Dr. Smith's ECG Blog

MARCH 8, 2019

A previously healthy middle-aged male presented shortly after the acute onset of chest pain very shortly before calling 911. On arrival, he was pain free: What do you think? Jerry Jones commented: "Any ST depression on the ECG of a patient with chest pain credible for ACS represents a reciprocal change until proved otherwise."

Chest Pain 52

Chest Pain STEMI Plaque Ischemia 52

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. If it is STEMI, it would have to be RBBB with STEMI. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. This ECG was sent from South Asia.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 1, 2023

Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms. During active chest pain an ECG was recorded: Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF.

Chest Pain 52

Chest Pain Ischemia Tachycardia Stenosis 52

Dr. Smith's ECG Blog

APRIL 22, 2019

The computer called it a normal ECG Algorithm unknown Aside : [There is some "sinus arrhythmia", which is indeed a normal finding. Sinus arrhythmia is sinus rhythm whose rate varies with respiration. If the longest P-P interval is 120 ms greater than the shortest, it is sinus arrhythmia. Burning pain subxiphoid and into throat."

Chest Pain 52

Chest Pain Arrhythmia Ischemia STEMI 52

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 52

Chest Pain SCAD STEMI Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). In my opinion — AI is not yet "there" with regard to interpretation of complex cardiac arrhythmias. This was sent to me by a friend.

Chest Pain 52

Chest Pain STEMI Blog Academic 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

Written by Jesse McLaren, with edits from Smith and Grauer A 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. Any objective, rule-based analysis of this ECG would scream "STEMI" or "OMI". And I recognized this as a STEMI mimic. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. This was texted to me in real time.

Chest Pain 52

Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

JULY 30, 2023

Written by Pendell Meyers A woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. It does not meet STEMI criteria. Luckily, 45 minutes later, with ongoing pain and a troponin I that resulted at 136 ng/L, the ECG was repeated: What do you think now? Anyway, she does say OMI.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

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

MAY 28, 2024

Note the Timed Contents that I detail below facilitate finding specific material. == ECG Podcast #4 — All About Comparison ECGs for 12-Leads and Arrhythmias ( Comparing ECGs seems so "easy" to do — but so often is not done correctly! ) — published by Mayo Clinic CV Podcast Series on 5/21/2024 ( 35 minutes ). What are the problems?

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Blog Arrhythmia Tachycardia CME 143

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? After cardiac arrest, I ALWAYS wait 15 minutes after an ECG like this and record another. The ST depression usually resolves, or is clearly resolving (getting much better).

Cardiac Arrest 124

Cardiac Arrest Ischemia Tachycardia Defibrillator 124

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? IV administration of potassium is indicated when arrhythmias are present or hypokalemia is severe (potassium level of less than 2.5

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

JULY 22, 2023

He denied chest pain or shortness of breath. In the clinical context of weakness and fever, without chest pain or shortness of breath, the likelihood of Brugada pattern is obviously much higher. Prior to Mizusawa's study, it was thought that the incidence of syncope, arrhythmia, or SCD in this cohort was low [7].

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

Dr. Smith's ECG Blog

AUGUST 28, 2020

This can only be due to STEMI. My THOUGHTS on ECG #1: We are told that the patient in today’s case had an episode of severe chest pain 3 nights prior to admission. However, cardiogenic shock usually takes some time to develop, so it is probably subacute." Then I was told that the troponin I returned at greater than 50,000 ng/L.

Cardiogenic Shock 40

Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Dr. Smith's ECG Blog

JULY 24, 2024

And regarding arrhythmias: For more on the regular WCT — See My Comment in the May 5, 2020 post and in the April 15, 2020 post in Dr. Smith's ECG Blog. 2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”. 27:00 — SUMMARY by Dr. Anthony Kashou.

Arrhythmia 52

Arrhythmia Blog Tachycardia CME 52

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. Chest pain was resolved upon arrival in the ED. Idioventricular rhythm is a common "reperfusion arrhythmia." Exactly how they relate to ischemia, chest pain, and reperfusion can only be speculated about.

