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. Former resident: "Just saw cath report, LAD stent was 100% acutely occluded."

Chest Pain 106

Chest Pain Aneurysm Stents Stent 106

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 89

Chest Pain Myocardial Infarction Stent Stents 89

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 74

Chest Pain STEMI Bradycardia Article 74

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. It is a ssociated with mild dyspnea on exertion.

Chest Pain 116

Chest Pain Myocardial Infarction Anatomy Angina 116

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 85

Chest Pain Ischemia Pericarditis Tachycardia 85

Dr. Smith's ECG Blog

JUNE 23, 2024

Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. He did not remember whether he had experienced any chest pain. The electrophysiologist is a reader of Dr. Smith's ECG Blog. Lesions less than 70% are generally considered to be non-flow limiting.

Chest Pain 108

Chest Pain Cardiac Arrest Sudden Cardiac Death Stent 108

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. His ECG is shown: What do you think? What do you think? This was the cost of preventing infarction of the anterior wall.)

Chest Pain 111

Chest Pain STEMI Bradycardia Ischemia 111

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

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chest pain with diaphoresis. The Importance of the History: As noted above — the onset of chest pain in today's case was acute. He had received aspirin and nitroglycerin by EMS, with some improvement. His vitals were within normal limits.

Chest Pain 52

Chest Pain Physiology Stent Stents 52

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. It was opened and stented. They recorded a prehospital ECG at 2112 and said that it was “normal”. It had already been crumpled up and put in the waste basket. So I uncrumpled it: What do you think?

Chest Pain 107

Chest Pain Critical Care STEMI Stent 107

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 70

Chest Pain STEMI Myocardial Infarction Electrocardiogram 70

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. Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis.

Chest Pain 101

Chest Pain STEMI Aneurysm Stent 101

Dr. Smith's ECG Blog

MARCH 13, 2023

A 40-something woman called 911 in the middle of the night for Chest pain that was intermittent. On arrival, she complained of severe pain. The medics had recorded this ECG and were uncertain whether it was recorded during chest pain: Let's get a better image with use of the PM Cardio app : What do you think?

Chest Pain 52

Chest Pain Myocardial Infarction Angioplasty Thrombosis 52

Dr. Smith's ECG Blog

APRIL 29, 2023

A 50-something with no previous cardiac history and no risk factors presented to the ED with acute chest pain (pressure) that radiated to the left arm. It was stented with good results. I've added links below to 10 cases of posterior OMI in Dr. Smith's ECG Blog — in which I illustrate application of the Mirror Test.

Chest Pain 52

Chest Pain Blog Stenosis Critical Care 52

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 90

Chest Pain STEMI Blog Stent 90

Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. The pain did not resolve with NTG, and so he went to emergent angiography: 1. LAD: severe in-stent restenosis in the mid (80%) and distal (90%) segment and diffuse disease distally.

Chest Pain 75

Chest Pain Stenosis Stents Stent 75

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. A single DES stent was placed, and the patient did well post-procedure.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

Chest Pain 52

Chest Pain STEMI Stent Stents 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

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, 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

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. It must have re-occluded between the ED and the cath lab) --Lesion was stented. Here is his initial ED ECG: What do you think?

Chest Pain 79

Chest Pain STEMI Physiology Research 79

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 Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 27, 2019

An elderly woman presented with chest pain that radiated to the back for several hours. The first troponin returned at 0.099 ng/mL (elevated, consistent with Non-Occlusion MI) Providers were concerned with aortic dissection, so they order a chest aorta CT. It is essentially normal.

Chest Pain 52

Chest Pain Blog Ischemia Article 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This is another case written by Pendell Meyers (who is helping to edit the blog and has many great recent posts) Case A 45 year old man was driving to work when he experienced acute onset sharp left sided chest pain with paresthesias of the left arm. A repeat ECG was recorded with pain 2/10: Not much change.

Chest Pain 52

Chest Pain STEMI Defibrillator Stent 52

Dr. Smith's ECG Blog

MAY 11, 2019

male was sitting at a work conference when he began having substernal chest pain with diaphoresis. The pain was 7 out of 10 when this ECG was recorded: The QTc = 375 What do you think? Here is the post stent ECG: This is probably the amount of ST elevation (zero) that this patient has at baseline.

Chest Pain 52

Chest Pain STEMI Stent Stents 52

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. He presented to the ED for evaluation chest pain. Pain was improved but not gone upon arrival.

STEMI 116

STEMI Chest Pain Myocardial Infarction Aneurysm 116

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. Angiogram: Culprit Lesion (s): Thrombotic occlusion of the proximal RCA -- stented. As discussed earlier — substitution in the chest leads with right-sided and posterior leads confirms RV and posterior MI. The patient was in clinical shock with a lactate of 8.

Chest Pain 82

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 82

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

AUGUST 17, 2019

Chris Mondie of the Newark Beth Israel Emergency Medicine Residency sent this case A 50-something man presented with acute chest pain. But after reading this blog, you all know that most OMI do NOT meet STEMI criteria. 100% proximal LAD successfully stented. mm in men over age 40. Some patient's baseline ECG has zero STE.

Chest Pain 52

Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 14, 2024

This was texted to me by a paramedic while I was out running one day: "54 yo male chest pain started at 1pm. History of diabetes type II and stent placement in 2018. This can be confirmed by obtaining right-sided chest leads ( See the May 30, 2023 post in Dr. Smith's ECG Blog for more on the ECG diagnosis of RV MI ).

Academic 116

Academic Stent Stents Thrombosis 116

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

JULY 30, 2023

Written by Pendell Meyers A woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. She was taken to cath and found to have total mid RCA occlusion, TIMI 0 flow, stented with excellent result. Here is her triage ECG during active symptoms: What do you think?

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

JULY 11, 2019

Written and submitted by Ashley Mogul, with edits by Pendell Meyers and Steve Smith A man in his 40s with recent smoking cessation but otherwise no known past medical history presented due to chest pain since the previous evening. The pain has been constant and associated with vomiting and diaphoresis.

Chest Pain 52

Chest Pain STEMI Article Stent 52

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. The patient had continued to have chest pain.

EKG Technician 114

EKG Technician Chest Pain Blog STEMI 114

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 116

Chest Pain Myocardial Infarction Blog Stent 116

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The door to balloon time was incredibly short and there was a 100% circumflex occlusion that was opened and stented. For more on ECG findings in pulmonary disease — Check out My Comment in the May 31, 2024 post in Dr. Smith's ECG Blog ).

Hospital 77

Hospital Chest Pain Blog Pulmonary 77

Dr. Smith's ECG Blog

JULY 19, 2019

Written by Pendell Meyers, with edits by Steve Smith A man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). The patient was still with ongoing chest pain at the time ECG #1 was done.

Chest Pain 52

Chest Pain STEMI Aneurysm Pericarditis 52