Frontiers in Cardiovascular Medicine

FEBRUARY 18, 2025

ObjectiveA significant proportion (85%) of low-risk non-ST-elevation acute coronary syndrome (NSTE-ACS) patients do not receive objective confirmation of ischemia by stress echocardiography (SE), yet remain a healthcare burden due to lower long-term survival and overuse of medical services.

Chest Pain 52

Chest Pain Exercise Angina Coronary Artery Disease 52

Dr. Smith's ECG Blog

MARCH 17, 2024

He also complained of intermittent mild chest pain radiating into into both shoulders and his back, as well as occasional unexplained sweating. Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive ). He had no further chest pain.

Angina 71

Angina Chest Pain Blog Ischemia 71

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. The most common “something else” symptom was shortness of breath.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

DAIC

MAY 14, 2024

The impact of this narrowing can ultimately result in angina (chest pain), which has been shown to double the risk of major cardiovascular events,1 as well as myocardial infarction ( heart attack ) or even death. Use Heart to Act on Angina. Available at: [link]. Accessed May 2024.

Coronary Artery Disease 111

Coronary Artery Disease Interventional Cardiology Innovation Physiology 111

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. 1] European guidelines add "regardless of biomarkers". But only 6.4%

STEMI 121

STEMI Chest Pain Myocardial Infarction Blog 121

Dr. Smith's ECG Blog

DECEMBER 14, 2018

This appears to be a classic Wellens' ECG, Pattern A, with terminal T-wave inversion in V2-V4, preserved R-waves, and it appears to be Wellens' syndrome, as it occurred after resolution of typical angina pain. The patient remained pain free. Unstable Angina still exists 2. Case continued All troponins were negative.

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 52

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.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

MARCH 9, 2017

Case A 42-year-old lady presented to the ED with complaints of intermittent episodes of chest pain associated with shortness of breath for the last 2 days. This was her ECG (it is unclear if this was with or without pain): Computerized ECG Read: “Normal sinus rhythm. Unstable Angina still exists. Thanks, Sam! Normal ECG.”

Chest Pain 52

Chest Pain Angina Ischemia Plaque 52

Dr. Smith's ECG Blog

MARCH 9, 2013

This male in his 40's had been having intermittent chest pain for one week. He awoke from sleep with crushing central chest pain and called ems. EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain. Ischemia may be so brief that Wellens' waves do not evolve 3. Lessons: 1.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Paddy Barrett

DECEMBER 5, 2023

Whether stenting a narrowed coronary artery improves symptoms such as chest pain (angina) or shortness of breath is a very different question. Share Angina The classic definition of angina involves the sensation of tightness in the centre of the chest that is brought on with exertion and is relieved with rest.

Stents 59

Stents Stent Angina Heart Attack 59

Dr. Anish Koka

MAY 16, 2023

This means that at every age, the probability a man complaining of chest pain has significant underlying coronary disease as a cause of this chest pain is much higher than a woman complaining of chest pain. The results of this dataset by age and gender follow.

Chest Pain 52

Chest Pain Coronary Artery Disease Cancer Heart Attack 52

EMS 12-Lead

JULY 24, 2023

But the symptoms returned with similar pattern – provoked by exertion, and alleviated with rest; except that on each occasion the chest pain was a little more intense, and the needed recovery period was longer in duration. It should be known that each category can easily manifest the generic subendocardial ischemia pattern.

Angina 52

Angina Ischemia Coronary Angiogram Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Plan was for admission for chest pain workup. Gottlieb SO, et al.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. BP was 160/100.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 19, 2018

A middle-aged woman had an acute onset of chest pain and dyspnea. The pain had almost resolved by the time an ECG was obtained in the ED: Here is the computer diagnosis What do you think? This confirms that there were dynamic signs of ischemia on the initial ECG. The ST depression in aVL is also resolved.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

APRIL 23, 2016

Some persistently denied that the T-wave in V2 was a specific sign of ischemia. 2 or 3 do not rule out unstable angina, even in the era of high sensitivity troponin: this study by Thelin et al. A 20-something presented with one hour of chest pain. Steps to verify LAD occlusion, or exclude it: 1. Angiography.

Chest Pain 52

Chest Pain STEMI Angina Ischemia 52

Dr. Smith's ECG Blog

MARCH 6, 2019

A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath. Back to the case: The providers recognized persistent ischemia and likely occlusion, and discussed this with cardiology who took the patient immediately for cath. They opened it.

STEMI 52

STEMI Chest Pain Ischemia Myocardial Infarction 52

MIBHS

OCTOBER 15, 2024

For example, if a coronary artery becomes blocked due to plaque buildup (a condition known as coronary artery disease), the heart muscle may not receive enough oxygen, leading to chest pain (angina) or, in more severe cases, a heart attack. CAD is one of the leading causes of heart attacks.

Circulation 52

Circulation Heart Attack Heart attacks Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 17, 2014

This case was recently posted by Tyron Maartens on Facebook EKG club (he agreed to let me post it here), with the following clinical information: "42 year old male with two weeks of intermittent chest discomfort, awoke 4 hours prior to this ECG with a more severe, heavy chest pain (5/10). BP 112/80, SpO2 100%.

Aneurysm 52

Aneurysm STEMI Chest Pain Risk Factors 52

DAIC

FEBRUARY 29, 2024

ET Main Tent (Hall B1) This session offers more insights from key clinical trials presented at ACC.24 24 and find out what it all means for your patients.

