2018, Chest Pain and Myocardial Infarction

Which patient has the more severe chest pain?

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

2 middle aged males presented with chest pain. Which had the more severe chest pain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chest pain at the time the ECG was recorded. 414 patients were included in the analysis.

Chest Pain

Chest Pain STEMI Myocardial Infarction Hospital

A man in his 70s with acute chest pain and paced rhythm.

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. Why is there this notion that myocardial infarction cannot be diagnosed in the setting of ventricular paced rhythm?

Chest Pain

Chest Pain Myocardial Infarction STEMI Pacemaker

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. Literature cited In inferior myocardial infarction, neither ST elevation in lead V1 nor ST depression in lead I are reliable findings for the diagnosis of right ventricular infarction Johanna E. The July 29, 2018 post ( LA-RA reversal ).

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

Chest Pain and Inferior ST Elevation.

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.

Chest Pain

Chest Pain Pericarditis Tachycardia Myocardial Infarction

HeartFlow Announces Revolutionary Five-Year Data Demonstrating a 63 Percent Mortality Reduction with FFRCT-Guided Care in PAD Patients

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. For more information: www.heartflow.com References 1 Krievins, Dainis K.,

Coronary Artery Disease

Coronary Artery Disease Chest Pain Myocardial Infarction Ischemia

An elderly male with shortness of breath

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. Timing of revascularization in patients with transient ST segment elevation myocardial infarction: a randomized clinical trial. Eur Heart J 2018. A 70-something y.o. Lemkes et al. Full text link.

Chest Pain

Chest Pain Myocardial Infarction STEMI Critical Care

A Middle-Aged male with Chest Pain and an Unusual ECG

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.

Chest Pain

Chest Pain STEMI Ischemia Myocardial Infarction

European Society of Cardiology 0/1-hour algorithm (high-sensitivity cardiac troponin T) performance across distinct age groups

Heart BMJ

MAY 23, 2024

Background To determine if the European Society of Cardiology 0/1-hour (ESC 0/1-h) algorithm with high-sensitivity cardiac troponin T (hs-cTnT) meets the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (MI) in older, middle-aged and young subgroups.

Chest Pain

Chest Pain Myocardial Infarction Risk Factors

If you had recorded an ECG during chest pain, what would it have shown?

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. Electrocardiographic diagnosis of reperfusion during thrombolytic therapy in acute myocardial infarction.

Chest Pain

Chest Pain Myocardial Infarction STEMI Article

Is OMI an ECG Diagnosis?

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%. Clin Cardiol 2022 4.

STEMI

STEMI Chest Pain Myocardial Infarction Stent

Agepha Pharma and Caristo Diagnostics Team Up to Fight Coronary Inflammation

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.” In June 2023, the U.S.

Heart attacks

Heart attacks Heart Attack Technology Cardiovascular Disease

A man in his 80s with chest pain and ventricular paced rhythm

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

Chest Pain Myocardial Infarction Pacemaker STEMI

The Advantages Of A CT Coronary Angiogram

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.

Coronary Angiogram

Coronary Angiogram Plaque Coronary Artery Disease Chest Pain

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. She's had multiple PCI procedures.

Chest Pain

Chest Pain Ischemia Pacemaker Stent

In Your 40s to 60s And Worried About Heart Disease? Here Is What You Can Do.

Dr. Paddy Barrett

JANUARY 30, 2024

MI = Myocardial Infarction/Heart Attack However, there are two very important caveats. 2023, 2 Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. 2018 Sep 6;379(10):924-933. So a very low chance. This was compared to using exercise stress testing. Journal of Cardiovascular Computed Tomography, Oct 9.

Heart Disease

Heart Disease Heart Attack Heart attacks Plaque

I'm so sorry when medics get abused for activating the cath lab

Dr. Smith's ECG Blog

OCTOBER 28, 2022

This is obviously diagnostic of inferior and lateral Occlusion Myocardial Infarction. The location of the infarct is clear, but that does not necessarily tell you what artery it is. Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria.

Chest Pain

Chest Pain Myocardial Infarction Pacemaker Cardiogenic Shock

Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm

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. Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Eur Heart J 2018 4. Who needs the cath lab? Int J Cardiol Heart Vasc 2021 2.

