Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Written by Jesse McLaren A 65 year old with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented with 3 days of fluctuating chest pain, which was ongoing at triage. So a patient with high pretest probability (prior CABG with new chest pain), had new ECG changes showing posterior OMI.

Chest Pain 114

Chest Pain STEMI Atrial Flutter Ischemia 114

Dr. Smith's ECG Blog

AUGUST 6, 2024

Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( Chest Pain ). As a result, this 45-year old man did not experince any delay in treatment — and a large diagonal branch of the LAD was stented with good outcome.

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

FEBRUARY 14, 2024

A 41-year-old male who presents to the emergency department with chest pain. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling. No shortness of breath. No recent travel.

Chest Pain 110

Chest Pain Angina Ischemia Outcomes 110

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. Smith : "What was the outcome?" x the QRS amplitude in any of V1-V4.

Chest Pain 114

Chest Pain Aneurysm Stents Stent 114

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA.

Chest Pain 111

Chest Pain Myocardial Infarction Stents Stent 111

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Written by Jesse McLaren Four patients presented with chest pain. 1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department.

Chest Pain 119

Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. What do you think? It should never have been published.

Chest Pain 119

Chest Pain STEMI Outcomes Electrocardiogram 119

Dr. Smith's ECG Blog

MAY 23, 2023

Written by Pendell Meyers A man in his early 40s experienced acute onset chest pain. The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset.

Chest Pain 98

Chest Pain STEMI Blog Stents 98

Dr. Smith's ECG Blog

JANUARY 27, 2024

Written by Jesse McLaren, comments by Smith A 55 year old with a history of NSTEMI presented with two hours of exertional chest pain, with normal vitals. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab? What do you think?

Chest Pain 117

Chest Pain STEMI Aneurysm Stents 117

Dr. Smith's ECG Blog

JUNE 5, 2023

A 40-something male presented by ambulance with one hour of chest pain that was improving after sublingual nitroglycerine and 325 mg of aspirin, chewed. Thus, in our ECG research, we need to find a surrogate outcome that reflects the state of the artery at the time of the ECG. Here is his initial ED ECG: What do you think?

Chest Pain 96

Chest Pain STEMI Physiology Stents 96

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 122

Chest Pain Blog Cardiac Arrest Cardiomyopathy 122

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A healthy 45-year-old female presented with chest pain, with normal vitals. The patient was previously healthy, with no atherosclerotic risk factors, and developed chest pain after an episode of stress. The pain was crushing retrosternal, radiated to the arms and was associated with lightheadedness.

Chest Pain 66

Chest Pain Pericarditis SCAD STEMI 66

Dr. Smith's ECG Blog

JULY 7, 2024

Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain with diaphoresis, and called EMS. Discharge diagnoses and MI classification should reflect patient outcomes of Occlusion vs non-Occlusion MI, not arbitrary STE vs Non-STE criteria, or rapid vs delayed time to cath. What do you think?

Chest Pain 66

Chest Pain STEMI Blog Arrhythmia 66

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. The primary outcomes were sensitivity/specificity of 1) STD in lead I ≥ 0.5 mm and 2) STE in lead V1 ≥ 0.5 mm, stratified by presence or absence of posterior (inferobasal) MI, as determined by ≥0.5 mm STD in lead V2, for differentiating RVMI from non-RVMI.

Chest Pain 97

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

There were no injuries and no chest pain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear.

Chest Pain 52

Chest Pain STEMI Hospital Blog 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. TIMI flow alone cannot be used as an outcome definition for OMI or STEMI. =

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

MAY 18, 2011

A 29 year old male presented with 6 hours of stuttering chest pain, constant for the last hour, worse with breathing. Take home point here : Obtain an ECG on anyone with chest pain. 3) Q-waves are independently associated with worse outcomes (78% relative increase in 90-day mortality in Armstrong et al.)