Chest Pain 52

Chest Pain Ischemia Dysrhythmia STEMI 52

Ken Grauer, MD

FEBRUARY 18, 2023

The presenting complaint was chest pain — and the patient collapsed soon after arrival in the ED. Looking at the location of ST elevation ( ie, in the inferior leads — and in V4,5,6 ) — and the location of ST depression ( ie, in leads I,aVL; V1,V2 ) — this ECG picture suggests an ongoing acute infero - postero - lateral STEMI.

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Blog AFIB Chest Pain STEMI 78

Ken Grauer, MD

MARCH 15, 2024

This includes sinus arrhythmia — in which there is often slight variation in the P-P interval. This slight variation in sinus P wave regularity tends to be greater when a 2nd- or 3rd-degree AV block is present ( called ventriculophasic sinus arrhythmia — as shown in ECG Blog #344 ). For clarity — I have done this in Figure-4.

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Blog Arrhythmia STEMI Ischemia 160

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. Is it STEMI? Chest pain in high risk patient. A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store. What is going on here?

Chest Pain 124

Chest Pain Ischemia Cardiac Arrest Blog 124

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 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

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.

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Strokes Stroke Chest Pain Cardiomyopathy 70

Ken Grauer, MD

JANUARY 26, 2023

The ECG in Figure-1 was obtained from a previously healthy older man — who complained of chest pain and “lightheadedness” while this tracing was recorded. His chest pain had begun the night before. Figure-1: 12-lead ECG and long lead II rhythm strip — obtained from an older man with chest pain and “lightheadedness. (

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Blog Chest Pain STEMI Arrhythmia 78

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. In any case, sinus arrhythmia is much less marked in ECG #2 after SL NTG with improvement of symptoms. Thelin et al.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

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 52

Chest Pain STEMI Stenosis Blog 52

All About Cardiovascular System and Disorders

MARCH 28, 2024

So this is a typical Brugada syndrome ECG, which can be easily mistaken for an acute myocardial infarction with ST elevation in anterior leads may be taken as STEMI if the person presents with chest pain for some other reason. An interesting fact is that many of the persons experience arrhythmias in Brugada syndrome with fever.

Sudden Cardiac Death 52

Sudden Cardiac Death Defibrillator Arrhythmia Atrial Fibrillation 52

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? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

OCTOBER 17, 2022

In fact, there was no chest pain either. If you were thinking that this is not anterior OMI because there is no reciprocal ST depression , it is important to remember that half of anterior STEMI do NOT have any reciprocal ST depression. BUT look at the very prominent J-waves (J point notching)!! It is several mm high!

Pericarditis 52

Pericarditis Chest Pain Blog Arrhythmia 52

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

They also documented "Reproducible chest tenderness." The patient said his chest pain was 4/10, down from 8/10 on presentation. Additional findings: No ST elevation." Remember that patients with OMI can have normal ECGs! Repeat hsTnI was 183 ng/L, up from 26 ng/L. Around noon, cardiology was called for evaluation.

Angina 121

Angina Plaque Document Stents 121

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. It was from a patient with chest pain: Note the obvious Brugada pattern. Bicarb 20, Lactate 4.2,

Heart Rhythm 52

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. This is a high troponin (most STEMI are above 10 ng/mL for troponin I). MY THOUGHTS on ECG #1 ( if it was the Only Tracing I Had ): There is sinus arrhythmia ( variable R-R interval — but all p waves conducting with a constant PR interval ).

Pericarditis 52

Pericarditis STEMI Chest Pain Arrhythmia 52

Ken Grauer, MD

JULY 15, 2023

This should result in at least some positivity of QRS complexes as one moves toward the lateral chest leads. The finding of all negative QRS complexes in leads V3-thru- V6 therefore strongly suggests that the arrhythmia-associated impulse is not traveling over an AP ( Steurer et al — Clin. Cardiol 17:306-308, 1994 ).

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

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. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What do you see?

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

AUGUST 13, 2020

Dyspnea, Right Bundle Branch block, and ST elevation Here are two more cases where the differential diagnosis is acute OMI vs. LV aneurysm: Is this acute STEMI? 9 Hours of Chest Pain and Deep Q-waves: Is it too late for Thrombolytics? LV Aneurysm? Would you give Thrombolytics?

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52