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.

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Chest Pain Pericarditis Pacemaker STEMI 60

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. If it is STEMI, it would have to be RBBB with STEMI. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. Bradycardia. This ECG was sent from South Asia.

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. 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 ).

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Dr. Smith's ECG Blog

NOVEMBER 10, 2017

This was sent to me by a former resident from a community hospital: A middle-aged woman complained of chest pain and was seen in triage. The computer interpreted the ECG (GE Marquette 12 SL) as: "Sinus Bradycardia. Here it is: Computer interpretation: "Sinus bradycardia. She had a ECG recorded. Normal ECG."

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Chest Pain Bradycardia Technology Electrocardiogram 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.

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Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

Written by Jesse McLaren, with edits from Smith and Grauer A 60 year old with no past medical history presented with two hours of chest pain radiating to the left arm, with normal vitals. But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. What do you think?

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Chest Pain Myocardial Infarction Ischemia STEMI 52

Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. Any objective, rule-based analysis of this ECG would scream "STEMI" or "OMI". And I recognized this as a STEMI mimic. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. This was texted to me in real time.

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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. Their apparently excessive length (QT interval) is due to bradycardia. This is a case I had quite a while back.

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Chest Pain Bradycardia Blog Electrocardiogram 116

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. 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 wrote most of it and I (Smith) edited.

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Chest Pain STEMI Echocardiogram Stent 116

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. The pain was completely resolved after coronary intervention. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. Blood pressure: 130/80 mmHg, heart rate: 45/min, respiratory rate: 18/min, SaO2: %98, body temperature: normal.

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STEMI Chest Pain Myocardial Infarction Electrocardiogram 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. It does not meet STEMI criteria. Luckily, 45 minutes later, with ongoing pain and a troponin I that resulted at 136 ng/L, the ECG was repeated: What do you think now? Anyway, she does say OMI.

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Dr. Smith's ECG Blog

OCTOBER 9, 2012

A middle-aged woman with a history of hypertension presented with typical chest pain. Here was her presenting ECG, with chest pain: Inferior leads show hyperacute T-waves and reciprocal STD in aVL, with a reciprocally hyperacute T-wave in aVL. Her BP was 160/80. This is all but diagnostic of inferior OMI.

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Dr. Smith's ECG Blog

JUNE 1, 2022

A 40-something male with no previous cardiac disease presented with chest pain. The pain continued and the first high sensitivity troponin I returned at 105 ng/L Another ECG was recorded: The ST segment in aVF has flattened a bit, revealing that there is some STD in addition to the non-specific findings in III and aVL.

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Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? There is also bradycardia. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. There is atrial fibrillation.

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Dr. Smith's ECG Blog

OCTOBER 11, 2020

Apparently he denied chest pain. The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain. Canto et al.

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Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion.

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Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. Is it STEMI? Chest pain in high risk patient. Syncope and Bradycardia Syncope in a 20-something woman Long QT: Do not trust the computerized QT interval when the QT is long An Alcoholic Patient with Syncope Cardiac Arrest. Here is his triage ECG: What do you think?

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Ischemia Chest Pain Cardiac Arrest Blog 124

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. There was no OMI.

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Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. Step 1 to missing posterior MI is relying on the STEMI criteria.

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Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? This is the initial ED ECG of a 46 year old male with chest pain: The QTc was 420 ST Elevation at 60 ms after the J-point in lead V3 = 2.5

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Dr. Smith's ECG Blog

FEBRUARY 2, 2024

A 55 year old with no previous cardiac history presented with 3 hours of chest pain. The pain was persistent and reportedly still present at the time of the ECG. But if the pain is persistent, as reported, then the patient must go to the cath lab even if the ECG suggests reperfusion.

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Dr. Smith's ECG Blog

MAY 5, 2022

He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. What is it?

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Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

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Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

JANUARY 5, 2024

Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The ECG shows sinus bradycardia but is otherwise normal. The patient said his chest pain was 4/10, down from 8/10 on presentation. The following ECG was obtained.

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Dr. Smith's ECG Blog

MARCH 30, 2014

Now chest pain free. Repeat ECG showing no STEMI, only non-specific ST-segment and T-wave abnormalities, unchanged from prior" Transferred to surgery for exploration but diagnostic studies were too indeterminate to be certain of intra-abdominal pathology. There is a junctional bradycardia. She was taken to the cath lab.

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EMS 12-Lead

JULY 21, 2022

We have borderline sinus bradycardia with 1 ° AVB and occasional PACs. ECG diagnosis: Borderline sinus bradycardia, 1st degree AVB, RBBB, and occasional PACs. Generally speaking, right bundle branch block does not mimic, or obscure, the ECG diagnosis of acute STEMI the way left bundle branch block does. What’s the rhythm?

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Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI.

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Dr. Smith's ECG Blog

JULY 26, 2023

The combination of absence of chest pain and history of LV aneurysm made it easy to assess that this patient does not have acute OMI. At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. We know today's patient had a documented inferior STEMI in 2010.

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Dr. Smith's ECG Blog

JANUARY 28, 2018

Here is his previous ECG: This was my interpretation of the first ECG: Sinus bradycardia with less than 1mm ST elevation in V4-V6, elevated compared to the previous ECG, suggestive of lateral MI. Moreover, T-wave inversion in aVL was also found to be 100% sensitive and 86% specific for inferior STEMI. mm ST depression in aVL.

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Dr. Smith's ECG Blog

FEBRUARY 15, 2018

Here are inferior leads, and aVL, magnified: A closer inspection of the inferior leads and aVL Sinus bradycardia. She went on to describe her chest pain as a "buffalo sitting on my chest" and a "weird" sensation in her jaw for 1 hour prior to arrival, associated with lightheadedness and diaphoresis. What do you think?

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Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI.

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Dr. Smith's ECG Blog

MARCH 2, 2019

Palpitations in a Young Healthy Male A pathognomonic ECG you should recognize instantly A middle-aged man with severe syncope, diffuse weakness Chest pain and Diffuse ST depression, with STE in aVR. You probably think it is left main. Are These Wellens' Waves??

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Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. It was from a patient with chest pain: Note the obvious Brugada pattern. Bicarb 20, Lactate 4.2,

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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. There’s sinus bradycardia, normal conduction, normal axis, delayed R wave progression, and normal voltages. STEMI negative : the EMS automated interpretation read, “STEMI negative. Sinus bradycardia.”

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Dr. Smith's ECG Blog

MARCH 24, 2023

Written by Jesse McLaren, with comments from Smith An 85 year old with a history of CAD presented with 3 hours of chest pain that feels like heartburn but that radiates to the left arm. There’s sinus bradycardia, first degree AV block, normal axis, delayed R wave progression, and normal voltages. Below is the ECG. Take home 1.

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Dr. Smith's ECG Blog

MAY 23, 2022

Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. Theres inferior STE which meets STEMI criteria, but this is in the context of tall R waves (18mm) and relatively small T waves, and the STD/TWI in aVL is concordant to the negative QRS. This was false positive STEMI with an ECG mimicking OMI.

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Dr. Smith's ECG Blog

DECEMBER 5, 2019

Regardless of further evaluation, she should avoid bradycardia, AV nodal blockers, Na channel blockers, and fevers. --If The patient denied any chest pain whatsoever, and a troponin at zero and 2 hours were both undetectable. EP study to further risk stratify her is recommended, with ICD placement depending on the results.

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