Dr. Smith's ECG Blog

MARCH 10, 2025

Written by Jesse McLaren A 50 year old presented to triage with one hour of chest pain, and the following ECG labeled normal by the computer (GE Marquette SL) algorithm. What do you think? Theres normal sinus rhythm, first degree AV block, early R wave, normal voltages. Here is her ECG: What do you think?

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Chest Pain Outcomes STEMI Electrocardiogram 89

Dr. Smith's ECG Blog

DECEMBER 26, 2023

I went to the patient's chart: Elderly woman with stuttering chest pain and SOB, and dizziness. For more on Giant T waves — See My Comment at the bottom of the page in the June 22, 2020 and September 19, 2022 posts in Dr. Smith's ECG Blog ). What do you think now? This is a very typical ECG for Hypertrophic Cardiomyopathy.

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Chest Pain Cardiomyopathy Blog AFIB 94

Dr. Smith's ECG Blog

MAY 23, 2023

Written by Pendell Meyers A man in his early 40s experienced acute onset chest pain. The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset.

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Chest Pain STEMI Blog Stent 98

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. Do either, both, or neither have occlusion MI? Vitals were normal.

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Chest Pain STEMI Pulmonary Embolism 73

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

A 60-something yo female presented w/ exertional chest pain for 3 days. Pain was 8/10 and constant. She has been experiencing progressively worsening exertional dyspnea and chest tightness mostly when climbing up flights of stairs since early September. But the patient has active chest pain.

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Chest Pain Echocardiogram Blog Ischemia 78

Dr. Smith's ECG Blog

JANUARY 8, 2024

Let me tell you about her hospitalization, discharged 1 day prior, but it was at another hospital (I wish I had the ECG from that hospitalization): The patient is 40 years old and presented to another hospital with chest pain and SOB. She had been sitting doing work when she experienced "waves of chest tightness". Sats were 88%.

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Chest Pain Pulmonary Embolism STEMI 71

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. The February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ). The August 28, 2020 post ( LA-LL reversal ). The November 19, 2020 post ( LA-LL reversal ). His prehospital ECG was diagnostic of inferior posterior OMI.

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

There were no injuries and no chest pain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear.

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Chest Pain STEMI Hospital Blog 52

Dr. Smith's ECG Blog

AUGUST 30, 2023

Case sent by Logan Stark MD, written by Pendell Meyers A woman in her 70s presented with acute chest pain. As I emphasize in my September 26, 2020 post of Dr. Smith's ECG Blog — the most common cause of a pause is a blocked PAC ( and not some form of AV block ). No prior ECG was available. This left 2 additional considerations.

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Chest Pain Blog Arrhythmia STEMI 71

Dr. Smith's ECG Blog

JANUARY 15, 2024

They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They described the chest pain as severe, crushing, and non-radiating. Altogether, this strongly suggests inferolateral OMI, particularly in a patient with acute chest pain.

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Chest Pain Blog Arrhythmia Critical Care 64

Dr. Smith's ECG Blog

JANUARY 6, 2023

Submitted and written by Anonymous, edits by Meyers and Smith A 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache. Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 Abstract 556.

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Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Sent by Drew Williams, written by Pendell Meyers A man in his 50s with history of hypertension was standing at the bus stop when he developed sudden onset severe pressure-like chest pain radiating to his neck and right arm, associated with dyspnea, diaphoresis, and presyncope. EMS arrived and administered aspirin and nitroglycerin.

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Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

APRIL 25, 2023

Healthy male under 25 years old with a pretty good story for acute onset crushing chest pain relieved with nitro. PEARL: Most patients who present with new chest pain + ECG changes + positive troponin — will not need Cardiac MRI. This was sent to me by a partner: "Curious what you think of this one we had overnight.

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Chest Pain Pericarditis Blog Cardiomyopathy 52

Dr. Smith's ECG Blog

MARCH 27, 2023

My Comment by K EN G RAUER, MD ( 2/22 /2023 ): = Today’s case is an important one, because as per Dr. Smith ( in this patient with new chest pain ) — “The initial ECG is diagnostic of infero-postero OMI.” The presence or absence of ST Elevation is a poor marker with which to describe a myocardial infarction. =

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Chest Pain Ischemia Myocardial Infarction Blog 52

Frontiers in Cardiovascular Medicine

JANUARY 2, 2024

Background Despite the crucial role of Chest pain centers (CPCs) in acute myocardial infarction (AMI) management, China's mortality rate for ST-segment elevation myocardial infarction (STEMI) has remained stagnant. The cohort was stratified by Killip classification at admission (Class 1: n  = 402, Class ≥2: n  = 262).

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Chest Pain Myocardial Infarction COVID-19 Catheterization Laboratory 59

Dr. Smith's ECG Blog

JANUARY 17, 2023

A 60 year old with chest pain presented to the ED. In this case, lead I does not look bizarre, but all other leads do. == N OTE : The reasons I especially liked today's case are: i ) The patient presented with chest pain — so the importance of distinguishing artifact from reality can not be overstated! —

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Chest Pain Physiology Blog Electrophysiology 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. 24 yo woman with chest pain: Is this STEMI?