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Aneurysm 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." Lobo et al. examined SCAD presenting as STEMI (unlike Hassan et al.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Submitted and written by Anonymous, edits by Meyers and Smith A 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache. Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

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

NOVEMBER 23, 2022

Case submitted by Rachel Plate MD, written by Pendell Meyers A man in his 70s presented with chest pain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. We've shown many cases on Dr. Smith's ECG Blog of subtle ECG findings that rapidly evolve into dramatic ST-T wave changes.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart Attack 52

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. The following ECG was obtained.

Chest Pain 130

Chest Pain Myocardial Infarction Blog Stents 130

Dr. Smith's ECG Blog

AUGUST 19, 2023

Because the patient had no chest pain or shortness of breath, they were initially diagnosed as gastroenteritis. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS.

Chest Pain 98

Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

APRIL 8, 2022

There is a patient with persistent chest pain and an initial troponin I over 52 ng/L; 52 ng/L has an approximate 70% PPV for acute type I MI in a chest pain patient. Pain was severe and persistent. CT angiography chest assessing for PE and dissection negative. Heparin drip was initiated. Is there STEMI?

Chest Pain 52

Chest Pain SCAD STEMI Blog 52

Dr. Smith's ECG Blog

MAY 16, 2023

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Other outcome information is not available.

Chest Pain 52

Chest Pain Pericarditis Tachycardia STEMI 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. More outcome Peak troponin I was 0.58 Case A 40-something male presented to triage. Am J Cardiol.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

DECEMBER 16, 2019

This case was texted to me by one of our residency graduates, and with the outcome, so I don't know how I would have interpreted it blindly. A 50-something male who is healthy and active with no previous medical history presented with 5 hours of continuous worrisome chest pain. The highest ST/S ratio is in V3, and is 2.5/13

Chest Pain 52

Chest Pain Myocardial Infarction Stents Stent 52

Dr. Smith's ECG Blog

APRIL 21, 2023

Written by Jesse McLaren, with comments from Smith A 50-year old patient on the medical wards developed acute chest pain, with an ECG labeled (see computer interpretation at the top) and confirmed as normal. What do you think? There’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages.

Chest Pain 52

Chest Pain STEMI Cancer Hemorrhage 52

Dr. Smith's ECG Blog

JUNE 30, 2023

These were texted to me only with "chest pain." It helps to know that the patient has active chest pain, as Wellen's is a post occlusion (reperfusion) state, with open artery and pain-free. Outcome: Patient ruled out for MI by troponins. First: 2nd: What was my response? Smith: Young thin black male.

Chest Pain 52

Chest Pain Blog Ischemia Document 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 ??

Chest Pain 52

Chest Pain Congenital Heart Disease Article Congenital 52

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.

STEMI 80

STEMI Chest Pain Pericarditis Ischemia 80

Dr. Smith's ECG Blog

APRIL 4, 2023

Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chest pain radiating to the neck, associated with shortness of breath. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. What do you think?

Chest Pain 52

Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

A 70-year-old man calls 911 after experiencing sudden, severe chest pain. These patients had worse outcomes than patients with ST depression without occlusion; half of these were circumflex. Does routine use of the 15-lead ECG improve the diagnosis of acute myocardial infarction in patients with chest pain?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

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 120

Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

DECEMBER 23, 2014

He underwent PCI and had a good outcome. However, the 1st, 3rd, and 5th complexes in V1 are PVCs with RBBB morphology. The 2nd and 4th are sinus with normal conduction with deep QS-waves (not LBBB). Notice how visible the ST elevation is in the PVCs. Learning Points: 1. T-wave size must be assessed relative to the QRS amplitude 2.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 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. This is a case I had quite a while back. See the explainability : She sees large T-waves in V2, V3.

Chest Pain 116

Chest Pain Bradycardia Blog Electrocardiogram 116

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

A 60-something woman called EMS for chest pain. link] Clinical Course I don't know if the medics noticed these ECG findings or not, but if not, they recognized the value of serial ECGs in a patient with chest pain. The medics administered aspirin (no Nitroglycerine), and the pain resolved. #5: mm in V2 and 0.65

Chest Pain 121

Chest Pain STEMI Stents Stent 121