Dr. Smith's ECG Blog

NOVEMBER 19, 2014

A male in late middle age with a history of RCA stent 8 years prior complained of chest pain. Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died. EMS recorded the following ECG: What do you see?

Chest Pain 52

Chest Pain Cardiac Arrest Myocardial Infarction Angioplasty 52

Ken Grauer, MD

FEBRUARY 3, 2024

Shortly after arrival in the ED ( E mergency D epartment ) — she suffered a cardiac arrest. BUT — Cardiac catheterization done a little later did not reveal any significant stenosis. Figure-1: The initial ECG in today's case — obtained after successful resuscitation from cardiac arrest. ( No CP ( C hest P ain ).

Blog 155

Blog Cardiac Arrest STEMI Plaque 155

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

This 80 year old with a history of CABG had a cardiac arrest. He did not state he had chest pain, but, then again, he couldn't remember anything. This is as clear a STEMI as you can get. So this is classic inferoposterior STEMI on the ECG but is NOT acute coronary syndrome!

Cardiac Arrest 52

Cardiac Arrest STEMI Ultrasound Chest Pain 52

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.

Cardiac Arrest 87

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 87

Dr. Smith's ECG Blog

OCTOBER 24, 2013

There is no way to tell the difference between GI etiology of chest pain and MI. Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. Could this have been avoided? Lesson : 1.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Anterolateral STEMI. The formula results in 23.43, just above the 23.4 He was defibrillated. Here is his post resuscitation ECG: Now the diagnosis is obvious.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 52

Ken Grauer, MD

JUNE 14, 2024

The ECG in Figure-1 — was obtained from a middle-aged man who presented to the ED ( E mergency D epartment ) in cardiac arrest. Prompt cath is therefore advised if the post-ROSC shows an acute STEMI. To Emphasize: The phenomenon of T-QRS-D is not needed in today's case to recognize the acute STEMI. Smith's ECG Blog ).

Blog 135

Blog STEMI Cardiac Arrest Tachycardia 135

Dr. Smith's ECG Blog

NOVEMBER 28, 2018

A 50-something presented with epigastric and chest pain. Saddleback ST Elevation is almost never STEMI 2. Here are other cases of saddleback STE: Is this Saddleback a STEMI?? Here is his ECG: What do you think? QTc 388 ms. The patient was diagnosed with reflux Learning Points : 1. wave in V1?? wave in V1??

STEMI 52

STEMI Chest Pain Cardiac Arrest Anatomy 52

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. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 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. ). Having looked for negative U waves in patients with chest pain over a period of decades — I'll emphasize that this is not a common finding.

Blog 100

Blog Chest Pain Ischemia STEMI 100

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia 52

Ischemia STEMI Stenosis Coronary Artery Disease 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.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JUNE 15, 2013

There was no chest pain. The cath lab was activated for STEMI. Unfortunately, the patient had a cardiac arrest on arrival to the cath lab, before return of the potassium. So, in retrospect, the first patient probably did not have STEMI at all. Hyperkalemia can result in ST elevation that imitates STEMI 3.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

This pattern is essentially always accompanied by cardiogenic shock and high rates of VT/VF arrest, etc. Code STEMI was activated. What is the Diagnosis in this 70-something with Chest Pain? 68 minutes with chest compressions, full recovery. Plus recommendations from a 5-member panel on cardiac arrest.

Cardiogenic Shock 52

Cardiogenic Shock Chest Pain Tachycardia Ischemia 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. His initial troponin T was 15 ng/L (only two hours since pain onset). He stated it was similar to prior heart attacks.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart Attack 52

Dr. Smith's ECG Blog

JANUARY 8, 2024

Let me tell you about her hospitalization, discharged 1 day prior, but it was at another hospital (I wish I had the ECG from that hospitalization): The patient is 40 years old and presented to another hospital with chest pain and SOB. She had been sitting doing work when she experienced "waves of chest tightness". Sats were 88%.

Chest Pain 75

Chest Pain Pulmonary Embolism STEMI 75

Dr. Smith's ECG Blog

JANUARY 4, 2021

Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), In Septal STEMI , transmural ischemia of the septum is recorded by the overlying lead V1 as ST Elevation. Lead III is also on the right and might manifest ST Elevation in Septal STEMI. with ADDED STE in III?

