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

--The STD in V2-V6 might be interpreted as subendocardial ischemia, but with the inferior STE, it is far more likely to represent posterior OMI. Here is the history: A 40-something male had intermittent chest discomfort until 90 minutes prior to presentation, when it became constant. At 100 minutes, the above ECG was recorded.

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Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chest pain with diaphoresis. The ECG was incorrectly interpreted as no signs of ischemia. The Importance of the History: As noted above — the onset of chest pain in today's case was acute. His vitals were within normal limits.

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Chest Pain Physiology Blog Stents 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. Is this Acute Ischemia? More on LVH.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 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. American Journal of Emergency Medicine 2022 4.

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Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

Written by Jesse McLaren, with edits from Smith and Grauer A 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. 2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia.

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Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. At this time he reported ongoing chest pain and was given aspirin and nitroglycerin. J Am Heart Assoc.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 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

DECEMBER 18, 2022

Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, Smith A woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. Ischemic ST depression includes posterior OMI and subendocardial ischemia.

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Chest Pain Ischemia Aortic Aortic valve 40

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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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

JUNE 30, 2023

These were texted to me only with "chest pain." It helps to know that the patient has active chest pain, as Wellen's is a post occlusion (reperfusion) state, with open artery and pain-free. And ECGs can change and evolve even when there is no ischemia. First: 2nd: What was my response? It was indeed.

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Chest Pain Blog Ischemia Document 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 130

Dr. Smith's ECG Blog

MAY 31, 2023

A 67 yo f developed chest pain this morning." There is probably a trickle of flow which is why there is both subendocardial ischemia (ST depression) and early subepicardial ischemia (hyperacute T-waves). And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!!

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STEMI Chest Pain Myocardial Infarction Ischemia 96

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. Clin Cardiol 2022 4. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI.

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STEMI Chest Pain Myocardial Infarction Blog 121

Ken Grauer, MD

MAY 20, 2023

NOTE: It's important to correlate ongoing circumstances at the time that a prior tracing was done ( ie, Was the patient stable and asymptomatic — or were they having chest pain, an exacerbation of heart failure, or some other ongoing process at the time the prior ECG was recorded? ). What is P recordial S wirl ?

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Blog Chest Pain Ischemia STEMI 145

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Because previous ischemia induces myocardial preconditioning, decreasing the likelihood of transmural myocardial necrosis and myocardial rupture, patients with evidence of diabetes mellitus, chronic angina or previous MI are less likely to experience a rupture. Not all patients with acute ( or recent ) MI have chest pain with their event.

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Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest. For now she can only say Not OMI.

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Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 82

Dr. Smith's ECG Blog

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. 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.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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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STEMI Ischemia Blog Chest Pain 119

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. The ST/T wave ratio ( ie, the ratio of ST elevation compared to T wave amplitude ) in lead V6 is well over 0.24 ( See My Comment in the June 8, 2022 post for more on this Ratio ). Pericarditis maybe." Spodick sign is present.

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Pericarditis Chest Pain Blog Aortic 116

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.

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Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

OCTOBER 15, 2022

It is due to transmural ischemia not only of the anterior wall and apex, but due to transmural ischemia of the septum, usually due to occlusion proximal to the first septal perforator. A 50-something with cocaine chest pain and ST Elevation in V1 - V3 This one is very tough. Is this Acute Ischemia? Read the case.

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Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Do you agree with this strategy?

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Tachycardia Electrophysiology Atrial Flutter Ischemia 119

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? Retrieved July 2, 2022, from [link] Moyé, D.

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

Dr. Smith's ECG Blog

JULY 14, 2024

Sent by anonymous, written by Pendell Meyers Case 1: A man in his 50s presented with acute chest pain. Click here to sign up for Queen of Hearts Access Case 2: A woman in her 60s presented with acute chest pain. Normal vital signs. Here is his ECG at triage: What do you think? Normal vitals. What do you think?

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AFIB Stents Stent Chest Pain 105

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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Chest Pain Blog Ischemia STEMI 52

Dr. Smith's ECG Blog

JUNE 1, 2022

A 40-something male with no previous cardiac disease presented with chest pain. Here is his ECG: There is no clear evidence of OMI or ischemia. This is suspicious for inferior reciprocal At this point, with continued pain, cath lab activation is indicated. even in the absence of ECG findings.

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Chest Pain STEMI Myocardial Infarction Bradycardia 52

Ken Grauer, MD

OCTOBER 13, 2023

She was hemodynamically stable — and did not have chest pain, lightheadedness or syncope. As a result — IF no "fixable" cause is found ( ie, ischemia/infarction — electrolyte disturbance — rate-slowing medication ) — then because of the AV block and very slow heart rate, this patient will probably need a pacemaker.

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Blog Arrhythmia Bradycardia Download 158

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours.

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Chest Pain STEMI Document Ischemia 52

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. Anything more on history? J Electrocardiol 2013;46:240-8 2.

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

DECEMBER 16, 2022

Superimposed OMI cannot be ruled out, but the patient has syncope, not chest pain. Here are many more examples of this: See this recent post: Chest pain and anterior ST depression. What’s the cause(s)? Would you have recognized the acute posterior OMI? How I wish we had follow-up on this case.

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Chest Pain Ischemia Blog 52

Dr. Smith's ECG Blog

JULY 16, 2024

This is the prehospital ECG from an 81 year old man with acute chest pain. I favor the P s, Q s, 3 R Approach — as a simple acronym to facilitate recall of the 5 KEY Parameters for rhythm interpretation ( See My Comment in the October 25, 2022 post in Dr. Smith’s ECG Blog ). The medics did NOT activate the cath lab. Arrhythmia?

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Atrial Flutter Chest Pain Tachycardia Arrhythmia 59

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.

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Chest Pain Bradycardia Blog Critical Care 52

Ken Grauer, MD

JULY 22, 2023

The message is clear — If, in a patient with new chest pain — ST-T wave depression is maximal in leads V2 , V3 and/or V4 — consider acute posterior MI until proven otherwise. C ASE C onclusion : On their way to the hospital, the EMS crew requested cath lab activation — because they recognized the above "dynamic" ST-T wave changes.

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Blog Chest Pain STEMI AFIB 78

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.

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

JUNE 28, 2023

RVOT VT: A 40-something without past history presents with wide complex tachycardia and crushing chest pain Regular Wide Complex Tachycardia. He got an MR, however that showed no scar or evidence of AVRD and he had a stress test with no evidence of inducible ischemia with almost 20 METs." There is no inferior axis.

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Tachycardia Ultrasound Heart Disease Atrial Fibrillation 98

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest.

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Coronary Angiogram Plaque Thrombosis STEMI 109