Aortic valve 103

Aortic valve Myocardial Infarction Aortic Blood Pressure 103

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. Therefore this is " Transient ST Elevation Unstable Angina." As there was ruptured plaque, this is NOT Prinzmetal's angina. You can see the deficiency of the definition of MI.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

JULY 31, 2018

About this time, the 4th troponin, drawn at 8 hours after onset of pain, peaked at 20.956 ng/mL. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. It they are static, then they are not due to ischemia. Again, cath lab was not activated. Int J Cardiol.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

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 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 18, 2011

3 hours prior to calling 911 he developed typical chest pain. When flow is restored, wall motion may completely recover so that echocardiogram does not detect the previous ischemia. Pain was typical for MI (substernal, not postional or sharp, resolved with NTG) b. This is not pericarditis because: a.

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

male with a history of HTN and ETOH developed squeezing epigastric abdominal pain with associated vomiting and diaphoresis, followed by a syncopal episode which lasted about 10 seconds. When medics arrived, he denied any chest pain, shortness of breath, or palpitations prior to the syncopal episode.

Chest Pain 40

Chest Pain Ischemia Angina Electrocardiogram 40

Ken Grauer, MD

JULY 15, 2023

Additional Teaching Points: Type-2 MI ( M yocardial I nfarction ) — is defined by an increase in troponin with evidence of ischemia that is not due acute coronary disease, but which instead results from a mismatch in oxygen supply and demand ( Smilowitz et al — Coron Artery Dis 29(1):46-52, 2018 ).

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Dr. Smith's ECG Blog

MARCH 11, 2016

A middle-aged woman had intermittent angina for 48 hours, then onset of constant, crushing chest pain for 1.5 More likely, the patient had crescendo angina, with REVERSIBLE ischemia for 48 hours that only became potentially irreversible (STEMI) at that point in time. hours when she called 911.

Myocardial Infarction 52

Myocardial Infarction Pericarditis STEMI Angina 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

Ischemic ST-segment depression maximal in V1-V4 (versus V5-V6) of any amplitude is specific for Occlusion Myocardial Infarction (versus nonocclusive ischemia). Smith : this proves my impression that the inferior T-waves on the first ECG are hyperacute. JAHA 2022 Grosmaitre P et al.

STEMI 40

STEMI Myocardial Infarction Chest Pain Angina 40

Dr. Smith's ECG Blog

JANUARY 28, 2012

A middle aged patient who was 3 weeks s/p STEMI came from cardiac rehab where he developed some chest pain, dyspnea and weakness on the treadmill. In the ED he had some continued chest pain and hypotension. Here was his ECG: There are inferior and lateral Q-waves with T-wave inversion in the corresponding leads.

Chest Pain 40

Chest Pain STEMI Pericarditis Ultrasound 40

Cardiometabolic Health Congress

MAY 10, 2024

In MSIMI (Mental Stress-induced Myocardial Ischemia) studies , mental stress activities like public speaking were evaluated for their impact on ischemia, measured via myocardial SPECT and vascular function (microvascular function, endothelial function). Combining behavioral and pharmacological treatment is most effective.

Coronary Artery Disease 59

Coronary Artery Disease Obesity Chest Pain Ischemia 59

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

Scenario 1 : The patient presents with 24 hours of substernal chest pain. Denying patients the potential benefit of revascularization just because their symptoms have lasted a certain amount of time shows poor understanding of the pathophysiology of myocardial ischemia. He presented to the emergency department for evaluation.

Chest Pain 89

Chest Pain Pericarditis Myocardial Infarction Dementia 89

Frontiers in Cardiovascular Medicine

JANUARY 8, 2025

BackgroundPainful left bundle branch block (LBBB) syndrome is an uncommon disease that is defined as intermittent episodes of angina associated with simultaneous LBBB changes on an electrocardiogram (ECG) with the absence of flow-limiting coronary artery disease or ischemia on functional testing.

Chest Pain 52

Chest Pain Angina Coronary Artery Disease Blood Pressure 52

Dr. Smith's ECG Blog

MARCH 25, 2025

Written by Willy Frick A woman in her 60s with very severe hyperlipidemia (LDL >200 mg/dL) presented with acute onset chest pain. She described the pain as moderate in severity, and said it had come and gone several times over the next few hours before ultimately resolving. Her symptoms began while getting off the bus.

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Chest Pain Ischemia Plaque Stents 63

Dr. Smith's ECG Blog

JANUARY 5, 2025

Written by Willy Frick A man in his 60s with hypertension and prior stroke presented with three days of crushing chest pain. He reported intermittent chest pain for the last few months, but never lasting this long. Moving on to ischemia , the ECG shows reperfused inferoposterolateral infarct. Repeat ECG is shown.

Chest Pain 77

Chest Pain Ischemia Angina Echocardiogram 77

Dr. Smith's ECG Blog

DECEMBER 6, 2024

A 50-something man presented with worsening severe exertional chest pain which was just resolving as he had an ECG recorded in triage. Watch what happends as the heart recovers from its episode of ischemia. The ECG shows inferior ischemia. Are the T-waves in leads I and II hyperacute? Hard to tell. How can we know?

Coronary Artery Bypass Graft 107

Coronary Artery Bypass Graft Ischemia Chest Pain Stenosis 107