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. It was normal. == MY Comment , by K EN G RAUER, MD ( 12/26 /2023 ): == It's always rewarding to encounter an ECG that allows you to make an instant clinical pathophysiologic diagnosis. What do you think now?

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Chest Pain Cardiomyopathy Blog AFIB 94

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Another ECG was recorded after the nitroglycerine and now without pain: All findings are resolved. This confirms that the pain was ischemia and is now resovled. The history is concerning ( This patient was awakened from sleep by chest pain that persisted for several hours — on a background of intermittent CP in recent weeks ).

Ischemia 122

Ischemia Plaque Stenosis Myocardial Infarction 122

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

MARCH 1, 2023

Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms. During active chest pain an ECG was recorded: Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF.

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Chest Pain Ischemia Tachycardia Stenosis 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 Abstract 556.

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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

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. The ECG does not show any definite signs of ischemia. The below ECG was recorded.

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Chest Pain Blog Cardiac Arrest Cardiomyopathy 122

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

DAIC

MARCH 28, 2024

The study describes the validation of Cleerly's artificial intelligence-guided quantitative coronary CT angiography (AI-QCT) ISCHEMIA technology for diagnostic accuracy and prognostic risk stratification. High Diagnostic Accuracy of AI-ISCHEMIA in Comparison to PET, FFR-CT, SPECT, and Invasive FFR: A Pacific Substudy. 2024.01.007.

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Ischemia Chest Pain Atherosclerosis Coronary Artery Disease 110

Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. As per Dr. Smith, in a patient with new chest pain — these flattened ST segments in leads V2,V3 suggest acute posterior OMI until proven otherwise. Here is his ED ECG: What do you think?

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Chest Pain Stenosis Stents Stent 75

DAIC

MAY 8, 2024

5 Revascularization to improve blood flow to the heart has been shown to reduce mortality in stable chest pain patients. 6 This novel study marks a significant milestone in the field, evaluating the effectiveness of FFR CT in detecting ischemia-producing coronary stenosis in patients with severe PAD. 10390, May 2023, pp.

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Coronary Artery Disease Chest Pain Ischemia Myocardial Infarction 111

Dr. Smith's ECG Blog

JULY 30, 2023

Written by Pendell Meyers A woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. The STD maximal in V1-V4 is diagnostic of acute transmural posterior wall ischemia, most likely due to posterior OMI. Subendocardial ischemia does not localize.

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Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

JULY 25, 2024

The ECG shows severe ischemia, possibly posterior OMI. But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. It takes time for that ischemia to resolve. Just as important is pretest probability: did the patient report chest pain prior to collapse?

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Cardiac Arrest Ischemia Tachycardia Defibrillator 124

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. He later developed mild continuous chest pain, that he describes as the sensation of someone standing on his chest. They agreed ischemia was likely in the setting of demand given DKA and infection.

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Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

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

FEBRUARY 1, 2023

Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. The chest pain was refractory to nitro so the cath lab was activated: 100% proximal LAD and 99% mid circumflex occlusions.

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Chest Pain STEMI Ischemia Stenosis 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.

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Chest Pain Blog Stenosis Myocardial Infarction 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 ). This point is discussed in detail in the March 24, 2023 post of Dr. Smith’s ECG Blog ).

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Blog Chest Pain STEMI Ischemia 145

Dr. Smith's ECG Blog

APRIL 4, 2023

Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chest pain radiating to the neck, associated with shortness of breath. Acute Q waves are a marker of severe ischemia and a predictor for delayed reperfusion. What do you think?

Chest Pain 52

Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

APRIL 9, 2023

Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell Meyers A man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath.

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Chest Pain Ischemia Stenosis Pulmonary 52

Circulation: Cardiovascular Imaging

NOVEMBER 20, 2023

Circulation: Cardiovascular Imaging, Volume 16, Issue 11 , Page e015800, November 1, 2023. of patients had evidence of ischemia on a prior functional test. of patients had evidence of ischemia on a prior functional test. were referred to CCTA and 22.5% were referred to CCTA and 22.5% In the follow-up ranging from 1 to 3.5

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Chest Pain Myocardial Infarction Cardiovascular Imaging Ischemia 40

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

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 ). ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL ( featured in Audio Pearl #2 in this blog post ).

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Blog STEMI Ischemia Chest Pain 151

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

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. The flutter waves can conceal or mimic ischemic repolarization findings, but here I don't see any obvious findings of OMI or subendocardial ischemia.

Chest Pain 52

Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. A prior ECG was available for comparison: Normal One might be tempted to interpret the ST depression as ischemia, but as Smith says, "when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave." Chest pain in high risk patient. Is it STEMI?

Chest Pain 124

Chest Pain Ischemia Cardiac Arrest Blog 124

Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. Here was my answer: "Not ischemia. This was texted to me in real time. What do you think? Maybe HOCM or another form of LVH. I would not activate cath lab. In this case, QOH was incorrect , saying "OMI High confidence."

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Chest Pain STEMI Congenital Heart Disease Heart Disease 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

OCTOBER 21, 2023

PEARL # 1: Although seeing an elevated Troponin would provide additional support for immediate cardiac catheterization — the clinical reality is that the initial Troponin reading will not always be elevated in patients with acute coronary occlusion ( See March 24, 2023 post in Dr. Smith's ECG Blog ).

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Blog Chest Pain Ischemia STEMI 98

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. EKG shown here: LAFB with no clear signs of OMI or ischemia. Triage ECG: What do you think? This is a huge anterolateral OMI.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 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. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI. McLaren and Smith.

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STEMI Chest Pain Myocardial Infarction Blog 121

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. Many health care providers will simply not attempt to assess ischemia in the presence of a wide QRS.

Chest Pain 111

Chest Pain Pacemaker Ischemia Stents 111

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

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). See this case: A man his 50s with chest pain. Figure-1: The initial tracing in today's case. (

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STEMI Chest Pain Myocardial Infarction Ischemia 96

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 first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. His wife contacted the ambulance service after the patient experienced an episode of loss of consciousness.

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 128

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

A 60-something awoke with 10/10 crushing chest pain. I would expect TIMI-3 flow (normal flow, no persistent ischemia) with a culprit in the RCA (or possibly Circumflex). But the patient's chest pain continues and so you order a 2nd ECG (ECG 2 here). He walked in to triage.

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Chest Pain STEMI Stents Stent 98

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 83