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

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." examined SCAD presenting as STEMI (unlike Hassan et al.

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Chest Pain SCAD STEMI Cardiogenic Shock 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

MAY 6, 2019

The patient presented with chest pain. If it is STEMI, it would have to be RBBB with STEMI. 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. This ECG was sent from South Asia.

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 27, 2023

I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI. Also ( as per Dr. Smith ) — there is subtle-but-real ST depression in chest leads V2-thru-V5. I was reading ECGs on the system, and saw this one: What do you think?

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Chest Pain Ischemia Myocardial Infarction Blog 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

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. So you are going to get to see what the ECG would have shown had you recorded one during pain!

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Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

OCTOBER 28, 2020

This ECG was texted to me with the implied question "Is this a STEMI?": I responded that it is unlikely to be a STEMI. Septal STEMI often has ST depression in V5, V6, reciprocal to V1. Then combine with clinical presentation and low pretest probability 2 Saddleback STEMIs A Very Subtle LAD Occlusion.T-wave wave in V1??

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STEMI Chest Pain Blog Tachycardia 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria.

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Chest Pain STEMI Blog Academic 52

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 importance of the new OMI ( vs the old STEMI ) Paradigm — See My Comment in the July 31, 2020 post in Dr. Smith's ECG Blog.

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Blog STEMI Ischemia Chest Pain 151

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. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

JULY 31, 2020

Meyers, Weingart and Smith published their OMI Manifesto — in which they extensively document the critically important concept that management of acute MI by separation into a “STEMI” vs “non-STEMI” classification is an irreversibly flawed approach.

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STEMI Article Chest Pain Blog 52

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. Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Eur Heart J 2018.

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Chest Pain Myocardial Infarction STEMI Pericarditis 116

Dr. Smith's ECG Blog

OCTOBER 9, 2018

October 2018. link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. They did not find one STEMI on their triage ECGs (no surprise! We at HCMC have 30 walk-in STEMIs per year; the rest come by ambulance. Fair enough.

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Chest Pain STEMI Cardiac Arrest Blog 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2018

A 50-something presented with epigastric and chest pain. Saddleback ST Elevation is almost never STEMI 2. Here are other cases of saddleback STE: Is this Saddleback a STEMI?? Here is his ECG: What do you think? QTc 388 ms. The patient was diagnosed with reflux Learning Points : 1. wave in V1??

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STEMI Chest Pain Cardiac Arrest Anatomy 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Written by Pendell Meyers Two adult patients in their 50s called EMS for acute chest pain that started within the last hour. Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization."

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STEMI Chest Pain Blog Pericarditis 125

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

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

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 Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. An ECG was recorded immediately at triage and, at this hospital, the Queen of Hearts is routinely used to determine cath lab activation.

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Hospital Chest Pain Blog Pulmonary 77

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

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Pericarditis Chest Pain Stent Stents 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. 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

Ken Grauer, MD

APRIL 18, 2023

Figure-1: The initial ECG in today's case — obtained from a 50-year old man with new chest pain. ( The deep anterior S waves and tall lateral chest lead R waves suggest significant LVH. The July 29, 2018 post ( LA-RA reversal ). The November 4, 2018 post ( Leads V1,V2 misplacement ). HINT: Is the rhythm sinus ?

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Blog STEMI Chest Pain Physiology 78

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Written by Pendell Meyers, edits by Steve Smith A man in his 60s with history of hypertension and MI 10 years ago, with PCI, presented to an outside hospital complaining of chest pain that started while mowing the lawn. The case was reviewed by all parties, and it was stated correctly that the ECG does not meet the STEMI criteria.

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Chest Pain STEMI Cardiac Arrest Aneurysm 52

Ken Grauer, MD

JANUARY 26, 2023

The ECG in Figure-1 was obtained from a previously healthy older man — who complained of chest pain and “lightheadedness” while this tracing was recorded. His chest pain had begun the night before. Figure-1: 12-lead ECG and long lead II rhythm strip — obtained from an older man with chest pain and “lightheadedness. (

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Blog Chest Pain STEMI Arrhythmia 78

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

DECEMBER 29, 2018

Written by Pendell Meyers A male in his 50s with history of HTN, DM, HLD presented with chest pain of less than one hour duration. Here is a repeat ECG 45 minutes later with persistent chest pain: Obviously progressing into a clear STEMI. Meets formal STEMI criteria in V2-V3.

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Chest Pain STEMI Diabetes Hypertension 52

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. My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. Smith.

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STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

JULY 26, 2023

The combination of absence of chest pain and history of LV aneurysm made it easy to assess that this patient does not have acute OMI. At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. The patient ruled out by serial troponins.

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Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

OCTOBER 8, 2018

Steffen writes this case: "A few weeks ago I was able to recognize a STEMI because of what I had seen on your blog." "I I have enclosed the ECG from a 50-something year old male who complained of chest pain. For clarity — I’ve labeled the compressed 12-lead tracing of this 50-ish year old man with new chest pain ( Figure-1 ).

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STEMI Chest Pain Blog Atherosclerosis 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

This appears to be a classic Wellens' ECG, Pattern A, with terminal T-wave inversion in V2-V4, preserved R-waves, and it appears to be Wellens' syndrome, as it occurred after resolution of typical angina pain. Wellens' syndrome represents the aftermath of an unrecorded occlusion (STEMI) with spontaneous reperfusion. Learning Points: 1.

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Chest Pain Angina Ischemia Stenosis 52

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.

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Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Am J Cardiol 2018; 122(8):1303-1309. Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? 100% LAD occlusion.

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Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

Denied headache, chest pain, nausea / vomiting. Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 mm in V2 and 4.08

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STEMI Chest Pain RN Anatomy 52

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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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. 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.

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Chest Pain STEMI Ischemia Blog 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? in leads with at least 1 mm STE.

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