ECG Cases

MAY 10, 2023

In this ECG Cases blog we look at 10 cases of patients with chest pain, including false positive STEMI, false negative STEMI, and other causes to help hone your ECG interpretation skills in time-sensitive cases where those very ECG skills might save a life.

Chest Pain 52

Chest Pain STEMI Blog Pericarditis 52

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

I came to work one day and one of my partners said, "Hey, Steve, we had a STEMI this afternoon!" Of course he said: "Yes, it was a 60 year old diabetic with Chest pain." That is not a STEMI. More cases can be found on the blog here. I said, "Cool, can I see the ECG?' He said: "What? What the heck is that?

Chest Pain 131

Chest Pain Diabetes STEMI Blog 131

Dr. Smith's ECG Blog

NOVEMBER 30, 2024

Written by Jesse McLaren, with edits from Meyers Four patients presented with chest pain or shortness of breath, and ECGs labeled ‘inferior STEMI’. Less concavity associated with hyperacuity This can help identify false negative STEMI, or STEMI(-)OMI, at risk for delayed reperfusion. More asymmetry 3.

STEMI 76

STEMI Chest Pain Pericarditis Coronary Artery Disease 76

Dr. Smith's ECG Blog

MAY 29, 2024

Written by Pendell Meyers Two patients with acute chest pain. Patient 1: Patient 2: Patient 1: A man in his 40s with minimal medical history presented with acute chest pain radiating to his R shoulder. Two patients with chest pain. Do either, neither, or both have OMI and need reperfusion?

Chest Pain 104

Chest Pain STEMI Pericarditis Stent 104

Dr. Smith's ECG Blog

APRIL 6, 2024

A young woman presented with acute chest pain. In fact, it read: ** **ACUTE MI / STEMI ** ** The physicians caring for the patient activated the cath lab for "STEMI". In fact, it read: ** **ACUTE MI / STEMI ** ** The physicians caring for the patient activated the cath lab for "STEMI".

Chest Pain 108

Chest Pain STEMI Hospital 108

ECG Cases

DECEMBER 20, 2022

Jesse McLaren discusses some key aspects of cocaine chest pain ECG interpretation in this month's blog including: Patients with cocaine-associated chest pain require benzodiazepines +/- nitroglycerine for symptom relief, aspirin and ECG to look for signs of occlusion and reperfusion.

Chest Pain 52

Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. Do either, both, or neither have occlusion MI? Vitals were normal.

Chest Pain 73

Chest Pain STEMI Pulmonary Embolism 73

Dr. Smith's ECG Blog

MARCH 31, 2024

The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation. The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). mm STE in the posterior leads.

Chest Pain 95

Chest Pain STEMI Ischemia Myocardial Infarction 95

Ken Grauer, MD

DECEMBER 8, 2023

For full discussion of this case — See ECG Blog #292 — == The 2 ECGs shown in Figure-1 were obtained from a man in his 30s — who presented to the ED ( E mergency D epartment ) with chest pain that began several hours earlier. ECG Blog #260 — Reviews another case that illustrates the concept of "dynamic" ST-T wave changes.

Blog 165

Blog Chest Pain STEMI Ischemia 165

Ken Grauer, MD

AUGUST 26, 2023

These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ). This point is discussed in detail in the March 24, 2023 post of Dr. Smith’s ECG Blog ).

Blog 145

Blog Chest Pain STEMI Ischemia 145

Ken Grauer, MD

DECEMBER 15, 2023

For full discussion of this case — See ECG Blog #392 — == The ECG in Figure-1 was obtained from a man in his 60s — who described the sudden onset of "chest tightness" that began 20 minutes earlier, but who now ( at the time this ECG was recorded ) — was no longer having symptoms. ECG Blog #387 — Dynamic change in 2 minutes.

Blog 152

Blog STEMI Ischemia Chest Pain 152

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

Written by Jesse McLaren A 45 year old presented with two weeks of recurring non-exertional chest pain, now constant for an hour. Because of the ECG changes in a patient with chest pain, and with inferolateral hypokinesis on POCUS, the cath lab was activated. Below is old and then new ECG (old on top; new below).

Chest Pain 91

Chest Pain STEMI Ischemia Anatomy 91

Ken Grauer, MD

JUNE 14, 2024

Prompt cath is therefore advised if the post-ROSC shows an acute STEMI. I i llustrate the ECG finding of T-QRS-D below in Figure-3 , which I've excerpted from My Comment in the November 14, 2019 post in Dr. Smith's ECG Blog. To Emphasize: The phenomenon of T-QRS-D is not needed in today's case to recognize the acute STEMI.

Blog 162

Blog STEMI Cardiac Arrest Tachycardia 162

Dr. Smith's ECG Blog

AUGUST 16, 2024

Written by Pendell Meyers A man in his 60s presented with acute chest pain and normal vital signs. Its hard to measure the STE in I exactly with the moving baseline, but there is almost certainly not enough STE to meet STEMI criteria. Here is his triage ECG: What do you think? They are symmetric, fat, convex on both sides, etc.

Chest Pain 105

Chest Pain STEMI Blog 105

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

Chest Pain 132

Chest Pain Defibrillator STEMI Coronary Artery Disease 132

Dr. Smith's ECG Blog

AUGUST 11, 2024

Written by Jesse McLaren A healthy 75 year old developed 7/10 chest pain associated with diaphoresis and nausea, which began on exertion but persisted. Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. What do you think?

