Dr. Smith's ECG Blog

APRIL 22, 2022

Written by Jesse McLaren, with comments from Smith and Grauer A 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. A prospective validation of the HEART score for chest pain patients at the emergency department. JAMA Intern Med 2019 9. Int J Cardiol 2013 2.

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Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

APRIL 22, 2019

He then went on to say: "40-something with chest pain for one hour. Burning pain subxiphoid and into throat." It does not usually represent subendocardial ischemia, but rather it is usually reciprocal ST depression, reciprocal to inferior ST elevation. (But Had episode of nausea and dizziness when it started.

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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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Dr. Smith's ECG Blog

DECEMBER 16, 2019

A 50-something male who is healthy and active with no previous medical history presented with 5 hours of continuous worrisome chest pain. Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated.

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Dr. Smith's ECG Blog

NOVEMBER 1, 2022

2 days later This is a typical LVH pattern, without ischemia Patient underwent 4 vessel CABG. Upon questioning patient, he denies having any chest pain or chest tightness of any sort. Pericarditis would be even more unlikely in someone without chest pain. Chest pain is squeezing or tight in nature.

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Dr. Smith's ECG Blog

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. His wife contacted the ambulance service after the patient experienced an episode of loss of consciousness.

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Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. A prior ECG was available for comparison: Normal One might be tempted to interpret the ST depression as ischemia, but as Smith says, "when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave." Chest pain in high risk patient. Is it STEMI?

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Ischemia Chest Pain Cardiac Arrest Blog 127

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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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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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 ).

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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.

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Dr. Smith's ECG Blog

MAY 3, 2024

When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI). Here are some cases of RBBB with LAFB: What is the Diagnosis in this 70-something with Chest Pain? There is STE in aVR.

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Dr. Smith's ECG Blog

AUGUST 2, 2024

Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain. In this patient's case, the RV ischemia manifested as dramatic anterior hyperacute T waves. This degree of STE is a bit atypical for LAD ischemia. His ECG is shown below.

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Ken Grauer, MD

APRIL 14, 2023

The ECG in Figure-1 was obtained from a 90-year old woman — who presented with a 2-to-3 day history of chest pain, that became worse on the day of admission. The terminology favored to describe these ECG findings is diffuse subendocardial ischemia ( See ECG Blog #271 — for more on diffuse subendocardial ischemia ).

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Dr. Smith's ECG Blog

AUGUST 4, 2024

Context: a man in his 40s presented to the emergency department with 1 day of sudden onset chest pain. That said — I did not interpret these differences as the result of acute ischemia. I sent this to our group without information and Dr. Smith responded: "Not OMI. Pericarditis maybe."

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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.

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Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

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Dr. Smith's ECG Blog

OCTOBER 15, 2024

He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. Still, such dramatic changes cannot be overlooked.

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Dr. Smith's ECG Blog

APRIL 24, 2020

A middle aged man had off and on chest pain for 2 weeks, then 2 hours of more severe and constant pain. Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Similarly, STD in aVL is usually reciprocal to inferior ST elevation, not "lateral ischemia."

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Ken Grauer, MD

MARCH 7, 2023

But, in a patient who presents to the ED for new chest pain — seeing these subtle findings that are localized to leads V2- thru -V4 should at the least make you consider acute posterior OMI ( O cclusion-based MI ) — until you prove otherwise. To EMPHASIZE: These are subtle findings. What do YOU think?

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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. I believe this is by far the most common outcome for this patient around the world in 2019. This ECG was recorded on arrival: What do you think? mm STE in V1 and 1.5-2.0

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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. Anything more on history?

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Dr. Smith's ECG Blog

MARCH 11, 2019

The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." Here is the patient's troponin I profile: These were interpreted as due to demand ischemia, or type II MI. ng/mL is seldom a result of demand ischemia (type 2 MI). First was 2.9

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Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain.

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Dr. Smith's ECG Blog

OCTOBER 12, 2024

or basilar ischemia. Not a STEMI: Reasons I did not think ECG #1 represented an acute STEMI — included the following: There was no history of chest pain. EKG on arrival to the ED is shown below: What do you think? On my initial interpretation, the patient has normal sinus rhythm with a narrow QRS complex, and LVH.

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Dr. Smith's ECG Blog

AUGUST 26, 2019

She did not report any chest pain or pressure. She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? The morphology of STE is not diagnostic of being due to acute transmural ischemia.

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Dr. Smith's ECG Blog

APRIL 7, 2019

The patient was a 70-something yo previously healthy male on no medications who presented to the ED with epigastric pain, onset over a few hours. He denied chest pain of any sort and his vitals were all normal. They cannot be assumed due to LV strain ( and they cannot be assumed to represent ischemia ).

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Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

This patient's ischemia was so brief that it did not cause any myocardial stunning. The patient is a 40-something year old man with new chest pain. In a patient with new chest pain — these T wave changes for beats labeled “ B ” in leads V1 , V2 and V3 constitute h yperacute T waves ! The QTc is normal.

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Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

A 40-something woman with diabetes and peripheral vascular disease who frequently needs the ED for chronic pain called 911 for sudden severe chest pain. Does this mean that the ST depression in V3 represents "anterior" subendocardial ischemia, and not posterior OMI? non-occlusive ischemia) 2.

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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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Ken Grauer, MD

JUNE 6, 2023

Part of the ST depression with deep T wave inversion in the lateral chest leads clearly reflects LV "strain" from the marked LVH — but despite the very large QRS amplitudes, this ST-T wave appearance looks disproportionate, suggesting at least a component of ischemia.

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Dr. Smith's ECG Blog

FEBRUARY 5, 2019

He was asked multiple times about chest pain or dyspnea, but repeatedly denied any such symptoms. Patient denied chest pain on initial review of symptoms. Was now endorsing chest pain which began 30 minutes ago. Upon further questioning, he states that he has had intermittent chest pain since yesterday.

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Dr. Smith's ECG Blog

FEBRUARY 10, 2023

Inferior ST Depression does NOT mean there is inferior subendocardial ischemia; it is generally reciprocal to high lateral (aVL) subepicardial ischemia (OMI/STEMI) == MY Comment by K EN G RAUER, MD ( 2/10/2023 ): == There are certain patterns in ECG interpretation that experienced providers are able to immediately recognize.

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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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Dr. Smith's ECG Blog

DECEMBER 15, 2023

The patient contacted EMS after a few hours of chest pain that started 5:30 AM. The pain was described as 6/10 radiating to the right shoulder. The chest pain was described as both sharp and pressure like. He is otherwise healthy. Vital signs were within normal limits, and the patient was not ill appearing.

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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. This, in turn, could produce platelet aggregation and vasospasm and result in an acute coronary syndrome." Clinical Context is everything !

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Dr. Smith's ECG Blog

AUGUST 8, 2020

Weren't you taught that "new tall T wave in V1" is concerning for ischemia, and so this is the opposite? Meyers, are the only leads thus far for which data documents the diagnostic benefit of this finding ( For brief review + illustration of T-QRS-D — SEE My Comment at the bottom of the November 14, 2019 post).

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