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

A 40-something with 100 minutes of chest pain

Dr. Smith's ECG Blog

MARCH 27, 2023

(Unusual and puzzling, as there was a large focal acute MI) Final Diagnosis: Acute MI, Non ST Elevation Myocardial Infarction. The presence or absence of ST Elevation is a poor marker with which to describe a myocardial infarction. = NSTEMI is extremely heterogenous, from a very tiny Non-OMI to a massive OMI.

Chest Pain

Chest Pain Ischemia Myocardial Infarction Blog

The computer calls this a “normal ECG”. We'll just keep making this point.

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? ng/ml , a three-fold increase from troponin #2, also confirming acute myocardial infarction. It was not normal!

Chest Pain

Chest Pain Ischemia Myocardial Infarction Angina

What do you think the echocardiogram shows in this case?

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. EMS gave 324 mg aspirin and 3 sublingual NTG, which the patient stated reduced the substernal chest pain from an 8/10 to 4/10. The ECG only tells you there is ischemia, not the etiology of it.

Echocardiogram

Echocardiogram Ischemia Chest Pain Blog

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Case An elderly patient had acute chest pain and 911 was called. Details cannot be shared here, but suffice it to say that inability to recognize acute occlusive myocardial infarction in the presence of ventricular paced rhythm contributed to a poor outcome. Here is our abstract from SAEM 2018. What do you think?

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article

Dr. Smith's ECG Blog

JULY 31, 2020

The finding of dynamic ST-T wave changes on serial tracings in association with a change in chest pain symptoms ( SEE My Comment in the July 21, 2020 post ). Any ST elevation in inferior leads that occurs in association with mirror-image opposite ST depression in lead aVL. ST depression that is maximal in leads V2-to-V4.

STEMI

STEMI Article Chest Pain Blog

Large T-waves and a Computer Interpretation of Acute MI

Dr. Smith's ECG Blog

NOVEMBER 24, 2018

Here it is: Computer Interpretation: SINUS RHYTHM INFERIOR MYOCARDIAL INFARCTION, POSSIBLY ACUTE ST ELEVATION, CONSIDER ANTERIOR INJURY [MARKED ST ELEVATION W/O NORMALLY INFLECTED T WAVE IN V2-V5] ACUTE MI What do you think? If it is a chest pain patient, I would get a formal echo and serial ECGs. And look for an old EKG."

Chest Pain

Chest Pain Exercise Myocardial Infarction Ischemia

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. His inpatient clinicians did not think that an urgent angiogram was warranted given that he was chest pain free, his EKG appeared nondiagnostic, and serial troponins were not elevating beyond 2 ug/L. Patients on dialysis often do not have chest pain in the setting of acute MI. Why is this?

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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. Am J Med 2019, 132(5):622-630. Miranda DF, Lobo AS, Walsh B, et al.

Ischemia

Ischemia STEMI Stenosis Coronary Artery Disease

An athletic 30-something woman with acute substernal chest pressure

Dr. Smith's ECG Blog

JULY 31, 2018

This is diagnostic of myocardial infarction. In middle age women, it accounts for 22-35% of all ACS presentations 1,3 , and the reported incidence of ST-elevation myocardial infarction in this subset of patients is variable, but estimated to be between 24-50% 4. She felt more comfortable being admitted. Int J Cardiol.

SCAD

SCAD Chest Pain Myocardial Infarction Ischemia

Acute OMI or "Benign" Early Repolarization?

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

Chest Pain Myocardial Infarction Blog Stent

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Electrocardiographic Differentiation of Early Repolarization FromSubtle Anterior ST-Segment Elevation Myocardial Infarction. 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

Chest Pain

Chest Pain STEMI Bradycardia Stenosis

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Dr. Smith's ECG Blog

OCTOBER 24, 2018

Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. First, the name (Myocardial Infarction or Not) is not important. A subsequent troponin drawn 6 hours after symptom onset , remained below the LoD.

