Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

No Chest Pain, but somnolent. The fact that this is syncope makes give it a far lower pretest probability than chest pain, but it was really more than syncope, as the patient actually underwent CPR and had hypotension on arrival of EMS. Here is the ED ECG (a photo of the paper printout) What do you think?

Chest Pain 106

Chest Pain Aneurysm Stent Stents 106

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. He described his chest pain as pleuritic and reported that it started the day prior while swinging a golf club. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive.

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Chest Pain Pericarditis Pacemaker STEMI 60

Dr. Smith's ECG Blog

APRIL 14, 2024

A 56 year old male with PMHx significant for hypertension had chest pain for several hours, then presented to the ED in the middle of the night. He reported chest pain that developed several hours prior to arrival and was 5/10 in intensity. The pain was located in the mid to left chest and developed after riding his bike.

Chest Pain 107

Chest Pain Ischemia Myocardial Infarction Ultrasound 107

Ken Grauer, MD

OCTOBER 27, 2023

That said — obvious findings include: i ) Marked bradycardia! — Given this patient's older age — if nothing "fixable" is found, she most likely has SSS ( S ick S inus S yndrome ) and will need a pacemaker ( See ECG Blog #342 for more on SSS ). See ECG Blog #188 for review on how to read and/or draw Laddergrams ). be regular! —

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Blog Pacemaker Bradycardia Arrhythmia 103

Ken Grauer, MD

JUNE 2, 2023

to 1828 msec. ) — which corresponds to a variation in the rate of sinus bradycardia from 36-to-33/minute. This makes sense given that the underlying rhythm in today's case appears to be marked sinus bradycardia and arrhythmia , with a ventricular escape rhythm appearing when the SA node rate drops below 33/minute.

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Blog Bradycardia Arrhythmia Tachycardia 78

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. At this time he reported ongoing chest pain and was given aspirin and nitroglycerin.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient’s chest pain spontaneously resolved before he was evaluated and has a repeat ECG obtained at 22:12 obtained shown below. Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. It is unclear if he received aspirin at triage. This ECG is more difficult.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Ischemia 52

Dr. Smith's ECG Blog

JUNE 5, 2024

The patient presented due to chest pain that was typical in nature, retrosternal and radiating to the left arm and neck. He denied any exertional chest pain. It is unclear if the patient was pain free at this time. He has a medical hx notable for hypertension, hyperlipidemia and previous tobacco use disorder.

Chest Pain 106

Chest Pain Blog Cardiac Arrest Cardiomyopathy 106

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. Unfortunately, the reality is — that many ( most ) WPW patients who present with chest pain do not manifest intermittent preexcitation.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

See our other countless hyperkalemia cases below: General hyperkalemia cases: A 50s year old man with lightheadedness and bradycardia Patient with Dyspnea. A woman with near-syncope, bradycardia, and hypotension What happens if you do not recognize this ECG instantly? Also: How did this happen? Is this just right bundle branch block?

Cardiac Arrest 136

Cardiac Arrest Bradycardia Tachycardia Chest Pain 136

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. Here is his ED ECG: There is bradycardia with a junctional escape. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. His prehospital ECG was diagnostic of inferior posterior OMI. He appeared gray in color, with cool skin.

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 82

Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. 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. What do you think? Here was my answer: "Not ischemia. Maybe HOCM or another form of LVH. I would not activate cath lab.

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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. Some of the concepts I review are basic , and should be understood, learned and applied by all providers who regularly follow Dr. Smith’s ECG Blog. The ED physician read this as "Normal sinus rhythm.

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Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2017

This was sent to me by a former resident from a community hospital: A middle-aged woman complained of chest pain and was seen in triage. The computer interpreted the ECG (GE Marquette 12 SL) as: "Sinus Bradycardia. Here it is: Computer interpretation: "Sinus bradycardia. She had a ECG recorded. Normal ECG."

Chest Pain 52

Chest Pain Bradycardia Technology Electrocardiogram 52

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. 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. Only 5-18% of ED patients with chest pain have a myocardial infarction of any kind. Bradycardia.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. Their apparently excessive length (QT interval) is due to bradycardia. This is a case I had quite a while back.

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Chest Pain Bradycardia Blog Electrocardiogram 103

Dr. Smith's ECG Blog

FEBRUARY 12, 2024

This ECG was recorded on arrival in the ED: Here is the interpretation of the conventional algorithm (Veritas): SINUS BRADYCARDIA ST ELEVATION, PROBABLY EARLY REPOLARIZATION [ST ELEVATION WITH NORMALLY INFLECTED T-WAVE] BORDERLINE ECG What do you think? Regional wall motion abnormality-apical septum and inferior wall.

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Pericarditis Chest Pain Bradycardia Aortic 84

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The computer called "Sinus Bradycardia" only (implying that everything else is normal. The overreading Cardiologist called it only "Sinus Bradycardia" with no other findings. There is zero ST Elevation.

Chest Pain 52

Chest Pain Bradycardia Blog Critical Care 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

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 arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. Angiography revealed a 30% nonobstructive stenosis of the mid LAD.

