Dr. Smith's ECG Blog

JULY 7, 2024

Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain with diaphoresis, and called EMS. So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. What do you think?

Chest Pain 66

Chest Pain STEMI Blog Arrhythmia 66

Dr. Smith's ECG Blog

APRIL 22, 2024

A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chest pain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest. At times the pain does go to his left neck. What do you think the prehospital ECG showed (with pain)?

Chest Pain 118

Chest Pain Myocardial Infarction Anatomy Angina 118

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity.

Chest Pain 121

Chest Pain STEMI Hypertension Blog 121

Dr. Smith's ECG Blog

JANUARY 27, 2024

Written by Jesse McLaren, comments by Smith A 55 year old with a history of NSTEMI presented with two hours of exertional chest pain, with normal vitals. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab? So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion.

Chest Pain 117

Chest Pain STEMI Aneurysm Stents 117

Dr. Smith's ECG Blog

MARCH 22, 2024

Written by Willy Frick A man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0.

Chest Pain 114

Chest Pain STEMI Bradycardia Ischemia 114

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 ). It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. The ECG shows ST depression in lead V3.

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

JULY 23, 2024

I was working at triage when the medics brought this patient who is 65 yo and has had chest pain for 12 hours. The pain had been intermittent until an hour before arrival, when he called 911. Another ECG was recorded while awaiting the cath team: Now there is STEMI Let's look at that first (prehospital ECG) again: Very subtle!

Chest Pain 115

Chest Pain Critical Care STEMI Stents 115

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.

Chest Pain 73

Chest Pain STEMI Pulmonary Embolism 73

Dr. Smith's ECG Blog

JANUARY 3, 2024

Written by Pendell Meyers A woman in her 70s had acute chest pain and called EMS. Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Ongoing OMI.

STEMI 103

STEMI Chest Pain Ischemia Outcomes 103

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A healthy 45-year-old female presented with chest pain, with normal vitals. The patient was previously healthy, with no atherosclerotic risk factors, and developed chest pain after an episode of stress. The pain was crushing retrosternal, radiated to the arms and was associated with lightheadedness.

Chest Pain 66

Chest Pain Pericarditis SCAD STEMI 66

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. He described his chest pain as pleuritic and reported that it started the day prior while swinging a golf club. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive.

Chest Pain 60

Chest Pain Pericarditis Pacemaker STEMI 60

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.

STEMI 121

STEMI Chest Pain Myocardial Infarction Blog 121

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.

Chest Pain 139

Chest Pain Embolism Pulmonary Tachycardia 139

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.

Chest Pain 113

Chest Pain STEMI Blog Exercise 113

Ken Grauer, MD

OCTOBER 25, 2024

The following are the KEY clinical and ECG features that establish the diagnosis of W ellens ' S yndrome : There should be a history of prior chest pain that has resolved at the time the defining ECG is obtained. The Chest Pain required for the definition of Wellens' Syndrome occurred at the time of coronary occlusion.

Blog 95

Blog Chest Pain STEMI Cardiogenic Shock 95

Dr. Smith's ECG Blog

MAY 13, 2024

Chest Pain – Benign Early Repol or OMI? Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain.

Chest Pain 120

Chest Pain STEMI Ultrasound Heart Attack 120

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

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Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

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.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stents 116

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.

Blog 155

Blog STEMI Cardiac Arrest Tachycardia 155

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

He reports significant chest pain at the base of his scapula on the right side along with new shortness of breath. Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE?

Chest Pain 116

Chest Pain Myocardial Infarction STEMI Pericarditis 116

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

AUGUST 2, 2024

Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain. This was a machine read STEMI positive OMI. We've highlighted a considerable number of acute RV MI cases in Dr. Smith's ECG Blog ( See the October 7, 2019 and May 10, 2024 posts , to name just two ).

STEMI 119

STEMI Ischemia Blog Chest Pain 119

Dr. Smith's ECG Blog

OCTOBER 10, 2024

Written by Pendell Meyers A man in his early sixties with no significant medical history (including a "negative cardiac workup a few years ago" for unclear indication) called 911 for acute chest pain constantly for the past 5 hours. However, this patient has active chest pain, and thus this this is inferior-posterior OMI.

Chest Pain 108

Chest Pain STEMI Blog Stenosis 108

Dr. Smith's ECG Blog

JULY 25, 2024

Just as important is pretest probability: did the patient report chest pain prior to collapse? Cardiac arrest #3: ST depression, Is it STEMI? or is he an ACCESS Trial Candidate? == MY Comment , by K EN G RAUER, MD ( 7/5 /2024 ): == Clinical ECG interpretation is a 2-Step process. Then assume there is ACS.

Cardiac Arrest 124

Cardiac Arrest Ischemia Tachycardia Defibrillator 124

Ken Grauer, MD

JUNE 7, 2024

Even without ECG changes — persistent ischemic-sounding chest pain is indication for prompt cath. ECG Blog #193 — Reviews the basics for predicting the " culprit " artery ( as well as reviewing why the term "STEMI" — should be replaced by "OMI" = O cclusion-based MI ).

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Blog Chest Pain STEMI Ischemia 135

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). With EMS, patient had a GCS of 3 and was saturating 60% on room air. ng/mL and 0.10

STEMI 116

STEMI Document Blog Ischemia 116

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast. The patient was given opiates which improved his chest pain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

Chest Pain 120

Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He was given aspirin and sublingual nitro and the pain resolved. 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

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Context: a man in his 40s presented to the emergency department with 1 day of sudden onset chest pain. I sent this to our group without information and Dr. Smith responded: "Not OMI.

Pericarditis 117

Pericarditis Chest Pain Blog Aortic 117

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. Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." The first ECG (10h14) showed TWI in inferior leads."

Chest Pain 66

Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. But the History in today's case was acute shortness of breath with dizziness and lightheadedness — and, essentially without chest pain!

Cardiogenic Shock 128

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

Ken Grauer, MD

MAY 28, 2024

My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. 2:00 — Dr. Kashou to Dr. Grauer: "In 2024 — Where do you see computerized ECG interpretations and AI?" 2:50 — Let’s start with comparison of 12-Lead ECGs.

Blog 133

Blog Arrhythmia Tachycardia CME 133

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. For more on ECG findings in pulmonary disease — Check out My Comment in the May 31, 2024 post in Dr. Smith's ECG Blog ).

Hospital 77

Hospital Chest Pain Blog Pulmonary 77

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. Troponin was ordered.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

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. There was no OMI.

Strokes 70

Strokes Stroke Chest Pain Cardiomyopathy 70

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

A 55 year old with no previous cardiac history presented with 3 hours of chest pain. The pain was persistent and reportedly still present at the time of the ECG. But if the pain is persistent, as reported, then the patient must go to the cath lab even if the ECG suggests reperfusion.

Hospital 85

Hospital STEMI Blog Chest Pain 85

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. Another missed OMI by the False STEMI-NonSTEMI Dichotomy Don't miss them!!! Normal vital signs.

AFIB 105

AFIB Stents Stent Chest Pain 105