Dr. Smith's ECG Blog

JANUARY 17, 2023

A 60 year old with chest pain presented to the ED. In the December 5, 2022 post of Dr. Smith's ECG Blog — We show 4 additional cases of this pulse-tap artifact. Here is his first ECG: What do you think? It looks bizarre, doesn't it? There are lots of ST-T abnormalities, but they just don't look recognizable.

Chest Pain 52

Chest Pain Physiology Blog Electrophysiology 52

Dr. Smith's ECG Blog

JUNE 14, 2017

There was apparently no syncope and he had no bony injuries, but he did complain of left sided chest pain. His chest was tender. A bedside cardiac ultrasound was normal. An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD IVCD type rhythm ??

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Chest Pain Congenital Heart Disease Article Congenital 52

Dr. Smith's ECG Blog

JULY 11, 2019

Written and submitted by Ashley Mogul, with edits by Pendell Meyers and Steve Smith A man in his 40s with recent smoking cessation but otherwise no known past medical history presented due to chest pain since the previous evening. The pain has been constant and associated with vomiting and diaphoresis.

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Chest Pain STEMI Blog Stent 52

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. Case A 40-something male presented to triage. There are classic Wellens' waves in V2-V5.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

MARCH 4, 2023

In the Marchik article, (assuming they defined it the same way, and the methods do not specify this), among patients with suspicion for PE, S1Q3T3 was found in 8.5% While I still had questions about this case given the limited information provided ( ie, Was chest pain in this younger adult diabetic from acute PE?

Chest Pain 52

Chest Pain Embolism Tachycardia Pulmonary 52

Dr. Smith's ECG Blog

MAY 19, 2022

Written by Pendell Meyers, edits by Smith and Grauer A man in his late 20s with history of asthma presented to the ED with a transient episode of chest pain and shortness of breath after finishing a 4-mile run. His symptoms of chest pain and shortness of breath were attributed to an asthma exacerbation during exercise.

Chest Pain 52

Chest Pain Exercise Pacemaker Coronary Angiogram 52

Dr. Smith's ECG Blog

JUNE 11, 2024

Sent by anonymous A man in his 40s with no previous heart disease presented within 30 minutes of onset of acute chest pain that started while exercising. We have shown many examples of this on this blog. Three patients with chest pain and “normal” ECGs: which had OMI? Chest pain and a computer ‘normal’ ECG.

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Chest Pain STEMI Blog Exercise 113

Dr. Smith's ECG Blog

MARCH 27, 2025

After only 90 minutes of chest pain, the first troponin was unsurprisingly in the normal range at 11ng/L (normal <26 in males and <16 in females), so the emergency physician waited for repeat troponin. Chest pain still persists. Paged cardiology 0800: patient complains of chest pain. Cardiology aware.

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STEMI Chest Pain Pericarditis Ischemia 80

Dr. Smith's ECG Blog

JULY 31, 2020

In the hope of dispelling continued dependence on millimeter-based STEMI criteria — we’ve published numerous cases in recent years in Dr. Smith’s ECG Blog of acute OMI ( O cclusion-based M yocardial I nfarction ) , in which patients have benefited from acute reperfusion despite not satisfying “STEMI criteria”.

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STEMI Article Chest Pain Blog 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2018

A middle-aged woman presented with chest pain. Brooks Walsh ( [link] ) has a great article on this topic, though he does not discuss septal Q-waves as a result: Misplacing V1 and V2 can have clinical consequences (full text). 27, 2018 blog post ). She had no history of cardiac disease.

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Chest Pain Anatomy Echocardiogram Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

A 60-something awoke with 10/10 crushing chest pain. But the patient's chest pain continues and so you order a 2nd ECG (ECG 2 here). It also is interpreted as "normal" and the patient's chest pain is now 10/10 and so you are really diligent and order a 3rd ECG. He walked in to triage. Jesse McLaren et al.

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Chest Pain STEMI Stent Stents 98

Dr. Smith's ECG Blog

JULY 14, 2023

Non-randomized trials show better outcomes (neurologic survival) using this device; see this article in Resuscitation: Head and Thorax Elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. The patient had ROSC and maintained it. First — Some thoughts on the post -resuscitation ECG.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. I described "Posterior Reperfusion T-waves" in this article. For more on ECG findings in pulmonary disease — Check out My Comment in the May 31, 2024 post in Dr. Smith's ECG Blog ). Here is that ECG: Original ECG What do you think?

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Hospital Chest Pain Blog Pulmonary 77

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. As I illustrated in detail in My Comment of the October 3, 2018 post of Dr. Smith's ECG Blog — I favor a qualitative approach based on shape. The question is, does she need to go urgently to the cath lab or can she wait.

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Chest Pain Pacemaker Ischemia Stent 111

Dr. Smith's ECG Blog

AUGUST 2, 2024

Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain. Readers of this blog can easily appreciate the hyperacute T waves in the precordium, clearest in V1-V4. His ECG is shown below. Pretty obvious anterior current of injury. This was a machine read STEMI positive OMI.

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STEMI Ischemia Blog Chest Pain 119

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. EMS gave 324 mg aspirin and 3 sublingual NTG, which the patient stated reduced the substernal chest pain from an 8/10 to 4/10. I have posted previous such cases, but in searching my own blog, I could not find them.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

While fully acknowledging that "Sometimes ya gotta be there!" — in order to optimally assess the patient — the clinical definition of hemodynamic stability is for the patient to be without significant symptoms such as chest pain, shortness of breath, hypotension and/or mental status changes — as a direct result of the fast heart rate.

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Tachycardia Electrophysiology Atrial Flutter Ischemia 119

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.

