2020, Bradycardia and Chest Pain - Cardiovascular Update

Serial ECGs for chest pain: at what point would you activate the cath lab?

Dr. Smith's ECG Blog

AUGUST 11, 2024

Written by Jesse McLaren A healthy 75 year old developed 7/10 chest pain associated with diaphoresis and nausea, which began on exertion but persisted. Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. What do you think?

Chest Pain

Chest Pain STEMI Bradycardia Stent

A 50-something with chest pain. Is there OMI? And what is the rhythm?

Dr. Smith's ECG Blog

MARCH 22, 2024

Written by Willy Frick A man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. preceding each of the fascicular beats — indicating a faster rate for the escape rhythm compared to the sinus bradycardia ).

Chest Pain

Chest Pain STEMI Bradycardia Ischemia

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. Here is his ED ECG: There is bradycardia with a junctional escape. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. The February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ).

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

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Normal angiogram one week prior. Must be myocarditis then?

Dr. Smith's ECG Blog

JUNE 5, 2024

The patient presented due to chest pain that was typical in nature, retrosternal and radiating to the left arm and neck. He denied any exertional chest pain. It is unclear if the patient was pain free at this time. He has a medical hx notable for hypertension, hyperlipidemia and previous tobacco use disorder.

Chest Pain

Chest Pain Blog Cardiac Arrest Cardiomyopathy

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. Bradycardia.

Chest Pain

Chest Pain STEMI Ischemia Myocardial Infarction

ECG Blog #396 — Why the Flat Line?

Ken Grauer, MD

SEPTEMBER 22, 2023

The rhythm is sinus bradycardia at a rate just over 50/minute. Although difficult to measure ( because of marked overlap of the QRS in multiple chest leads ) — there appears to be greatly increased QRS amplitude, consistent with voltage for LVH. The February 11, 2020 post ( LA-RA reversal ).

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Blog Chest Pain Bradycardia Physiology

ECG Blog #392 — Repolarization T Waves?

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. PEARL # 2: Applying PEARL #1 to today's case — the fact that this patient's symptoms began before ECG #1 was obtained, and that his chest pain had resolved by the time ECG #1 was recorded — strongly suggests that the "culprit" artery may have spontaneously opened.

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Blog Chest Pain STEMI Ischemia

See what happens when a left main thrombus evolves from subtotal occlusion to total occlusion.

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 history in today's case with sudden loss of consciousness followed by chest pain is very suggestive of ACS and type I ischemia as the cause of the ECG changes. What do you think?

Cardiogenic Shock

Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest

What are treatment options for this rhythm, when all else fails?

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. Written By Magnus Nossen — with edits by Ken Grauer and Smith. The below ECG was recorded.

Arrhythmia

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

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. Angiography revealed a 30% nonobstructive stenosis of the mid LAD.

Chest Pain

Chest Pain STEMI Echocardiogram Stent

A Middle Aged Male diagnosed with Gastroesophageal Reflux

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The computer called "Sinus Bradycardia" only (implying that everything else is normal. The overreading Cardiologist called it only "Sinus Bradycardia" with no other findings. There is zero ST Elevation.

Chest Pain

Chest Pain Bradycardia Blog Critical Care

Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?

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. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. He complained of generalized weakness and left lower extremity numbness. What is it? Activate the Cath Lab?

Chest Pain

Chest Pain Bradycardia Cardiac Arrest STEMI

Cardiologist declines taking patient to the cath lab. Patient dies.

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Apparently he denied chest pain. JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain. Chest pain and Concordant ST Depression in a patient with aortic valve and previously normal angiogram Right Bundle Branch Block and ST Depression in V1-V3.

Chest Pain

Chest Pain STEMI Blog Tachycardia

Why do we NOT name Occlusion MI (OMI) after an EKG finding? (In contrast to STEMI, which is named after ST Elevation)

Dr. Smith's ECG Blog

JUNE 1, 2022

A 40-something male with no previous cardiac disease presented with chest pain. The pain continued and the first high sensitivity troponin I returned at 105 ng/L Another ECG was recorded: The ST segment in aVF has flattened a bit, revealing that there is some STD in addition to the non-specific findings in III and aVL.

Chest Pain

Chest Pain STEMI Myocardial Infarction Bradycardia

What kind of AV block is this? And why does she develop Ventricular Tachycardia?

Dr. Smith's ECG Blog

JANUARY 23, 2024

There was no chest pain. For example — bradycardia and AV conduction disturbances are not uncommon with Hyperkalemia , with these conduction disturbances most often resolving once serum K+ is corrected. This was written by Magnus Nossen The patient is a female in her 50s. She was feeling fine prior to the last seven days.

