Dr. Smith's ECG Blog

JANUARY 15, 2024

They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They described the chest pain as severe, crushing, and non-radiating. Altogether, this strongly suggests inferolateral OMI, particularly in a patient with acute chest pain.

Chest Pain 64

Chest Pain Blog Arrhythmia Critical Care 64

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.

Chest Pain 139

Chest Pain Embolism Pulmonary Tachycardia 139

Dr. Smith's ECG Blog

JUNE 17, 2018

A middle-aged patient with lung cancer had presented to clinic complaining of generalized malaise, cough, and chest pain. Symptoms other than chest pain (malaise, cough in a cancer patient) 2. Inclusion criteria were chest pain, at least 2 serial cTnI in 24 hours, sinus rhythm , and at least 1 ECG.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

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." The initial troponin I was elevated at 0.75

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

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. Pain better still. What do you think the echocardiogram shows? NTG drip started.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Upon questioning patient, he denies having any chest pain or chest tightness of any sort. In the absence of chest pain and negative troponin , it appears less likely that he is having acute coronary syndrome though EKG appears concerning. Pericarditis would be even more unlikely in someone without chest pain.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

MAY 13, 2017

He complained of severe chest pain and was extremely agitated, so much so that he was throwing chairs in triage. On this blog, the warning is this : It is critical to use it only when the differential is subtle LAD occlusion vs. early repol. His chest pain resolved. He had an ECG recorded and was brought to a room.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Myocardial Infarction 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

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. He later developed mild continuous chest pain, that he describes as the sensation of someone standing on his chest. See this post: What do you think the echocardiogram shows in this case?

Chest Pain 119

Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

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. Formal echocardiogram: Systolic function is at the lower limits of normal. We have shown many examples of this on this blog. Chest pain and a computer ‘normal’ ECG.

Chest Pain 114

Chest Pain STEMI Blog Exercise 114

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast. The patient was given opiates which improved his chest pain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

Chest Pain 121

Chest Pain Blog Hospital Tachycardia 121

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. In context, of course, it is clear that the patient is reperfusing, as pain has dissipated and the diagnostic findings of OMI have become more nonspecific. This ECG is more difficult.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

DECEMBER 9, 2023

The medics stated he had been nauseated and diaphoretic, but he did not have any chest pain or SOB. And especially suspect Old MI when the patient gives a history of MI and has no chest pain or SOB. Case continued The patient underwent an emergency formal echocardiogram and it was unchanged. Learning Points: 1.

Aneurysm 116

Aneurysm Chest Pain Echocardiogram STEMI 116

Dr. Smith's ECG Blog

NOVEMBER 4, 2018

A middle-aged woman presented with chest pain. She had a normal echocardiogram, with normal shortening and thickening of the septum. 27, 2018 blog post ). She had no history of cardiac disease. Septal Q-waves may be caused by placing leads V1 and V2 too high. American Journal of Emergency Medicine 36(5):865-870; May 2018.

Chest Pain 52

Chest Pain Anatomy Echocardiogram Article 52

Dr. Smith's ECG Blog

DECEMBER 11, 2023

See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. This is different from nitroglycerin which produces vasodilation and can improve by pain improving myocardial perfusion. Her contrast enhanced echocardiogram is shown below in the parasternal short axis view. At midnight. The case continues.

Myocardial Infarction 123

Myocardial Infarction Chest Pain STEMI Blood Pressure 123

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Triage EKG: What do you think? Do NOT use them.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 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.

Chest Pain 117

Chest Pain STEMI Echocardiogram Stents 117

Dr. Smith's ECG Blog

JULY 14, 2023

Formal Echocardiogram: Normal left ventricular size and wall thickness. As I emphasized in My Comment at the bottom of the page in the October 10, 2022 post in Dr. Smith's ECG Blog — Interpretation of a post-resuscitation ECG can be extremely challenging. First — Some thoughts on the post -resuscitation ECG.

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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. First troponin I returns at 48 ng/L ECG 5 143 min No significant change ECG 6 261 min Same hs Troponin I profile (peaked at 1849): Formal Echocardiogram SUMMARY The estimated left ventricular ejection fraction is 74 %.