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Pericarditis Chest Pain Aortic Blog 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2015

The supposition that beta blockade in the presence of cocaine intoxication would lead to unopposed alpha constriction is not based in accurate pharmacology, and the study that showed this effect with human intracoronary administration was done, as mentioned in the article, with propranolol, a nonselective beta blocker. Marcus, G. Flores, E.D.

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Tachycardia Chest Pain Pharmacology Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 26, 2017

There was no chest pain or SOB at the tim of the ECG: Computerized QTc is 464 ms A previous ECG from 8 years prior was normal. Absence of chest pain or SOB at the time of the ECG is important; had the patient had active chest pain, I would have recommended at least an emergency formal echo, if not cath lab activation.

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Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

NOVEMBER 8, 2022

The patient had come to the ED for SOB, but without any chest pain. Other cases of Pulse Tapping Artifact: Acute chest pain and a bizarre ECG Bizarre (Hyperacute??) NOTE: I reproduce in the ADDENDUM below ( in Figures-3 , - 4 and - 5 ) — the 3-page article by Rowlands and Moore ( J. He had a 10 pound weight loss.

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Article Chest Pain Blog Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

She did not report any chest pain or pressure. She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? A male in his 60s with chest pain A Male in his 60s with Chest pain.

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Chest Pain STEMI Biomarkers Article 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.

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Chest Pain Thrombosis Myocardial Infarction STEMI 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%.

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Aneurysm STEMI Chest Pain Risk Factors 52

Dr. Smith's ECG Blog

MARCH 8, 2021

This was just published in JAMA Internal Medicine: The de Winter Electrocardiogram Pattern Evolving From Hyperacute T Waves It reminded me that many believe, due to the assertions in the original de Winter's article, that de Winter's waves are stable. He was a 30-something with chest pain. Here is one case of a patient I saw.

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Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

She went on to describe her chest pain as a "buffalo sitting on my chest" and a "weird" sensation in her jaw for 1 hour prior to arrival, associated with lightheadedness and diaphoresis. The patient was given fentanyl initially for chest pain with minimal effect and then vomited which was followed by zofran and famotidine.

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Chest Pain Critical Care Article Pacemaker 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).

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Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 20, 2013

He said that his pain does not feel like his previous episode of pericarditis, and is not related to meals. He denied chest pain, shortness of breath, nausea, fever, chills, rashes, cough, and leg pain. He admitted to lifting some heavy objects a few days ago but denied trauma. in V6 and J-point notching.

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Pericarditis Chest Pain Pulmonary STEMI 52

Dr. Smith's ECG Blog

JUNE 12, 2017

This was sent by : Jacob Smith, DO Emergency Medicine Resident Ohio Health Doctors Hospital Emergency Residency Christopher Lloyd, DO, FACEP Director of Clinical Education, USACS Midwest Case A 30 year old patient presents to triage with chest pain. link] Here is the history: A 30 yo man presented complaining of severe chest pain.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

OCTOBER 26, 2011

This 42 yo diabetic male presented with cough and foot pain. In spite of aggressive questioning, he denied chest pain, but he did tell one triage nurse that he had had some chest burning, and so he underwent an ECG: There are deep Q-waves and QS-waves in precordial leads V2-V3, with a bit of R-wave left in V4.

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STEMI Chest Pain Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

The patient's chest pain had resolved by the time of the ECG 2. But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. He presents with an episode of brief, new-onset chest pain that had resolved by the time E CG # 1 was obtained.

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Angina Stent Stents Aneurysm 52

Dr. Smith's ECG Blog

MARCH 12, 2018

Wellens' is a syndrome of a painless period following an anginal (chest pain) event. Chest pain, SOB, Precordial T-wave inversions, and positive troponin. She also complained of generalized weakness, lightheadedness, diaphoresis, chest pain, and cough. What is the Diagnosis? What is an S1Q3T3? Kosuge et al.

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Chest Pain Pulmonary Embolism Tachycardia 40

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

And some similar ECGs from Pulmonary Embolism: A young woman with altered mental status and hypotension An elderly woman transferred to you for chest pain, shortness of breath, and positive troponin - does she need the cath lab now? S1Q3T3, or even just the T3, may help to differentiate Wellens' from PE. What is an S1Q3T3?

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Chest Pain Pulmonary Tachycardia Embolism 52

Dr. Smith's ECG Blog

JULY 31, 2018

Post by Smith, with short article by Angie Lobo ( [link] ), a third year intermal medicine resident at Abbott Northwestern Hospital Case A 30-something woman with no past history, who is very fit and athletic, presented with 1.5 hours of substernal chest pressure. She had zero CAD risk factors. Circulation, 137(19), p.e523.

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SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 5, 2022

Acute chest pain and a bizarre ECG Bizarre (Hyperacute??) Arterial pulse tapping artifact [link] This online article references the article below by Emre Aslanger, a great guy who occasionally corresponds with me about ECGs. Figure-3: Page 475 from the Rowlands and Moore article that I reference above.

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Article Chest Pain Circulation Electrocardiogram 52

Dr. Smith's ECG Blog

MAY 6, 2018

This 50-something otherwise healthy male presented with one hour of epigastric and lower chest pain. Here is an ECG with N-waves, from the article: Are these N-waves in our ECG? Here is his initial ECG: What do you think? The QRS is 90 ms and the QTc is 400 ms. There is also ST depression in V2 and V3.

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STEMI Chest Pain Myocardial Infarction Article 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Case A 39-year-old male without prior medical history presents with chest pain that started 2 hours prior to presentation. He says that the pain intensity was 10/10 at home but now about 4/10. Despite the clinical stability and decreasing pain, this patient needs an immediate angiogram. Here are his publications.)

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40