called. Here is our abstract from SAEM 2018. And, in cases like the elderly patient with new-onset chest pain presented here — definitive diagnosis of acute STEMI is sometimes deceptively easy. What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

JULY 31, 2018

About this time, the 4th troponin, drawn at 8 hours after onset of pain, peaked at 20.956 ng/mL. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. It they are static, then they are not due to ischemia. Again, cath lab was not activated. Circ Cardiovasc Interv.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

male with a history of HTN and ETOH developed squeezing epigastric abdominal pain with associated vomiting and diaphoresis, followed by a syncopal episode which lasted about 10 seconds. When medics arrived, he denied any chest pain, shortness of breath, or palpitations prior to the syncopal episode.

Chest Pain 52

Chest Pain Ischemia Angina Electrocardiogram 52

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. She was reportedly "pacing in her room while holding her chest". Journal of Electrocardiology 2018. TnI peaked at 67.10

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Am J Cardiol 2018; 122(8):1303-1309. This is the initial ED ECG of a 46 year old male with chest pain: The QTc was 420 ST Elevation at 60 ms after the J-point in lead V3 = 2.5 ng/ml) A 45 year old male called 911 for chest pain: The QTc was 400 ST Elevation at 60 ms after the J-point in lead V3 = 3.5 QRS V2 = 15.5

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Ken Grauer, MD

JULY 15, 2023

Additional Teaching Points: Type-2 MI ( M yocardial I nfarction ) — is defined by an increase in troponin with evidence of ischemia that is not due acute coronary disease, but which instead results from a mismatch in oxygen supply and demand ( Smilowitz et al — Coron Artery Dis 29(1):46-52, 2018 ).

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Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Dr. Smith's ECG Blog

APRIL 15, 2019

If a patient presents with chest pain and a normal heart rate, or with shockable cardiac arrest, then ischemic appearing ST elevation is STEMI until proven otherwise. CLICK HERE — for the ESC/ACC/AHA/WHF 2018 Consensus Document on the 4th Universal Definition of MI, in which these concepts are discussed and illustrated.

Tachycardia 52

Tachycardia STEMI Chest Pain Ischemia 52

Ken Grauer, MD

APRIL 5, 2024

As a result, the ST elevation ( with especially tall, peaked T wave in lead V2) — is not indication of acute ischemia. Today's patient is a middle-aged woman who presented with low back pain, shortness of breath and marked hypertension — but no chest pain.

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Blog Ischemia Chest Pain Hypertension 96

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.

Chest Pain 120

Chest Pain Myocardial Infarction Blog Stent 120

Dr. Smith's ECG Blog

DECEMBER 27, 2018

But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI. All bets would be off if instead of no chest pain, this patient had worrisome new-onset symptoms. The Ratios of STE to S-wave: V1: 2.5/16 P EARL : Clinical correlation is KEY in this case.

Chest Pain 52

Chest Pain Hypertension STEMI Heart Disease 52

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.

Chest Pain 52

Chest Pain Tachycardia Atrial Flutter Ultrasound 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

Denied headache, chest pain, nausea / vomiting. If this patient had chest pain and the value suggested early repol, I would be very hesitant to act on it. 2) There are three causes of tall T waves; hyperkalemia, hyperacute ischemia and normal variant (Atlas of Electrocardiography by K. Wang, (pages 222-224).

STEMI 52

STEMI Chest Pain RN Anatomy 52

Ken Grauer, MD

JANUARY 13, 2024

My written interpretation on a tracing such as this one would read, "Marked LVH and 'strain' and/or ischemia — with need for clinical correlation." BOTTOM Line: Today's patient presented with a 2-3 day history of chest pain and the ECG shown in Figure-1. ECG Blog #276 — and ECG Blog #309 — Reviews the entity of Giant T waves.

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Blog Ischemia AFIB Hypertension 148

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. Smith. But maybe not. You can see the deficiency of the definition of MI. Thelin et al.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 52

Ken Grauer, MD

JUNE 2, 2023

ie, with syncope-presyncope, fatigue, dyspnea, chest pain? ). Ruling out other potential causes of bradycardia ( ie, recent ischemia-infarction; hypothyroidism ). The July 5, 2018 post in Dr. Smith's ECG Blog — ( Please see My Comment at the bottom of the page for Review on the ECG diagnosis of S ick S inus Syndrome).

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Blog Bradycardia Arrhythmia Tachycardia 78

DAIC

JANUARY 3, 2024

Traditional methods of non-invasive ischemia testing (stress EKG , stress echo, SPECT , PET , direct-to-cath) can result in false negatives 20-30 percent of the time, which can lead to undetected disease, and false positives over 50 percent of the time, which can lead to unnecessary invasive procedures. Neth Heart J 2018. Patel et al.

Coronary Artery Disease 59

Coronary Artery Disease Chest Pain Plaque Technology 59

Dr. Smith's ECG Blog

MARCH 15, 2023

She did notice something slightly wrong subjectively, but had no palpitations, chest pain, or SOB, or any other symptom. For more on SSS — See My Comment at the bottom of the page in the July 5, 2018 post in Dr. Smith’s ECG Blog. Her Apple Watch suddenly told her that she is in atrial fibrillation. She was on no medications.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 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. Written by Pendell Meyers A man in his 70s with no cardiac history presented with acute weakness, syncope, and fever.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 70

Dr. Smith's ECG Blog

OCTOBER 26, 2020

There is sinus rhythm with a relatively normal QRS complex followed by a hint of STD that is maximal in V4-V6, which appears to me to be an expected amount of supply-demand mismatch ischemia from his immediately post-ROSC state. The patient was not experiencing any typical coronary chest pain at these short episodes of ST-E.

Ischemia 52

Ischemia Arrhythmia Defibrillator Chest Pain 52

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. Back to the case: The providers recognized persistent ischemia and likely occlusion, and discussed this with cardiology who took the patient immediately for cath. They opened it.

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STEMI Chest Pain Myocardial Infarction Ischemia 52