STEMI

STEMI Angina Myocardial Infarction Plaque

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

Cardiology felt her chest pain to be, most likely, the result of coronary supply-demand mismatch in the context of HCM endothelial remodeling (i.e. New insights into the use of the 12-lead electrocardiogram for diagnosing acute myocardial infarction in the emergency department. Below are two examples of this.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

Another Inadequate Paper Published on Triage ECGs, whose Conclusions Need Scrutiny.

Dr. Smith's ECG Blog

OCTOBER 9, 2018

The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction. 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).

Chest Pain

Chest Pain STEMI Cardiac Arrest Heart Failure

A young patient with diminishing pain with a subtle but diagnostic ECG.

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Case A 39-year-old male without prior medical history presents with chest pain that started 2 hours prior to presentation. He says that the pain intensity was 10/10 at home but now about 4/10. mm STE even in the fourth universal definition of myocardial infarction. Here are his publications.) What do you think ?

Myocardial Infarction

Myocardial Infarction Chest Pain Blog Echocardiogram

What will you do for this patient transferred to you who is now asymptomatic?

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. Mechanical Reperfusion in Patients with Acute Myocardial Infarction Presenting More than 12 Hours from Symptom Onset: A Randomized Controlled Trial. mm STE in V1 and 1.5-2.0

STEMI

STEMI Chest Pain Myocardial Infarction Ischemia

A "normal ECG" on a busy night

Dr. Smith's ECG Blog

OCTOBER 6, 2018

We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. The day prior to presentation (about 12 hours prior to presentation) he described sudden onset chest pain and shortness of breath while gardening in his back yard. He had no further pain and went to bed that night with no complaints.

Chest Pain

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease

Is there a Right Ventricular MI in addition to Infero-postero-lateral MI?

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. But which myocardial walls are affected? Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI. She called 911. Figure-2: TOP — Initial ECG obtained pre-hospital.

Chest Pain

Chest Pain STEMI Ischemia Blog

I was shown this ECG without any information. What do you think?

Dr. Smith's ECG Blog

NOVEMBER 8, 2022

The patient had come to the ED for SOB, but without any chest pain. This was not a myocardial infarction of any kind. Other cases of Pulse Tapping Artifact: Acute chest pain and a bizarre ECG Bizarre (Hyperacute??) Therefore, as many as 11 of the 12 leads can look bizarre. He had a 10 pound weight loss.

Article

Article Chest Pain Blog Myocardial Infarction

Cardiovascular Update

Which patient has the more severe chest pain?

A man in his 70s with acute chest pain and paced rhythm.

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Chest Pain and Inferior ST Elevation.

HeartFlow Announces Revolutionary Five-Year Data Demonstrating a 63 Percent Mortality Reduction with FFRCT-Guided Care in PAD Patients

An elderly male with shortness of breath

A Middle-Aged male with Chest Pain and an Unusual ECG

European Society of Cardiology 0/1-hour algorithm (high-sensitivity cardiac troponin T) performance across distinct age groups

If you had recorded an ECG during chest pain, what would it have shown?

Is OMI an ECG Diagnosis?

Agepha Pharma and Caristo Diagnostics Team Up to Fight Coronary Inflammation

A man in his 80s with chest pain and ventricular paced rhythm

The Advantages Of A CT Coronary Angiogram

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

In Your 40s to 60s And Worried About Heart Disease? Here Is What You Can Do.

I'm so sorry when medics get abused for activating the cath lab

Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm

A 40-something with 100 minutes of chest pain

The computer calls this a “normal ECG”. We'll just keep making this point.

What do you think the echocardiogram shows in this case?

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article

Large T-waves and a Computer Interpretation of Acute MI

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

An athletic 30-something woman with acute substernal chest pressure

Acute OMI or "Benign" Early Repolarization?

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Hypertrophic Cardiomyopathy

Another Inadequate Paper Published on Triage ECGs, whose Conclusions Need Scrutiny.

A young patient with diminishing pain with a subtle but diagnostic ECG.

What will you do for this patient transferred to you who is now asymptomatic?

A "normal ECG" on a busy night

Is there a Right Ventricular MI in addition to Infero-postero-lateral MI?

I was shown this ECG without any information. What do you think?

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