2022, Chest Pain and Echocardiogram - Cardiovascular Update

A man in his 40s with acute chest pain. What do you think?

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.

Chest Pain

Chest Pain Tachycardia STEMI Blog

VF arrest at home, no memory of chest pain. Angiography non-diagnostic. Does this patient need an ICD? You need all the ECGs to know for sure.

Dr. Smith's ECG Blog

JUNE 23, 2024

Echocardiogram showed LVEF 66% with normal wall motion and normal diastolic function. He did not remember whether he had experienced any chest pain. Two subsequent troponins were down trending. Within a few days, the patient was extubated and was neurologically intact.

Chest Pain

Chest Pain Cardiac Arrest Sudden Cardiac Death Stent

Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

AUGUST 6, 2024

Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( Chest Pain ). Elevated troponins prompted an echocardiogram — which revealed an apical wall motion abnormality (WMA). Patient #1 in today's post did not get expert ECG interpretation.

Chest Pain

Chest Pain Ischemia Pericarditis Tachycardia

Noisy, low amplitude ECG in a patient with chest pain

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.

Chest Pain

Chest Pain Blog Critical Care Arrhythmia

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

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.

Chest Pain

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog

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. It is also important to recognize that BTWI patterns can be very dynamic.

Chest Pain

Chest Pain STEMI Echocardiogram Stents

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. This is different from nitroglycerin which produces vasodilation and can improve by pain improving myocardial perfusion. Her contrast enhanced echocardiogram is shown below in the parasternal short axis view. At midnight.

Myocardial Infarction

Myocardial Infarction Chest Pain STEMI Blood Pressure

A teenager involved in a motor vehicle collision with abnormal ECG

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Hopefully a repeat echocardiogram will be performed outpatient. ECG of pneumopericardium and probable myocardial contusion shows typical pericarditis Male in 30's, 2 days after Motor Vehicle Collsion, complains of Chest Pain and Dyspnea Head On Motor Vehicle Collision. Diagnosing myocardial contusion after blunt chest trauma.

Tachycardia

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia

A 40-something presented after attempted prehospital resuscitation with persistent Ventricular Fibrillation

Dr. Smith's ECG Blog

JULY 14, 2023

Formal Echocardiogram: Normal left ventricular size and wall thickness. As I emphasized in My Comment at the bottom of the page in the October 10, 2022 post in Dr. Smith's ECG Blog — Interpretation of a post-resuscitation ECG can be extremely challenging. First — Some thoughts on the post -resuscitation ECG.

Cardiac Arrest

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

Dr. Smith's ECG Blog

OCTOBER 22, 2024

He reported typical chest pain since 4H AM and arrived at our ED at 10h with ongoing chest pain. The echocardiogram shows a preserved left ventricular ejection fraction (LVEF) of 55% with marked basal and mid inferolateral and basal anterolateral hypokinesia. The first ECG (10h14) showed TWI in inferior leads."

Chest Pain

Chest Pain STEMI Myocardial Infarction Angioplasty

"Non-STEMI" is a worthless term.

Dr. Smith's ECG Blog

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. He had no h/o heart failure. Regional wall motion abnormality-inferior. Regional wall motion abnormality-inferolateral. This means posterior in common terminology) --Normal LV cavity size with moderately increased thickness.

STEMI

STEMI Heart Failure Stent Stents

A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean.

Strokes

Strokes Stroke Chest Pain Cardiomyopathy

A man in his 70s with weakness and syncope

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. Formal echocardiogram showed normal EF, no wall motion abnormalities, no pericardial effusion.

Chest Pain

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia

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 initial troponin I returned at 1500 ng/L and another ECG was recorded as the patient complained of 9/10 chest pain at 10 hours after the first Now the T-wave in III is fully upright, suggesting re-occlusion.

Chest Pain

Chest Pain Bradycardia Blog Critical Care

Posterior leads can give false reassurance

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. Echocardiogram: The estimated left ventricular ejection fraction is 34% Regional wall motion abnormality-lateral, akinetic. A massive acute OMI.

Chest Pain

Chest Pain Blog Ischemia STEMI

"The dye don't lie".except when it does. Angiogram Negative, or is it?

