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.

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Chest Pain STEMI Defibrillator Blog 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Written by Pendell Meyers and Peter Brooks MD A man in his 30s with no known past medical history was reported to suddenly experience chest pain and shortness of breath at home in front of his family. Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

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Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

None of these findings are diagnostic of ischemia, but they should give you a high index of suspicion and prompt serial ECGs at a minimum. The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Ischemia comes and goes. He was defibrillated. Anterolateral STEMI.

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Chest Pain Cardiac Arrest Ischemia STEMI 52

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. 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.

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Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. A prior ECG was available for comparison: Normal One might be tempted to interpret the ST depression as ischemia, but as Smith says, "when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave." Chest pain in high risk patient. What does the ECG show?

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Ischemia Chest Pain Cardiac Arrest Blog 124

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, Smith A woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. Ischemic ST depression includes posterior OMI and subendocardial ischemia.

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Chest Pain Ischemia Aortic Aortic valve 40

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. Potassium was normal. Cardiology did not think it was "STEMI", but repeated the troponin. Take home 1.

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Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

APRIL 29, 2020

A 60-something woman presented after a witnessed cardiac arrest. This is commonly found after epinephrine for cardiac arrest, but could have been pre-existing and a possible contributing factor to cardiac arrest. A recent similar case: A 40-something with chest pain. Is this inferior MI?

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Dr. Smith's ECG Blog

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. This patient is actively dying from a left main coronary artery OMI and cardiac arrest from VT/VF or PEA is imminent!

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 129

MIBHS

OCTOBER 31, 2024

This may result in ischemia (lack of oxygen to the heart muscle), causing parts of the heart to weaken and enlarge. Cardiac Arrest or Sudden Death: Cardiomegaly increases the risk of life-threatening arrhythmias, which can cause sudden cardiac arrest.

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Blood Pressure Blood Clot Heart Valves Heart Rhythm 52

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

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Blog Chest Pain Ischemia STEMI 98

Dr. Smith's ECG Blog

MAY 3, 2024

When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI). Here are some cases of RBBB with LAFB: What is the Diagnosis in this 70-something with Chest Pain? There is STE in aVR.

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Cardiogenic Shock Cardiac Arrest Hospital Ischemia 127

Dr. Smith's ECG Blog

OCTOBER 8, 2023

All of the patients presented with chest pain , and they are all in triage. Remember, in diffuse subendocardial ischemia with widespread ST-depression there may b e ST-E in lead s aVR and V1. There are well formed R-waves with good voltage/amplitude which is uncommon for ischemia. True Positive ECG#2 : Also sinus rhythm.

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Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 123

Dr. Smith's ECG Blog

JUNE 11, 2021

Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. On arrival, GCS was 13 and the patient complained of ongoing chest pain. Vitals were HR 58 BP 167/70 R20 sat 96%.

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Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

An ECG was recorded during pain: What do you think? This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with reciprocal ST depression in aVL, and some STE in V1. These suggest inferior OMI with possible RV involvement. with ADDED STE in III?

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Ischemia Pulmonary STEMI Chest Pain 40

Dr. Smith's ECG Blog

JULY 22, 2023

Written by Pendell Meyers A man in his 70s with no cardiac history presented with acute weakness, syncope, and fever. He denied chest pain or shortness of breath. In the clinical context of weakness and fever, without chest pain or shortness of breath, the likelihood of Brugada pattern is obviously much higher.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

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. There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Wellnest

DECEMBER 21, 2022

If you experience any symptoms, such as chest pain, dizziness, unusual tiredness or fatigue, shortness of breath, or irregular heartbeat, your doctor would want you to go for an ECG test to find out the underlying cause. Cardiac arrest Cardiac arrest is a medical emergency in which the heart stops pumping blood to the body.

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Cardiac Arrest Heart attacks Heart Attack Atrial Fibrillation 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia. Anything more on history? J Electrocardiol 2013;46:240-8 2.

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

AUGUST 1, 2020

He has done a lot of great work on cardiac arrest, including as co-author of our study on esmolol in refractory cardiac arrest, and much more with Keith Lurie. A 40-something woman was in a remote alpine location when she complained of crushing chest pain. See his Google Scholar profile here. It was not.

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Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). Later on during the night of his admission he had a short episode of chest pain that resolved with sublingual nitroglycerin. His vitals were initially normal.

