Aortic, Chest Pain and STEMI - Cardiovascular Update

Acute chest pain and ST Elevation. CT done to look for aortic dissection.

Dr. Smith's ECG Blog

MARCH 9, 2024

Written by Willy Frick A 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. Due to the chest pain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. He had associated nausea, vomiting, and dyspnea.

Chest Pain

Chest Pain Pericarditis Aortic Echocardiogram

ECG Cases 42 – Approach to ECG Interpretation in Patients with Chest Pain: OMI, False Positive & Negative STEMI & Other Causes

ECG Cases

MAY 10, 2023

In this ECG Cases blog we look at 10 cases of patients with chest pain, including false positive STEMI, false negative STEMI, and other causes to help hone your ECG interpretation skills in time-sensitive cases where those very ECG skills might save a life.

Chest Pain

Chest Pain STEMI Blog Embolism

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Dr. Smith's ECG Blog

MAY 20, 2024

A 63 year old man with a history of hypertension, hyperlipidemia, prediabetes, and a family history of CAD developed chest pain, shortness of breath, and diaphoresis after consuming a large meal at noon. He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.

Chest Pain

Chest Pain Blood Pressure Ischemia STEMI

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Chest pain and a "normal" ECG

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This is another case written by Pendell Meyers (who is helping to edit the blog and has many great recent posts) Case A 45 year old man was driving to work when he experienced acute onset sharp left sided chest pain with paresthesias of the left arm. A repeat ECG was recorded with pain 2/10: Not much change.

Chest Pain

Chest Pain STEMI Defibrillator Blog

Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. At midnight.

Dr. Smith's ECG Blog

DECEMBER 14, 2016

A middle aged male presented at midnight after 14 hours of constant, severe substernal chest pain, radiating to his throat and to bilateral jaws, and associated with diaphoresis. The pain was not positional, pleuritic, or reproducible. The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI?

Chest Pain

Chest Pain STEMI Aortic Myocardial Infarction

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

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. 50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. Pericarditis?

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Why the sudden shock after a few days of malaise?

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Left ventricular afterload reduction is essential to decrease the trans-se ptal pressure gradient and thus decrease shunt volume, making a larger proportion of the blood flow from the left ventricle through the aortic valve. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

Cardiogenic Shock

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction

Do you need to be a trained health care professional to diagnose subtle OMI on the ECG?

Dr. Smith's ECG Blog

MAY 5, 2024

The provider had sent the patient for an aortic dissection scan which had shown extremely heavy calcification of the LAD. The patient had continued to have chest pain.

EKG Technician

EKG Technician Chest Pain Blog STEMI

See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

As his pain was very severe, emergency physicians concerned of aortic dissection and ordered a thoracic CT scan. The pain was completely resolved after coronary intervention. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. Bi-phasic scan showed no dissection or pulmonary embolism. 2021.21026.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

Dr. Smith's ECG Blog

JULY 18, 2014

A man in his 60's presented after 4 days of chest pain, with some increase of pain on the day of presentation. Exact pain history was difficult to ascertain. Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? There was some SOB. How acute is it?

STEMI

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock

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. They also wanted an aortic CT which was negative. What do you think the prehospital ECG showed (with pain)?

Chest Pain

Chest Pain Myocardial Infarction STEMI Pericarditis

Massive Excessively Discordant Anterior ST Elevation in a Paced Rhythm

Dr. Smith's ECG Blog

SEPTEMBER 14, 2014

He presented with chest pain, not relieved by nitro, pain reproducible on exam and centered around the pacemaker insertion site. is very specific for STEMI , and there is some evidence, as well as rationale, that a paced rhythm behaves similarly. Here is one case of anterior STEMI in a paced rhythm.

Chest Pain

Chest Pain Cardiomyopathy Pacemaker STEMI

What does this ECG show?

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

Pericarditis Chest Pain Blog Aortic

Cardiologist declines taking patient to the cath lab. Patient dies.

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Apparently he denied chest pain. The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain. Canto et al.

Chest Pain

Chest Pain STEMI Blog Tachycardia

"Pericarditis" strikes again

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms.

Pericarditis

Pericarditis Chest Pain Aortic Blog

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. Step 1 to missing posterior MI is relying on the STEMI criteria. But it is still STEMI negative. What do you think? A 15 lead ECG was done (below).

STEMI

STEMI Myocardial Infarction Chest Pain Ischemia

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

Dr. Smith's ECG Blog

MARCH 6, 2023

If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation? However, in the context of the first ECG and the waning chest pain, this is diagnostic of reperfusion. Due to the severity of the pain and the high BP, they obtained an aortic dissection CT.

Chest Pain

Chest Pain STEMI Stenosis Blog

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

The computer and the cardiologist called this a "Normal EKG"

Dr. Smith's ECG Blog

JUNE 4, 2019

A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. Case continued The patient continued having pain. The patient arrived looking like an aortic dissection patient, so CTA was done and negative." OMI often does not meet STEMI criteria.

Chest Pain

Chest Pain STEMI Ischemia Aortic

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? His response: “subendocardial ischemia.