Chest Pain 106

Chest Pain STEMI Echocardiogram Stents 106

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. Written By Magnus Nossen — with edits by Ken Grauer and Smith. The below ECG was recorded.

Arrhythmia 113

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 113

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. But the angiogram was clean.

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Strokes Stroke Chest Pain Cardiomyopathy 70

Dr. Smith's ECG Blog

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The history in today's case with sudden loss of consciousness followed by chest pain is very suggestive of ACS and type I ischemia as the cause of the ECG changes. What do you think?

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 125

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. Chest pain in high risk patient. Syncope and Bradycardia Syncope in a 20-something woman Long QT: Do not trust the computerized QT interval when the QT is long An Alcoholic Patient with Syncope Cardiac Arrest. Here is his triage ECG: What do you think? Is it STEMI? What is going on here?

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Ischemia Chest Pain Cardiac Arrest Blog 112

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Apparently he denied chest pain. Like other cases on this blog who died before cath was done, I cannot prove that this patient had OMI. JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain. Here is his first ED ECG: What do you see? Canto et al.

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Chest Pain STEMI Blog Tachycardia 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

He has been following the blog for 4 years. A 55 year old with no previous cardiac history presented with 3 hours of chest pain. The pain was persistent and reportedly still present at the time of the ECG. Jean-christophe Reiters, an interventionalist in Belgium. He has now implemented the Queen of Hearts in his hospital.

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Hospital STEMI Blog Chest Pain 102

Dr. Smith's ECG Blog

JUNE 1, 2022

A 40-something male with no previous cardiac disease presented with chest pain. The pain continued and the first high sensitivity troponin I returned at 105 ng/L Another ECG was recorded: The ST segment in aVF has flattened a bit, revealing that there is some STD in addition to the non-specific findings in III and aVL.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

DECEMBER 5, 2023

days of chest pain that started as substernal and crushing in nature awakening him from sleep and occasionally traveling to right side of neck. The pain was described as constant, worse with deep inspiration and physical activity, sometimes sharp. He reported 1.5

Pediatrics 112

Pediatrics Pericarditis COVID-19 Congenital Heart Disease 112

Ken Grauer, MD

OCTOBER 4, 2024

To improve visualization — I've digitized the original ECG using PMcardio ) MY Thoughts on the ECG in Figure-1: This is a challenging tracing to interpret — because there is marked bradycardia with an irregular rhythm and a change in QRS morphology. In my ECG Blog #61 — I addressed the issue of vagotonic block. second in duration ).

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Blog Bradycardia Arrhythmia Pacemaker 103

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

ECG of pneumopericardium and probable myocardial contusion shows typical pericarditis Male in 30's, 2 days after Motor Vehicle Collsion, complains of Chest Pain and Dyspnea Head On Motor Vehicle Collision. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma?

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 107

Dr. Smith's ECG Blog

MAY 5, 2022

He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. He complained of generalized weakness and left lower extremity numbness. What is it? Activate the Cath Lab?

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

DECEMBER 5, 2016

This ECG could easily be seen in an ED chest pain patient, and I have seen many) What do you think? Description Sinus bradycardia. Comment I (Smith) have seen many similar ECGs in ED chest pain patients. I have seen this innumerable times in chest pain patients in the Emergency Department.

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Chest Pain Ischemia Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

JANUARY 15, 2023

Even if you don't see the OMI, you can usually prevent such a long delay to reperfusion by recording serial ECGs every 15 minutes for a patient with persistent chest pain. The rhythm in ECG #1 is sinus bradycardia and arrhythmia. Record serial ECGs every 15 minutes!! Hillinger et al.

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Chest Pain Blog Bradycardia Stents 52

Dr. Smith's ECG Blog

JULY 26, 2023

The combination of absence of chest pain and history of LV aneurysm made it easy to assess that this patient does not have acute OMI. In view of the History with the current admission ( ie, presenting to the ED for vertigo — with no new chest pain ) — I interpreted ECG #1 as no OMI.

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Aneurysm Chest Pain STEMI Bradycardia 52

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. Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. What do you think?

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 9, 2012

A middle-aged woman with a history of hypertension presented with typical chest pain. Here was her presenting ECG, with chest pain: Inferior leads show hyperacute T-waves and reciprocal STD in aVL, with a reciprocally hyperacute T-wave in aVL. Her BP was 160/80. This is all but diagnostic of inferior OMI.

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Chest Pain Bradycardia STEMI Hypertension 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. See these similar cases: A man in his sixties with chest pain Why is there inferior ST elevation, and would you get posterior leads? Sudden CP and SOB with Inferior ST Elevation and in STE in V1.

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Blog Bradycardia Ischemia Exercise 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

The chest pain quickly subsided. During the night, while on telemetry, the patient became bradycardic, with periods of isorhythmic AV dissociation (nodal escape rhythm alternating with sinus bradycardia), and there were sporadic PVCs. Are you worried about OMI in this case? His response was: "I would not call it OMI.

Cardiac Arrest 104

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 104