Chest Pain 76

Chest Pain STEMI Bradycardia Article 76

Ken Grauer, MD

FEBRUARY 3, 2024

Despite the absence of significant coronary stenosis on her post-arrest cath — the ECG in Figure-1 is clearly diagnostic of an extensive anterolateral STEMI ( presumably from acute LAD [ L eft A nterior D escending ] coronary artery occlusion). The rhythm in ECG #1 is regular and supraventricular at a rate of ~75/minute. What is T-QRS-D?

Blog 164

Blog Cardiac Arrest STEMI Plaque 164

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

Written by Willy Frick A young woman with a history of paroxysmal nocturnal hemoglobinuria presented with acute substernal chest pain. Documentation does not indicate whether she had persistent chest pain during this time. Five days prior, she had a similar presentation to a different hospital.

Chest Pain 66

Chest Pain Hospital Anatomy Aneurysm 66

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 113

Chest Pain STEMI Atrial Flutter Ischemia 113

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The patient continued having chest pain. This has been discussed many times before on this blog. Is there STEMI?

Chest Pain 87

Chest Pain Arrhythmia Myocardial Infarction STEMI 87

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Written by Jesse McLaren Two 70 year olds had acute chest pain with nausea and shortness of breath, and called paramedics. There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JUNE 21, 2023

Sent by Magnus Nossen MD, written by Pendell Meyers A man in his 50s, previously healthy, developed acute chest pain. The primary care physician there evaluated this patient and deemed the chest pain to be due to gastrointestinal causes. In this case, the EMS provider was routed to the urgent care facility.

Chest Pain 98

Chest Pain Cardiac Arrest STEMI Defibrillator 98

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. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI?

Chest Pain 52

Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

JANUARY 29, 2024

This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chest pain The tech came running with the ECG as the computer called "STEMI!" So signed it NO STEMI and triaged him OK to not be in RESUS." What do you think? Sam sent this to me and asked: "What do you think, Steve?" My answer: --Tough one! --But

Chest Pain 80

Chest Pain STEMI Blog Outcomes 80

Dr. Smith's ECG Blog

OCTOBER 30, 2024

All of the patients contacted EMS due to acute onset chest pain. The above ECG is from a 70 something male with chest pain. ECG #2 Case 2 : The above ECG was obtained from a diabetic 45 year old smoker with chest pain. I have only 2 such cases on this blog up until now (now 3!). ECG #1 Case 1.

Chest Pain 91

Chest Pain Aortic Myocardial Infarction STEMI 91

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.

Chest Pain 60

Chest Pain Pericarditis Pacemaker STEMI 60

Dr. Smith's ECG Blog

OCTOBER 27, 2024

This was submitted by a paramedic, Hailey Kennedy A late 50s male called 911 following 2 hours of chest pain that started while working at his desk. He reported the crushing chest pain radiated down his left arm. The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI".

STEMI 118

STEMI Chest Pain Myocardial Infarction Aneurysm 118

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.

Chest Pain 122

Chest Pain Tachycardia STEMI Blog 122

Ken Grauer, MD

MARCH 15, 2024

By the P s, Q s, 3 R Approach ( which I review in ECG Blog #185 ): Lots of P waves are present — being well seen in the long lead II rhythm strip. 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 ).

Blog 161

Blog Arrhythmia STEMI Ischemia 161

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

NOVEMBER 10, 2024

Written by Pendell Meyers, few edits by Smith A woman in her 70s was woken from sleep by midsternal chest pain radiating to left arm with nausea. The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. Very frustrating.

STEMI 81

STEMI Chest Pain Echocardiogram Stent 81

Dr. Smith's ECG Blog

SEPTEMBER 1, 2023

A 50-something male had onset of chest pain 1 hour prior to ED arrival. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. It was tested on a large database of known outcomes and was more than twice as senstivity as STEMI criteria and much better than cardiologists.

Chest Pain 125

Chest Pain STEMI Stenosis Myocardial Infarction 125

Dr. Smith's ECG Blog

MARCH 22, 2024

Written by Willy Frick A man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0.

Chest Pain 112

Chest Pain STEMI Bradycardia Ischemia 112

Dr. Smith's ECG Blog

MARCH 9, 2024

Written by Willy Frick A 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. Due to the chest pain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. He had associated nausea, vomiting, and dyspnea.

Chest Pain 113

Chest Pain Pericarditis Aortic Echocardiogram 113

Ken Grauer, MD

OCTOBER 21, 2023

PEARL # 1: Although seeing an elevated Troponin would provide additional support for immediate cardiac catheterization — the clinical reality is that the initial Troponin reading will not always be elevated in patients with acute coronary occlusion ( See March 24, 2023 post in Dr. Smith's ECG Blog ). BLUE arrows in Figure-2 ).

Blog 99

Blog Chest Pain Ischemia STEMI 99

Ken Grauer, MD

OCTOBER 29, 2023

Based on ECG Blog #351 ( www.tinyurl.com/KG-Blog-351 ) LINK to this Page — www. tinyurl.com/KG-MedAll-351 — = = ECG Blog #205 = The Systematic Approach I favor. The "formula" = [link] LINK for Blog #205 = [link] - = Figure: The Systematic Approach that I favor. The talk will be recorded and posted on-line.

Blog 78

Blog Chest Pain STEMI 78

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity.

Chest Pain 117

Chest Pain STEMI Hypertension Ischemia 117