Dr. Smith's ECG Blog

OCTOBER 26, 2010

This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. He had this ECG recorded. Are the lungs clear?

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

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. EKG shown here: LAFB with no clear signs of OMI or ischemia. Triage ECG: What do you think? This is a huge anterolateral OMI.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

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.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

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.

Ischemia 123

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%.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

APRIL 24, 2020

A middle aged man had off and on chest pain for 2 weeks, then 2 hours of more severe and constant pain. Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Similarly, STD in aVL is usually reciprocal to inferior ST elevation, not "lateral ischemia."

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

There is normal R-wave progression in the precordial leads with no evidence of ischemia. Just the fact of chest pain and highly elevated troponin is enough to activate the cath lab, but here you can see just how subtle hyperacute T-waves can be. Here the image quality is enhanced using the PM Cardio app. What do you think?

Pulmonary 116

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 116

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). The patient arrived to the ED in cardiogenic shock but awake.

Chest Pain 52

Chest Pain Cardiogenic Shock Tachycardia Ischemia 52

DAIC

FEBRUARY 29, 2024

ET Main Tent (Hall B1) This session offers more insights from key clinical trials presented at ACC.24 24 and find out what it all means for your patients.

Aortic valve 103

Aortic valve Myocardial Infarction Aortic Blood Pressure 103

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.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

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.

Angina 52

Angina Ischemia Coronary Angiogram Stenosis 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 6, 2023

This is one case where it made a difference: Right Ventricular MI seen on ECG helps Angiographer to find Culprit Lesion Nevertheless, it is sometimes a fun academic exercise to try to predict the infarct artery: An elderly patient had onset of chest pain one hour prior. His included cardiogenic shock, V Tach, AV block.

Aneurysm 66

Aneurysm Chest Pain Cardiogenic Shock Blog 66

Dr. Smith's ECG Blog

MARCH 30, 2014

Then the notes mention "cardiogenic shock" but without any reference to a cardiac echo or to a chest x-ray. Now chest pain free. Cardiologist note says: "Elevated troponin explained by type II MI due to her shock." This is the etiology of the syncope and hypotension and shock and elevated CVP.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

He was asked multiple times about chest pain or dyspnea, but repeatedly denied any such symptoms. Patient denied chest pain on initial review of symptoms. Was now endorsing chest pain which began 30 minutes ago. Upon further questioning, he states that he has had intermittent chest pain since yesterday.

Myocardial Infarction 52

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI 52

Dr. Smith's ECG Blog

JANUARY 11, 2025

Written by Pendell Meyers An adult man presented with acute chest pain. The ECG shows sinus tachycardia, RBBB+LAFB, and signs of anterolateral acute transmural ischemia (most likely due to acute coronary occlusion), with concordant STE in I and aVL, inappropriate STE in V4-6 (though limited a bit by motion, still definite).

Cardiogenic Shock 137

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137

Dr. Smith's ECG Blog

MARCH 27, 2025

"Hi Steve wonder what you think of this ecg in a 60 yo woman w cp, known CAD" Presentation ECG (ECG 1): Here is her previous from one week prior when she presented with heart failure and trops were "negative" (ECG 2): My response: "They both look like active ischemia. The previous ECG also shows active ischemia." Just awful all around.

Ischemia 106

Ischemia Chest Pain Cardiogenic Shock Heart Failure 106

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. She awoke in the morning with sharp chest pain which worsened throughout the morning. As her pain worsened, so did her dyspnea. This was written by Hans Helseth.

Tachycardia 74

Tachycardia Pulmonary Chest Pain Stenosis 74

Dr. Smith's ECG Blog

MARCH 25, 2025

Written by Willy Frick A woman in her 60s with very severe hyperlipidemia (LDL >200 mg/dL) presented with acute onset chest pain. She described the pain as moderate in severity, and said it had come and gone several times over the next few hours before ultimately resolving. Her symptoms began while getting off the bus.

Chest Pain 63

Chest Pain Ischemia Plaque Stents 63