Ischemia

Ischemia STEMI Stenosis Chest Pain

PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don't miss case 4 at the bottom.

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. An elderly patient with a ruptured abdominal aortic aneurysm: Formal ECG Interpretation (final read in the chart!) : "Inferior ST elevation, lead III, with reciprocal ST depression in aVL."

STEMI

STEMI Chest Pain Cardiac Arrest Stents

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. Look at the aortic outflow tract. Aortic angiogram did not reveal aortic dissection. What do you see? Answer below in the still shot.

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

ECG Blog #383 — Is this Coronary Disease?

Ken Grauer, MD

JUNE 6, 2023

But limitation of this ST elevation to a single lead is not consistent with any distribution of a STEMI. The plan was to proceed as soon as possible with aortic valve replacement. This patient needed prompt aortic valve replacement. Then there is the significant ST elevation we see in lead V1.

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Blog Pulmonary Hypertension Aortic

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

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

There is ventricular hypertrophy in the absence of abnormal loading conditions, such as aortic stenosis, or hypertension, for example – of which the most common variant is Asymmetric Septal Hypertrophy. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below are two examples of this.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

A 34 yo Man with chest pain and Zero ST Elevation

Dr. Smith's ECG Blog

JANUARY 28, 2025

Written by Hans Helseth A 34 year old man with no known medical history presented to the ED after an hour of chest pain. He described the pain as a mid sternal "burning sensation" and rated it 8.5 out of 10 at onset, but on presentation to the ED, reported that the pain had improved to 4.5. 10 chest pain.

Chest Pain

Chest Pain STEMI Hospital Blood Pressure

Chest pain and Saddleback STE. For Which of these 6 Cases should we Activate the cath lab? And how does the Queen of Hearts perform?

Dr. Smith's ECG Blog

OCTOBER 30, 2024

All of the patients contacted EMS due to acute onset chest pain. The above ECG is from a 70 something male with chest pain. ECG #2 Case 2 : The above ECG was obtained from a diabetic 45 year old smoker with chest pain. Aortic dissection was apparently ruled out by a negative CT scan ). ECG #1 Case 1.

Chest Pain

Chest Pain Aortic Myocardial Infarction STEMI

Which patient needs a CT scan?

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Case 1: 20-something woman with chest pain Case 2: 50-something man with chest pain Case 1 A 20-something yo woman presented in the middle of the night with severe crushing chest pain. They also recommended a NTG drip, after which she reported complete resolution of pain. She was a walk-in at triage.

Chest Pain

Chest Pain Aortic STEMI Ultrasound

Chest pain followed by 6 days of increasing dyspnea -- what happened?

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

Chest Pain Pericarditis Myocardial Infarction Dementia

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. She awoke in the morning with sharp chest pain which worsened throughout the morning. As her pain worsened, so did her dyspnea. Also see these posts of Type II STEMI.

Tachycardia

Tachycardia Pulmonary Chest Pain Stenosis

Chest (or abdominal?) pain and ECG artifact.

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

It is diagnostic of OMI, but this is SUBACUTE OMI I sent this ECG to my "EKG Nerdz" friends, without any clinical info at all and they answered "OMI" The Queen said: "STEMI-Equivalent with High Confidence:" Notice she sees findings in both normal beats and PVCs. If this were ACUTE (vs. SUBACUTE) OMI, that would result in an undesirable delay.

Blog

Blog Chest Pain Myocardial Infarction Critical Care

Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"

Dr. Smith's ECG Blog

OCTOBER 27, 2024

This was submitted by a paramedic, Hailey Kennedy A late 50s male called 911 following 2 hours of chest pain that started while working at his desk. He reported the crushing chest pain radiated down his left arm. The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI".

STEMI

STEMI Chest Pain Myocardial Infarction Aneurysm

Acute chest pain and ST Elevation. CT done to look for aortic dissection.

ECG Cases 42 – Approach to ECG Interpretation in Patients with Chest Pain: OMI, False Positive & Negative STEMI & Other Causes

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Webinars

Chest pain and a "normal" ECG

Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. At midnight.

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Why the sudden shock after a few days of malaise?

Do you need to be a trained health care professional to diagnose subtle OMI on the ECG?

See OMI vs. STEMI philosophy in action

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

An elderly male with shortness of breath

Massive Excessively Discordant Anterior ST Elevation in a Paced Rhythm

What does this ECG show?

Cardiologist declines taking patient to the cath lab. Patient dies.

"Pericarditis" strikes again

7 steps to missing posterior Occlusion MI, and how to avoid them

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

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

The computer and the cardiologist called this a "Normal EKG"

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don't miss case 4 at the bottom.

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

ECG Blog #383 — Is this Coronary Disease?

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

Hypertrophic Cardiomyopathy

A 34 yo Man with chest pain and Zero ST Elevation

Chest pain and Saddleback STE. For Which of these 6 Cases should we Activate the cath lab? And how does the Queen of Hearts perform?

Which patient needs a CT scan?

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Chest (or abdominal?) pain and ECG artifact.

Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"

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