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). Both support acute anterior STEMI.

Aneurysm 52

Aneurysm STEMI Chest Pain Risk Factors 52

Dr. Smith's ECG Blog

MAY 1, 2016

Chest Pain in a 61 year old male. Inferior STEMI without inferior ST elevation. Chest Pain in a Male in his 20's; Inferior ST elevation: Inferior lead "early repol" diagnosed. The development of an inferior-posterior STEMI, from prehospital to hospital Case 6. Is this STEMI?

Chest Pain 52

Chest Pain STEMI Angina Hospital 52

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. 3 hours prior to calling 911 he developed typical chest pain. But it could be anterior STEMI. is likely anterior STEMI).

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

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. Wellens' syndrome represents the aftermath of an unrecorded occlusion (STEMI) with spontaneous reperfusion.

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. Therefore this is " Transient ST Elevation Unstable Angina." Why is this important? JACC 2016;67:1531.

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STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, the patient does not (yet) get a formal diagnosis of MI and must be called unstable angina unless further troponins return above the 99th percentile. The patient said his chest pain was 4/10, down from 8/10 on presentation. On the basis of unresolved angina, cardiology decided to perform rescue PCI. of the time.

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Angina Plaque Document Stent 121

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. This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline."

STEMI 52

STEMI Chest Pain Ischemia Myocardial Infarction 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. Type B waves are deeper and symmetric. Lessons: 1. de Zwaan C., Janssen J.H.A.,

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 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. Jernberg T, 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. See the list below.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. The pain initially started the day prior to presentation. The ST elevation from today is ~0.2

Pericarditis 52

Pericarditis Chest Pain Stent Stents 52

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

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. He described it as "10/10" intensity, radiating across his chest from right to left. This is written by Willy Frick, an amazing cardiology fellow in St.

Plaque 127

Plaque Angina Blog Stent 127

Dr. Smith's ECG Blog

APRIL 23, 2016

But beware the few false negatives, especially when there are hyperacute T-waves but no ST elevation (see Case 2 below): Formula to differentiate Normal Variant ST Elevation (Early Repolarization) from Anterior STEMI. 2 or 3 do not rule out unstable angina, even in the era of high sensitivity troponin: this study by Thelin et al.

Chest Pain 52

Chest Pain STEMI Angina Ischemia 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. Troponin was ordered. As per Drs.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

MAY 10, 2023

A 34 yo woman with a history of HTN, h/o SVT s/p ablation 2006, and 5 months post-partum presented with intermittent central chest pain and SOB. She had one episode of pain the previous night and two additional episodes early on morning the morning she presented. Deep breaths are painful and symptoms come and go.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 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

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. Again, cath lab was not activated. Int J Cardiol. 2016;207:341–348.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

While this ECG is negative for “posterior STEMI”, the resolution of anterior ST depression (accompanied by the troponin elevation) confirms posterior OMI with spontaneous reperfusion. The second opportunity to make the diagnosis and expedite angiography was missed because the ECG never met STEMI criteria and continued to be labeled ‘normal.’

STEMI 40

STEMI Myocardial Infarction Chest Pain Angina 40

Dr. Smith's ECG Blog

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

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 cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." hours when she called 911. LV Thrombus , 1.5 0 0 1 95 544 MMRF 4 1 638 14.0

Myocardial Infarction 52

Myocardial Infarction Pericarditis STEMI Angina 52

Ken Grauer, MD

JULY 15, 2023

But immediate resolution of chest pain once VT was converted — and — the normal CT coronary angiogram — essentially ruled out acute coronary disease as the cause. Subsequent testing supported the presumption of apical cardiomyopathy as the cause of this patient's sustained VT.

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Blog Coronary Angiogram Cardiomyopathy Ischemia 78

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

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. There is no acute STEMI. This is diagnostic of recent, reperfused STEMI. Plummer D et al.

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Chest Pain STEMI Pericarditis Ultrasound 40

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

Scenario 1 : The patient presents with 24 hours of substernal chest pain. 50% of LAD STEMI have Q-waves by one hour. Smith : In limb leads, the ST vector is towards lead II (STE lead II STE lead III, which is more likely with pericarditis than with STEMI). He presented to the emergency department for evaluation.

Chest Pain 89

Chest Pain Pericarditis Myocardial Infarction Dementia 89

Dr. Smith's ECG Blog

MARCH 17, 2025

Written by Willy Frick A man in his 60s with a history of hypertension and 40 pack-year history presented to the ER with 1 day of intermittent, burning substernal chest pain radiating into both arms as well as his back and jaw. In the world of STEMI, we are incapable of recognizing the first ECG as a false negative.

STEMI 81

STEMI Chest Pain Myocardial Infarction Document 81

Dr. Smith's ECG Blog

DECEMBER 29, 2024

Dizziness is so unlikely to be OMI without an obvious ECG, that I am going to pretend that this patient presented with chest pain. The PMCardio Queen of Hearts app asks you, before giving an interpretation of OMI ("STEMI-Equivalent"), whether the patient's clinical presentation is high risk for OMI. Was it unstable angina?

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Stent Stents Chest Pain Angina 66

Dr. Smith's ECG Blog

FEBRUARY 8, 2025

Written by Jesse McLaren An 80 year old with a history of CHF, ESRD on dialysis, and multiple prior cardiac stents presented to the emergency department with 3 days of intermittent chest pain and shortness of breath that resolved after nitro, which felt like prior episodes of angina. Discharge diagnosis was Non-STEMI.

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Chest Pain Stent Stents STEMI 64

Dr. S. Venkatesan MD

JANUARY 22, 2025

The fear comes built in with the diagnosis often amplified by young felllows on call (& often times by senior consultants as well) It may appear real, from a clinical angle, but trust, when we deal with the whole gamut of so-called ACS (other than STEMI), there is indeed a benign face in many of them.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Anatomy Angina 52