Chest Pain 116

Chest Pain Myocardial Infarction STEMI Pericarditis 116

Dr. Smith's ECG Blog

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. He had no h/o heart failure. Regional wall motion abnormality-inferior. Regional wall motion abnormality-inferolateral. This means posterior in common terminology) --Normal LV cavity size with moderately increased thickness.

STEMI 124

STEMI Heart Failure Stents Stent 124

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. Formal echocardiogram showed normal EF, no wall motion abnormalities, no pericardial effusion.

Chest Pain 91

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 91

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? 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. Description Sinus bradycardia.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

JULY 11, 2024

Because: 1) He has been reading this blog for a long time. Case A 43 year old male with a history of DM II, hyperlipidemia, and a family history of myocardial infarction presented to a family clinic with two days of epigastric pain that started after consuming a meal. An echocardiogram showed an EF of 20-25%.

Outcomes 113

Outcomes Stenosis Outpatient Echocardiogram 113

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. The echocardiogram shows a preserved left ventricular ejection fraction (LVEF) of 55% with marked basal and mid inferolateral and basal anterolateral hypokinesia. The first ECG (10h14) showed TWI in inferior leads."

Chest Pain 67

Chest Pain STEMI Myocardial Infarction Angioplasty 67

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. The pain initially started the day prior to presentation. The ST elevation from today is ~0.2

Pericarditis 52

Pericarditis Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

Although the patient reported experiencing mild pressure-like chest pain, there was suspicion among clinicians that this might be indicative of an older change. A rapid echocardiogram was performed, revealing an ejection fraction of 20% with thinning of the anterior-apical walls.

Tachycardia 113

Tachycardia Blog Ischemia Heart Failure 113

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 initial troponin I returned at 1500 ng/L and another ECG was recorded as the patient complained of 9/10 chest pain at 10 hours after the first Now the T-wave in III is fully upright, suggesting re-occlusion.

Chest Pain 52

Chest Pain Bradycardia Blog Critical Care 52

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Echocardiogram was obtained and showed mild LVH without regional wall motion abnormality. Not a STEMI: Reasons I did not think ECG #1 represented an acute STEMI — included the following: There was no history of chest pain. Following PCI, the patient ruled out by troponins : troponin increased to 0.08 ng/mL and 0.10

STEMI 116

STEMI Document Blog Ischemia 116

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 52

Pericarditis Chest Pain Aortic Blog 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. He described it as "10/10" intensity, radiating across his chest from right to left. His echocardiogram showed normal wall motion.

Plaque 127

Plaque Angina Blog Stents 127

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.

Strokes 70

Strokes Stroke Chest Pain Cardiomyopathy 70

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Hopefully a repeat echocardiogram will be performed outpatient. 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. 1900: RBBB and LAFB are almost fully resolved.

Tachycardia 116

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 116

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. The peak troponin I was 0.364 ng/ml.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

A 40-something woman with diabetes and peripheral vascular disease who frequently needs the ED for chronic pain called 911 for sudden severe chest pain. Echocardiogram: The estimated left ventricular ejection fraction is 34% Regional wall motion abnormality-lateral, akinetic. A massive acute OMI.

Chest Pain 52

Chest Pain Blog Ischemia STEMI 52

Dr. Smith's ECG Blog

APRIL 12, 2013

He had no chest pain. The computer read is: **Acute MI ** The protocol for prehospital activation in the EMS system that this patient presented to requires 2 elements: 1) Chest pain 2) A computer read of **Acute MI ** Only 1 of 2 was present, so there was no prehospital activation. The patient was transported to the ED.

STEMI 52

STEMI Pulmonary Stent Stents 52

Dr. Smith's ECG Blog

OCTOBER 26, 2010

This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain. He presented to the Emergency Department with a blood pressure of 111/66 and a pulse of 117. He had this ECG recorded. Troponins peaked at 0.275 ng/ml.

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

MARCH 2, 2009

Pain is similar, but associated with less SOB. A stat echocardiogram would have helped to make this diagnosis and facilitate timely reperfusion. Possibilities include: serial ECGs (which were done but still nondiagnostic), stat echocardiogram, or posterior ECG. The pain is very nitroglycerine responsive.

Heart attacks 52

Heart attacks Heart Attack STEMI Echocardiogram 52