Tachycardia

Tachycardia Arrhythmia Heart Disease Sudden Cardiac Death

7 steps to missing posterior Occlusion MI, and how to avoid them

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. Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. JAMA Cardiol 2020 5. -- Litell JM, Meyers HP, Smith SW.

STEMI

STEMI Myocardial Infarction Chest Pain Ischemia

31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!

Dr. Smith's ECG Blog

DECEMBER 20, 2013

He said that his pain does not feel like his previous episode of pericarditis, and is not related to meals. He denied chest pain, shortness of breath, nausea, fever, chills, rashes, cough, and leg pain. He admitted to lifting some heavy objects a few days ago but denied trauma.

Pericarditis

Pericarditis Chest Pain Pulmonary Embolism

A man in his 40s with epigastric pain and ST Elevation

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. See these similar cases: A man in his sixties with chest pain Why is there inferior ST elevation, and would you get posterior leads? Sudden CP and SOB with Inferior ST Elevation and in STE in V1.

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Blog Bradycardia Ischemia Exercise

Syncope and Block

EMS 12-Lead

JUNE 1, 2022

Smith and Myers found that in otherwise classic Wellens syndrome – that is, prior anginal chest pain that resolves with subsequent dynamic T wave inversions on the ECG – even the T waves of LBBB behave similarly. [2] 2] Although the clinical context in today’s case does not fit these descriptors for Type I OMI (e.g. 5] Isnard, R.

Heart Failure

Heart Failure Myocardial Infarction Bradycardia Chest Pain

Cardiac Arrest. What does the ECG show? Also see the bizarre Bigeminy.

Dr. Smith's ECG Blog

APRIL 29, 2020

A recent similar case: A 40-something with chest pain. 3 of the 4 have similarly bizarre PVCs. == MY Comment by K EN G RAUER, MD ( 4/29/2020 ): == Cardiac Arrest with Bizarre PVCs/Torsades de Pointes: Intriguing case with many interesting features. Is this inferior MI? There is a bigeminy with very Bizarre looking PVCs.

Cardiac Arrest

Cardiac Arrest Defibrillator Ischemia Tachycardia

Hyperthermia and ST Elevation

Dr. Smith's ECG Blog

JANUARY 30, 2019

It was from a patient with chest pain: Note the obvious Brugada pattern. The elevated troponin was attributed to either type 2 MI or to non-MI acute myocardial injury. There is no further workup at this time. Smith: Here is a case that was just texted to me today from a former resident. This patient ruled out for MI.

Heart Rhythm

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Dr. Smith's ECG Blog

DECEMBER 5, 2023

days of chest pain that started as substernal and crushing in nature awakening him from sleep and occasionally traveling to right side of neck. The pain was described as constant, worse with deep inspiration and physical activity, sometimes sharp. He reported 1.5

Pediatrics

Pediatrics Pericarditis COVID-19 Congenital Heart Disease

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Dr. Smith's ECG Blog

MARCH 19, 2025

Despite the baseline artifact theres sinus bradycardia, convex ST elevation in III, reciprocal ST depression in aVL and possible anterior ST depression indicating inferoposterior OMI. He was given two separate sprays of nitroglycerin sublingually, neither of which improved his pain but did cause him to become briefly hypotensive ( 600 ng/L.

Chest Pain

Chest Pain STEMI Stents Stent

Normal ECG by many measures. Is it normal?

Dr. Smith's ECG Blog

JANUARY 15, 2025

Case A 68 year old man with a medical history of hypertension, hyperlipidemia, and CAD with stent deployment in the RCA presented to the emergency department with chest pain. A post-cath EKG was recorded at 0719: The computer interpretation read Sinus bradycardia, otherwise normal ECG. He had an EKG recorded right away.

Chest Pain

Chest Pain Stent Stents Risk Factors

Serial ECGs for chest pain: at what point would you activate the cath lab?

A 50-something with chest pain. Is there OMI? And what is the rhythm?

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

Webinars

Normal angiogram one week prior. Must be myocarditis then?

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

ECG Blog #396 — Why the Flat Line?

ECG Blog #392 — Repolarization T Waves?

See what happens when a left main thrombus evolves from subtotal occlusion to total occlusion.

What are treatment options for this rhythm, when all else fails?

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

A Middle Aged Male diagnosed with Gastroesophageal Reflux

Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?

Cardiologist declines taking patient to the cath lab. Patient dies.

Why do we NOT name Occlusion MI (OMI) after an EKG finding? (In contrast to STEMI, which is named after ST Elevation)

What kind of AV block is this? And why does she develop Ventricular Tachycardia?

7 steps to missing posterior Occlusion MI, and how to avoid them

31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!

A man in his 40s with epigastric pain and ST Elevation

Syncope and Block

Cardiac Arrest. What does the ECG show? Also see the bizarre Bigeminy.

Hyperthermia and ST Elevation

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Normal ECG by many measures. Is it normal?

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