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 Embolism 52

Dr. Smith's ECG Blog

JUNE 8, 2023

Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. The patient has a history of CABG so some of these changes could be old, but with ongoing chest pain and bradycardia in a high risk patient this is still acute OMI until proven otherwise. HR 40, BP 135/70, RR16, O2 100%.

Chest Pain 62

Chest Pain STEMI Bradycardia Myocardial Infarction 62

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 103

Chest Pain STEMI Pericarditis Stent 103

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

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

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 Stent 76

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 94

Chest Pain STEMI Ischemia Myocardial Infarction 94

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 Ischemia Blog 52

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

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 133

Chest Pain Defibrillator STEMI Coronary Artery Disease 133

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 135

Blog STEMI Cardiac Arrest Tachycardia 135

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 88

Chest Pain Arrhythmia Myocardial Infarction STEMI 88

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 138

Blog Chest Pain STEMI Ischemia 138

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 128

Blog STEMI Ischemia Chest Pain 128

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

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 155

Blog Cardiac Arrest STEMI Plaque 155

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 63

Chest Pain Pericarditis Pacemaker STEMI 63

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 96

Chest Pain Cardiac Arrest STEMI Defibrillator 96

Dr. Smith's ECG Blog

AUGUST 10, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLaren A 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram.

Chest Pain 89

Chest Pain STEMI Ischemia Nursing 89

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

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 113

Chest Pain STEMI Bradycardia Ischemia 113

Dr. Smith's ECG Blog

JUNE 13, 2024

Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chest pain that started 2-3 hours earlier while sitting on a porch swing. See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6. Also seen in inferior + RV OMI.)

Chest Pain 92

Chest Pain Document STEMI Defibrillator 92

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

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

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 100

Blog Chest Pain Ischemia STEMI 100

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

APRIL 22, 2024

A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chest pain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest. At times the pain does go to his left neck. What do you think the prehospital ECG showed (with pain)?

Chest Pain 120

Chest Pain Myocardial Infarction Anatomy Angina 120

Dr. Smith's ECG Blog

DECEMBER 29, 2023

Written by Jesse McLaren A previously healthy 50 year-old presented with 24 hours of intermittent exertional chest pain, radiating to the arms and associated with shortness of breath. In a previously healthy patient with new and ongoing chest pain, this is concerning for acute occlusion of the first diagonal artery.

Chest Pain 74

Chest Pain STEMI Myocardial Infarction Electrocardiogram 74

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Written by Jesse McLaren Four patients presented with chest pain. Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. have published a number of warnings about the previous reassuring studies.[4,5] minutes).

Chest Pain 121

Chest Pain STEMI Electrocardiogram Ischemia 121

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. Barely any STE, and thus not meeting STEMI criteria.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Blog 52

Ken Grauer, MD

MAY 20, 2023

Voltage for LVH is satisfied — at least by Peguero Criteria ( Sum of deepest S in any chest lead + S in V4 ≥23 mm in a woman — as discussed in ECG Blog #73 ). In the October 15, 2022 post of Dr. Smith's ECG Blog — Drs. Intervals ( PR, QRS and the QTc ) and the frontal plane axis are normal. What is P recordial S wirl ?

Blog 129

Blog Chest Pain Ischemia STEMI 129

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 92

Chest Pain Myocardial Infarction Stent Stents 92

Ken Grauer, MD

MARCH 7, 2023

But, in a patient who presents to the ED for new chest pain — seeing these subtle findings that are localized to leads V2- thru -V4 should at the least make you consider acute posterior OMI ( O cclusion-based MI ) — until you prove otherwise. To EMPHASIZE: These are subtle findings. What do YOU think?

Blog 78

Blog Chest Pain STEMI Ischemia 78

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? So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion.

Chest Pain 104

Chest Pain STEMI Aneurysm Stent 104

Dr. Smith's ECG Blog

JULY 23, 2024

I was working at triage when the medics brought this patient who is 65 yo and has had chest pain for 12 hours. The pain had been intermittent until an hour before arrival, when he called 911. Another ECG was recorded while awaiting the cath team: Now there is STEMI Let's look at that first (prehospital ECG) again: Very subtle!

Chest Pain 110

Chest Pain Critical Care STEMI Stent 110

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you manage the patient?

Chest Pain 131

Chest Pain Blog STEMI 131