Angioplasty, Chest Pain and STEMI - Cardiovascular Update

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

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

Chest Pain Myocardial Infarction Anatomy Angina

Is OMI an ECG Diagnosis?

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

STEMI Chest Pain Myocardial Infarction Stents

A man in his 50s with chest pain

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. Barely any STE, and thus not meeting STEMI criteria.

Chest Pain

Chest Pain STEMI Myocardial Infarction Blog

Chest Pain and Right Bundle Branch Block

Dr. Smith's ECG Blog

NOVEMBER 19, 2014

A male in late middle age with a history of RCA stent 8 years prior complained of chest pain. Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died. EMS recorded the following ECG: What do you see?

Chest Pain

Chest Pain Cardiac Arrest Myocardial Infarction Angioplasty

Right precordial ST depression in a patient with chest pain

Dr. Smith's ECG Blog

AUGUST 3, 2017

A 70-year-old man calls 911 after experiencing sudden, severe chest pain. The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! But if there is none - then you are looking at least at an Isolated Posterior STEMI until proven otherwise.

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

[link] A 30 year-old woman was brought to the ED with chest pain. She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying "I'm just an anxious person." examined SCAD presenting as STEMI (unlike Hassan et al.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

Chest Pain

Chest Pain SCAD STEMI Blog

If you had recorded an ECG during chest pain, what would it have shown?

Dr. Smith's ECG Blog

JUNE 28, 2018

He had suffered a couple bouts of typical chest pain in the last 24 hours. This ECG (ECG #3) was recorded immediately after the last episode of pain spontaneously resolved. The pain had lasted about one hour. So you are going to get to see what the ECG would have shown had you recorded one during pain! Am Heart J.

Chest Pain

Chest Pain Myocardial Infarction STEMI Article

Four anterior STEMIs: acute and reperfused vs. won't reperfuse, subacute and reperfused vs. not reperfused

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. He had been awakened by cough at 3 AM 2 days earlier.

STEMI

STEMI Myocardial Infarction Chest Pain Angioplasty

A Non STEMI that needs the cath lab now.

Dr. Smith's ECG Blog

APRIL 2, 2014

A male in his 60's called 911 for chest pain. His pain was intermittent and he was vague about when it was present and when it was resolved. He had an immediate ED ECG: There is artifact, but the findings appear to be largely gone now The diagnosis is acute MI, but not STEMI. Here is his prehospital ECG: Diagnosis?

STEMI

STEMI Ischemia Chest Pain Angioplasty

An elderly male with shortness of breath

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

Chest Pain Myocardial Infarction STEMI Critical Care

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

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

Chest Pain STEMI Myocardial Infarction Angioplasty

A Tough ECG, But Learn From It!

Dr. Smith's ECG Blog

JUNE 18, 2013

This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion. His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI.

STEMI

STEMI Chest Pain Myocardial Infarction Webinar

Precordial ST depression. What is the diagnosis?

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. There is no ST elevation.

STEMI

STEMI Ischemia Chest Pain Myocardial Infarction

ECG Blog #380 — What is "Swirl"?

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? ).

Blog

Blog Chest Pain Ischemia STEMI

First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

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. Wehrens X.H., Doevendans P.A., Ophuis T.J.,

Myocardial Infarction

Myocardial Infarction Chest Pain Ischemia Angina

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

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

Coronary Angiogram Chest Pain Stenosis STEMI

Compare these two ECGs. Do either, neither, or both show anything important?

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.

Chest Pain

Chest Pain STEMI Document Ischemia

An elderly woman with acute vomiting, presyncope, and hypotension, and a wide QRS complex

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

Code STEMI was activated. What is the Diagnosis in this 70-something with Chest Pain? 68 minutes with chest compressions, full recovery. A man in his 80s with chest pain What, besides large anterior STEMI, is so ominous about this ECG? The patient arrived to the ED in cardiogenic shock but awake.

Cardiogenic Shock

Cardiogenic Shock Chest Pain Tachycardia Ischemia

How does Acute Total Left Main Coronary occlusion present on the ECG?

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

Myocardial Infarction Ischemia STEMI Cardiogenic Shock

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. His inpatient clinicians did not think that an urgent angiogram was warranted given that he was chest pain free, his EKG appeared nondiagnostic, and serial troponins were not elevating beyond 2 ug/L. The lesion was intervened on with balloon angioplasty and had subsequent TIMI 3 flow. Why is this?

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

What is the ECG Diagnosis?

Dr. Smith's ECG Blog

FEBRUARY 10, 2023

Inferior ST Depression does NOT mean there is inferior subendocardial ischemia; it is generally reciprocal to high lateral (aVL) subepicardial ischemia (OMI/STEMI) == MY Comment by K EN G RAUER, MD ( 2/10/2023 ): == There are certain patterns in ECG interpretation that experienced providers are able to immediately recognize.

STEMI

STEMI Ischemia Chest Pain Angioplasty

75 year old with 24 hours of chest pain, STEMI negative

Dr. Smith's ECG Blog

JUNE 8, 2023

Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. The patient has a history of CABG so some of these changes could be old, but with ongoing chest pain and bradycardia in a high risk patient this is still acute OMI until proven otherwise. HR 40, BP 135/70, RR16, O2 100%.

Chest Pain

Chest Pain STEMI Bradycardia Myocardial Infarction

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Is OMI an ECG Diagnosis?

A man in his 50s with chest pain

Chest Pain and Right Bundle Branch Block

Right precordial ST depression in a patient with chest pain

A young peripartum woman with Chest Pain

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

If you had recorded an ECG during chest pain, what would it have shown?

Four anterior STEMIs: acute and reperfused vs. won't reperfuse, subacute and reperfused vs. not reperfused

A Non STEMI that needs the cath lab now.

An elderly male with shortness of breath

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

A Tough ECG, But Learn From It!

Precordial ST depression. What is the diagnosis?

ECG Blog #380 — What is "Swirl"?

First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

Compare these two ECGs. Do either, neither, or both show anything important?

An elderly woman with acute vomiting, presyncope, and hypotension, and a wide QRS complex

How does Acute Total Left Main Coronary occlusion present on the ECG?

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

What is the ECG Diagnosis?

75 year old with 24 hours of chest pain, STEMI negative

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