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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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.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MAY 31, 2023

A 67 yo f developed chest pain this morning." Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. See this case: A man his 50s with chest pain.

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STEMI Chest Pain Myocardial Infarction Ischemia 96

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch.

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

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

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. Conclusion CPC quality control metrics affect STEMI mortality based on Killip class.

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Chest Pain Myocardial Infarction COVID-19 Catheterization Laboratory 59

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. Jason was very skeptical of STEMI. This also argues against STEMI. Look for old ECGs Do serial ECGs Do echocardiography June 17, 2016 Anterior STEMI? There was no chest pain.

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Chest Pain STEMI Hospital Blog 52

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.

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STEMI Chest Pain Myocardial Infarction Blog 121

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. When is it anterior STEMI? Is this Acute Ischemia?

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Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). Because the patient had no chest pain or shortness of breath, they were initially diagnosed as gastroenteritis. Potassium was normal. Take home 1.

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Chest Pain STEMI Myocardial Infarction Blog 98

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

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

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 Lupu L, et al.

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Chest Pain Ischemia Myocardial Infarction ICU 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. Instead, in view of the history of new chest pain — it is the sum total of 11/12 leads showing subtle-but-real ECG findings that have to be taken as acute until proven otherwise.

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Chest Pain Ischemia Myocardial Infarction Blog 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. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). No pericardial effusion on ultrasound."

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Chest Pain Pericarditis Blog Cardiomyopathy 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. 50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. Pericarditis?

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Chest Pain Aneurysm STEMI Thrombosis 52

Ken Grauer, MD

AUGUST 26, 2023

These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ). Figure-2: Comparison between the 2 ECGs recorded in today's case.

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Blog Chest Pain STEMI Ischemia 144

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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Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

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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 148

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

JUNE 17, 2016

There were no injuries and no chest pain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. Jason was very skeptical of STEMI. This also argues against STEMI. There was no chest pain. He had a seizure this morning and rolled out of bed unable to get up. What do you think?

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STEMI Chest Pain Hospital Blog 52

Dr. Smith's ECG Blog

JUNE 11, 2024

Sent by anonymous A man in his 40s with no previous heart disease presented within 30 minutes of onset of acute chest pain that started while exercising. Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Chest pain and a computer ‘normal’ ECG.

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Chest Pain STEMI Blog Exercise 113

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

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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

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

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

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. Chest pain is squeezing or tight in nature.

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. See this case: A man his 50s with chest pain.

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Myocardial Infarction Chest Pain STEMI Blood Pressure 123

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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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

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. 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 wrote most of it and I (Smith) edited.

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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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Ken Grauer, MD

JUNE 14, 2024

Prompt cath is therefore advised if the post-ROSC shows an acute STEMI. To Emphasize: The phenomenon of T-QRS-D is not needed in today's case to recognize the acute STEMI. Once the J-point is recognized in the chest leads ( RED arrows in leads V2,V3,V4 of Figure-2 ) — the marked ST elevation becomes obvious.

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Dr. Smith's ECG Blog

JANUARY 28, 2023

Case 1 A middle aged woman presented with acute chest pain and shortness of breath, unclear time since onset, and likely with episodic symptoms off and on throughout the day. Only very slight STE which does not meet STEMI criteria at this time. The computer did read "STEMI". Additional case by Smith.

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Dr. Smith's ECG Blog

JUNE 27, 2024

COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab. N Engl J Med [Internet] 2019;Available from: [link] Should all patients with shockable arrest be taken to angiography regardless of STEMI or No STEMI?

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Defibrillator Cardiac Arrest STEMI Chest Pain 113

Dr. Smith's ECG Blog

JANUARY 10, 2020

He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain. Another similar case: Teenager with chest pain and slightly elevated troponin. He had this ECG at time 0 What do you think? What happens then? Pericarditis? 13, 2019 Dr.

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