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

Written by Willy Frick A 40 year old woman was at home cooking when she developed chest pain. The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. Bedside echocardiogram showed hypokinesis of the mid to distal anterior wall and apex.

Plaque

Plaque Stent Stents Chest Pain

See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His medical history is unremarkable except a similar pain occurred 4-5 times in the previous 3 months with less intensity, short duration, unrelated to exertion. He visited an outpatient clinic for it and an echocardiogram and exercise stress test was normal. He has 40 packs-year of smoking history. He denies taking any medication.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain. It is also NOT the clinical scenario of takotsubo (a week of intermittent chest pain).

Plaque

Plaque Chest Pain Thrombosis Stenosis

A young patient with diminishing pain with a subtle but diagnostic ECG.

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Case A 39-year-old male without prior medical history presents with chest pain that started 2 hours prior to presentation. He says that the pain intensity was 10/10 at home but now about 4/10. Despite the clinical stability and decreasing pain, this patient needs an immediate angiogram. 2022 Mar-Apr;71:44-46.

Myocardial Infarction

Myocardial Infarction Chest Pain Blog Echocardiogram

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

A 40 something otherwise healthy man presented with substernal chest pain. Formal Echocardiogram: The estimated left ventricular ejection fraction is 58 %. 2022 Jan;51:384-387. It had occurred once 3 days prior and resolved without any medical visit. What do you think? This ECG is DIAGNOSTIC of acute LAD Occlusion.

Chest Pain

Chest Pain STEMI Article Myocardial Infarction

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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. See this case: what do you think the echocardiogram shows in this case?

Ischemia

Ischemia STEMI Stenosis Chest Pain

Patient in Single Vehicle Crash: What is this ST Elevation, with Peak Troponin of 6500 ng/L?

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

The pneumothorax was expanded with a chest tube At 17 hours, another ECG was recorded: It is now much less dramatic and has the morphology of Type 2 Brugada The hs troponin I peaked at 6500 ng/L -- this strongly suggests myocardial contusion. An echocardiogram was done. Is there also Brugada? Right ventricular prominence.

Arrhythmia

Arrhythmia Blog Chest Pain Cardiac Arrest

The latest CDC paper on vaccine myocarditis is NOT reassuring

Dr. Anish Koka

SEPTEMBER 24, 2022

The current study should dispel the ludicrous notion that clinical myocarditis - a disease entity that comes to light when you have chest pain because cells in your heart are dying — is mild. The CDC study published in Lancet on previously healthy 12-29 years old’s is a survey-based study. That work is far from complete.

COVID-19

COVID-19 Hospital Chest Pain Quality of Life

Back to basics: what is this rhythm? What are your options for treating this patient?

Dr. Smith's ECG Blog

OCTOBER 25, 2022

She reports that she is now unable to vagal out of her palpitations and is having shortness of breath and dull chest pain. She had an echocardiogram which was normal. She reported a prior history of SVT and has previously performed vagal maneuvers at home with symptom resolution. Her initial EKG is below.

Tachycardia

Tachycardia Atrial Flutter Dysrhythmia Ablation

A man in his 40s with acute chest pain. What do you think?

VF arrest at home, no memory of chest pain. Angiography non-diagnostic. Does this patient need an ICD? You need all the ECGs to know for sure.

Three prehospital ECGs in patients with chest pain

Noisy, low amplitude ECG in a patient with chest pain

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

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

Occlusion myocardial infarction is a clinical diagnosis

A teenager involved in a motor vehicle collision with abnormal ECG

A 40-something presented after attempted prehospital resuscitation with persistent Ventricular Fibrillation

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

"Non-STEMI" is a worthless term.

A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

A man in his 70s with weakness and syncope

A Middle Aged Male diagnosed with Gastroesophageal Reflux

Posterior leads can give false reassurance

"The dye don't lie".except when it does. Angiogram Negative, or is it?

See OMI vs. STEMI philosophy in action

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

A young patient with diminishing pain with a subtle but diagnostic ECG.

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Patient in Single Vehicle Crash: What is this ST Elevation, with Peak Troponin of 6500 ng/L?

The latest CDC paper on vaccine myocarditis is NOT reassuring

Back to basics: what is this rhythm? What are your options for treating this patient?

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