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Chest Pain Aneurysm STEMI Thrombosis 52

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. Is it Brugada pattern?

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 29, 2023

A 50-something with no previous cardiac history and no risk factors presented to the ED with acute chest pain (pressure) that radiated to the left arm. But even without these additional findings — the "Must Recognize" ECG pattern in this patient with new chest pain — is the unmistakeable shape of the ST depression in leads V2 and V3!

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Chest Pain Blog Stenosis Critical Care 52

Dr. Smith's ECG Blog

APRIL 8, 2022

There is a patient with persistent chest pain and an initial troponin I over 52 ng/L; 52 ng/L has an approximate 70% PPV for acute type I MI in a chest pain patient. Pain was severe and persistent. CT angiography chest assessing for PE and dissection negative. Heparin drip was initiated. Is there STEMI?

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Chest Pain SCAD STEMI Blog 52

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. Int J Cardiol Heart Vasc 2020 3. Today's patient is a 70-year old adult who called EMS because of new-onset chest pain , associated with nausea and shortness of breath. Who needs the cath lab?

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

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.

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Chest Pain Blog Cardiac Arrest Cardiomyopathy 122

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Upon questioning patient, he denies having any chest pain or chest tightness of any sort. In the absence of chest pain and negative troponin , it appears less likely that he is having acute coronary syndrome though EKG appears concerning. Pericarditis would be even more unlikely in someone without chest pain.

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

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. Am J Emerg Med 2020 3. Int J Cardiol 2013 2.

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Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2020

== MY Comment by K EN G RAUER, MD ( 9/17/2020 ): == Todays patient is a previously healthy, 60-something year-old woman who presented with chest pain that began at a reception. We are indebted to Dr. Smith for developing Modified Smith-Sgarbossa Criteria for assessing ST-T wave changes in chest pain patients with LBBB.

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Chest Pain STEMI Blog Myocardial Infarction 52

Dr. Smith's ECG Blog

MAY 19, 2022

Written by Pendell Meyers, edits by Smith and Grauer A man in his late 20s with history of asthma presented to the ED with a transient episode of chest pain and shortness of breath after finishing a 4-mile run. His symptoms of chest pain and shortness of breath were attributed to an asthma exacerbation during exercise.

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Chest Pain Exercise Pacemaker Coronary Angiogram 52

Dr. Smith's ECG Blog

MAY 24, 2022

A 30-something male presented in the middle of the night with several hours of sharp, non-radiating, left sided chest pain. But this is not the mix-up that occurred in today’s case — because we do not see global negativity ( of P wave, QRS and T wave ) in lead I ( See the February 11, 2020 post). I initially missed that one.

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Chest Pain Blog Coronary Angiogram Coronary Artery Disease 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Because the patient had no chest pain or shortness of breath, they were initially diagnosed as gastroenteritis. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS.

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Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

JULY 7, 2023

An 80-something woman who presented with chest pain and dyspnea. That said — QOH is already highly sophisticated and accurate in her assessment of ECGs from acute chest pain patients, in which the ECG is not complicated by uncommon OMI mimics. After all, this patient did also present with chest pain. ) — See below.

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Chest Pain AFIB Blog Atrial Fibrillation 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? Up until recently — all computerized ECG interpretation programs that I am aware of used standard millimeter-based STEMI critieria as the basis for determining which chest pain patients should "qualify" for prompt cath with PCI. This was sent to me by a friend.

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Chest Pain STEMI Blog Academic 52

Ken Grauer, MD

SEPTEMBER 22, 2023

Impression: In this middle-aged man with palpitations and dyspnea, but no chest pain — I suspect that the T wave peaking and slight, upward-sloping chest lead ST elevation represent a repolarization variant. The February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ).

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Blog Chest Pain Bradycardia Physiology 174

Dr. Smith's ECG Blog

AUGUST 14, 2023

Written by Pendell Meyers, with some edits by Smith A man in his 40s with many comorbidities presented to the ED with chest pain, hypotension, dyspnea, and hypoxemia. An 80-something woman who presented with chest pain and dyspnea. Here is his triage ECG: What do you think? Lots of info here.

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Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

AUGUST 22, 2020

== MY Comment by K EN G RAUER, MD ( 8/22/2020 ): == The patient is a mid-50s man who presented to the ED for new-onset chest pain of ~1 hour duration. He was still having chest pain in the ED at the time ECG #1 was done ( Figure-1 ). His symptoms awakened him from sleep. The cath lab was not activated at this time.

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Chest Pain Blog Exercise Hospital 40

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 150

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Triage EKG: What do you think? 1] Wereski, R.,

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Chest Pain Ultrasound STEMI Myocardial Infarction 52

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.

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Chest Pain Myocardial Infarction Blog Stents 131

Ken Grauer, MD

AUGUST 26, 2023

As discussed in many posts in this ECG Blog — despite not satisfying the millimeter-based definition of a STEMI — in this patient with new chest pain, the ECG findings in Figure-1 merit prompt cath lab activation without any need to wait for serum troponin to return elevated ( See ECG Blog #193 — regarding the new "OMI" paradigm ).

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Blog Chest Pain STEMI Ischemia 141