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Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern). What is the Diagnosis in this 70-something with Chest Pain?

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Chest Pain Cardiogenic Shock Tachycardia Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Written by Pendell Meyers, edits by Steve Smith A man in his 60s with history of hypertension and MI 10 years ago, with PCI, presented to an outside hospital complaining of chest pain that started while mowing the lawn. TOP Initial ECG of this 60-year old man with a history of prior MI, who presented with new-onset chest pain.

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Chest Pain STEMI Cardiac Arrest Aneurysm 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2022

Although in the context of chest pain such ST depression would be all but diagnostic of posterior OMI, one should make no conclusions in such an unusual case. This Transesophageal ED Echo was recorded: Cardiac POCUS.mov from Stephen Smith on Vimeo. In all leads, there is a 2nd wave after the initial QRS.

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Cardiac Arrest Bradycardia Chest Pain Ischemia 40

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Case A 47 year old male called 911 for severe chest pain. He had a previous MI with cardiac arrest 2 years prior. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. Data from stress testing proves that the ST depression of ischemia does not localize.

Ischemia 40

Ischemia Chest Pain STEMI Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

Case 3 : Male in 30's with chest pain, cough, and fever. Is there likely to be fixed coronary stenosis that led to demand ischemia during pneumonia? --Was Was the ST elevation due to transient demand ischemia, or is it false positive? What do you think? He has clinical pneumonia. Called 911. Does he need a stress test? --Is

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STEMI Chest Pain Cardiac Arrest Stents 40

EMS 12-Lead

JULY 24, 2023

But the symptoms returned with similar pattern – provoked by exertion, and alleviated with rest; except that on each occasion the chest pain was a little more intense, and the needed recovery period was longer in duration. It should be known that each category can easily manifest the generic subendocardial ischemia pattern.

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Angina Ischemia Coronary Angiogram Stenosis 52

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. If cardiac arrest from hypokalemia is imminent (i.e., Most recent echo showed EF of 60%.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

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. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. Steve, what do you think of this ECG in this Cardiac Arrest Patient?" What is it?

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Chest Pain Bradycardia Cardiac Arrest STEMI 52

Ken Grauer, MD

JUNE 6, 2023

Part of the ST depression with deep T wave inversion in the lateral chest leads clearly reflects LV "strain" from the marked LVH — but despite the very large QRS amplitudes, this ST-T wave appearance looks disproportionate, suggesting at least a component of ischemia. He could not be resuscitated.

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Blog Pulmonary Hypertension Aortic 78

Ken Grauer, MD

APRIL 9, 2023

No chest pain. Figure-1: The initial ECG in today's case — obtained from an 86-year old man with presyncope, but no chest pain. ( The other main consideration — is to take another look at the 12-lead ECG, and assess this for recent ischemia or infarction. How would YOU interpret the ECG in Figure-1 ?

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Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain. It is also NOT the clinical scenario of takotsubo (a week of intermittent chest pain).

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Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

APRIL 15, 2019

If a patient presents with chest pain and a normal heart rate, or with shockable cardiac arrest, then ischemic appearing ST elevation is STEMI until proven otherwise. This, in turn, could produce platelet aggregation and vasospasm and result in an acute coronary syndrome." Clinical Context is everything !

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Tachycardia STEMI Chest Pain Ischemia 40

Ken Grauer, MD

OCTOBER 27, 2023

This suggests ischemia of uncertain duration. Unfortunately, before this could be accomplished — the patient went into cardiac arrest. She was successfully resuscitated — with a post-arrest rhythm similar to that seen in Figure-1. Cardiac cath did not reveal significant coronary disease!

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Blog Pacemaker Bradycardia Arrhythmia 101

Dr. Smith's ECG Blog

NOVEMBER 18, 2019

This is often quite challenging to recognize — but the finding of negative U waves in a patient with chest pain is highly suggestive of ischemia ! N OTE # 2 — On rare occasions, the U wave may be negative. Figure-2: Sequential development of ST-T wave changes with hypokalemia. Note increasing U wave amplitude ( See text ).

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Chest Pain Cardiac Arrest Bradycardia Ischemia 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

It was from a patient with chest pain: Note the obvious Brugada pattern. The elevated troponin was attributed to either type 2 MI or to non-MI acute myocardial injury. There is no further workup at this time. Smith: Here is a case that was just texted to me today from a former resident. This patient ruled out for MI.

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Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52