Ischemia 52

Ischemia Pulmonary STEMI Chest Pain 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. Case 3 : Male in 30's with chest pain, cough, and fever. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think?

STEMI 52

STEMI Chest Pain Cardiac Arrest Stents 52

Dr. Smith's ECG Blog

DECEMBER 13, 2023

This middle aged patient presented with chest pain: What do you think? There is VERY low voltage. There is some ST Elevation, but it is MINIMAL. But look how small the QRS is!! Let's stretch out the QRS vertically so it is not so tiny: On upper left is the original.

Blog 116

Blog Chest Pain Cardiac Arrest Hemorrhage 116

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.

Arrhythmia 116

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 116

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.

Tachycardia 52

Tachycardia STEMI Chest Pain Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 25, 2009

He was at the gym when he had the onset of chest pain. RBBB in acute STEMI has a very high mortality. Were it not for this prehospital ECG and the cardiac arrest, the diagnosis may have been significantly delayed. This patient is 38 years old with hyperlipidemia. There is a wide S-wave in V6.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Defibrillator STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. His inpatient clinicians did not think that an urgent angiogram was warranted given that he was chest pain free, his EKG appeared nondiagnostic, and serial troponins were not elevating beyond 2 ug/L. Patients on dialysis often do not have chest pain in the setting of acute MI. Why is this?

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

MAY 13, 2017

He complained of severe chest pain and was extremely agitated, so much so that he was throwing chairs in triage. Technically, the STE meets STEMI criteria because there is greater than 2.5 These kinds of cases were excluded from the study as obvious anterior STEMI. His chest pain resolved. What do you think?

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Myocardial Infarction 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. He had multiple cardiac arrests with ROSC regained each time. Submitted by a Med Student, with Great Commentary on Bias!

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

FEBRUARY 17, 2023

This patient had many complaints including chest pain. The computer called this Acute STEMI What do you think? STEMI never has a very short QT. There is Bazett, Fridericia, Hodges, Framingham and Rautaharju -- see here at mdcalc: [link] If the ST Elevation here were due to STEMI, it would be an LAD Occlusion.

Chest Pain 52

Chest Pain Cardiac Arrest STEMI Arrhythmia 52

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. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. Some are STEMI-equivalents.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

OCTOBER 5, 2011

It turns out that this was a 27 yo African American male who presented with pressure-like (non-pleuritic) chest pain and dyspnea. Here is a case of a 45 year old with chest pain: There is ST elevation in inferior leads only, with no reciprocal ST depression in aVL. Would you be certain that it is not STEMI?

Chest Pain 52

Chest Pain STEMI Pericarditis Cardiac Arrest 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 Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? I was texted these ECGs by a recent residency graduate after they had all been recorded, along with the following clinical information: A 50-something with no cardiac history, but with h/o Diabetes, was doing physical work when he collapsed.

STEMI 52

STEMI Hospital Blog Defibrillator 52

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." About two hours after admission, he suffered a cardiac arrest (whether it was VF/VT or PEA is not available) and expired. Canto et al.

Chest Pain 52

Chest Pain STEMI Blog Tachycardia 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest. Is it STEMI? Chest pain in high risk patient. Here is his triage ECG: What do you think? What does the ECG show? Also see the bizarre Bigeminy.

Ischemia 115

Ischemia Chest Pain Cardiac Arrest Blog 115

Dr. Smith's ECG Blog

OCTOBER 9, 2018

link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. They did not find one STEMI on their triage ECGs (no surprise! We at HCMC have 30 walk-in STEMIs per year; the rest come by ambulance. Am J Emerg Med 36(10):1771-1774.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Heart Failure 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. 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?

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52

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.

Chest Pain 69

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 69

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).

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Ken Grauer, MD

JUNE 6, 2023

But limitation of this ST elevation to a single lead is not consistent with any distribution of a STEMI. Unfortunately — the patient abruptly developed hypoxemia, followed by cardiac arrest with PEA. It was thought that this action precipitated the patient's desaturation, and led to his cardiac arrest.

Blog 78

Blog Pulmonary Hypertension Aortic 78