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.

STEMI 52

STEMI Article Chest Pain Blog 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!

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 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.

Chest Pain 116

Chest Pain Myocardial Infarction STEMI Critical Care 116

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

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.

Blog 128

Blog STEMI Ischemia Chest Pain 128

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??

STEMI 52

STEMI Chest Pain Cardiac Arrest Anatomy 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 ).

Blog 100

Blog Chest Pain Ischemia STEMI 100

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. There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

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.

Aneurysm 52

Aneurysm Chest Pain STEMI Bradycardia 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."

STEMI 120

STEMI Chest Pain Blog Pericarditis 120

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 ?

Blog 78

Blog STEMI Chest Pain Physiology 78

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?

Chest Pain 106

Chest Pain Myocardial Infarction Pacemaker STEMI 106

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?

Pericarditis 78

Pericarditis Blog Chest Pain Coronary Angiogram 78

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. (

Blog 78

Blog Chest Pain STEMI Arrhythmia 78

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?

Ischemia 52

Ischemia STEMI Stenosis Coronary Artery Disease 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.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 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 ).

STEMI 52

STEMI Chest Pain Blog Atherosclerosis 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?

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 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

STEMI 52

STEMI Chest Pain RN Anatomy 52

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.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

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. Is this OMI?

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Tachycardia 52

Tachycardia STEMI Chest Pain Ischemia 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.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 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??

STEMI 52

STEMI Chest Pain Blog Tachycardia 52

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. 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.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 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. That may be the case.

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 52

EMS 12-Lead

APRIL 14, 2022

Factors consistently manifesting as such, in addition to chest pain, include, diaphoresis, vomiting, radiation of pain (most alarming when inclusive of both arms), and pain aggravated by exertion. [1] It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS).

ACE Inhibitor 52

ACE Inhibitor Physiology Chest Pain Academic 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. Again, cath lab was not activated. Circ Cardiovasc Interv.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

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 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

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

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 ).

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

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

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.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Heart Failure 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."

STEMI 52

STEMI Chest Pain Myocardial Infarction Ischemia 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.

Chest Pain 70

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 70

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 52

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 52

Dr. Smith's ECG Blog

MAY 5, 2022

He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. What is it?

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52