Cardiogenic Shock, Chest Pain and Ischemia

3 days of shoulder and chest pain, and now cardiogenic shock

Dr. Smith's ECG Blog

AUGUST 28, 2020

Bad chest pressure with severe left shoulder pain 3 nights ago. Now appears to be in cardiogenic shock." This is ischemia until proven otherwise. However, cardiogenic shock usually takes some time to develop, so it is probably subacute." I was texted these ECGs. Then SOB and nausea the next day.

Cardiogenic Shock

Cardiogenic Shock Chest Pain Ischemia Stenosis

See what happens when a left main thrombus evolves from subtotal occlusion to total occlusion.

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. His wife contacted the ambulance service after the patient experienced an episode of loss of consciousness.

Cardiogenic Shock

Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest

A man with chest pain off and on for two days, and "No STEMI" at triage.

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

Chest Pain STEMI Cardiogenic Shock Ischemia

Why the sudden shock after a few days of malaise?

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

The VSR is what is causing the cardiogenic shock! Mechanical complications occur acutely and significantly alter hemodynamics leading to comp ensatory mechanism which usually involve vasoconstriction and tachycardia, both hallmarks of cardiogenic shock. PIRP is strongly associated with myocardial rupture.

Cardiogenic Shock

Cardiogenic Shock Pericarditis Chest Pain Myocardial Infarction

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

[link] A 30 year-old woman was brought to the ED with chest pain. She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying "I'm just an anxious person." This strongly suggests reperfusing RCA ischemia. Lobo et al.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

A man in his 70s with acute chest pain and paced rhythm.

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

Chest Pain Myocardial Infarction STEMI Pacemaker

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest. For now she can only say Not OMI.

Chest Pain

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction

Sudden shock with a Nasty looking ECG. What is it?

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.

Cardiogenic Shock

Cardiogenic Shock Cardiac Arrest Hospital Ischemia

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

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

Ischemia Cardiogenic Shock Aortic Stenosis

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

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

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock

An elderly woman with acute vomiting, presyncope, and hypotension, and a wide QRS complex

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.

Cardiogenic Shock

Cardiogenic Shock Chest Pain Tachycardia Ischemia

What are treatment options for this rhythm, when all else fails?

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

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

Guess the culprit with ST Elevation in posterior leads

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

Ischemia Chest Pain Stenosis Cardiogenic Shock

Should we activate the cath lab? A Quiz on 5 Cases.

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

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest

Critical Left Main

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

Angina Ischemia Coronary Angiogram Stenosis

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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

Ischemia STEMI Stenosis Chest Pain

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

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

STEMI Cardiogenic Shock Tachycardia Aneurysm

Chest discomfort and a dilated right ventricle. What's going on?

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

Pulmonary Tricuspid Chest Pain Cardiogenic Shock

What is the infarct artery? What does the post PCI ECG show? What does the convalescent ECG show?

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

Aneurysm Chest Pain Cardiogenic Shock Blog

American College of Cardiology ACC.24 Late-breaking Science and Guidelines Session Summary

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

Aortic valve Myocardial Infarction Aortic Blood Pressure

How does Acute Total Left Main Coronary occlusion present on the ECG?

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

Myocardial Infarction Ischemia STEMI Cardiogenic Shock

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

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

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI

The ECG told the whole story, but no one listened: ECG interpretation skills are critical to patient outcomes.

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

Outcomes Cardiogenic Shock STEMI Chest Pain

Cardiovascular Update

3 days of shoulder and chest pain, and now cardiogenic shock

See what happens when a left main thrombus evolves from subtotal occlusion to total occlusion.

A man with chest pain off and on for two days, and "No STEMI" at triage.

Why the sudden shock after a few days of malaise?

A young peripartum woman with Chest Pain

A man in his 70s with acute chest pain and paced rhythm.

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Sudden shock with a Nasty looking ECG. What is it?

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

An elderly woman with acute vomiting, presyncope, and hypotension, and a wide QRS complex

What are treatment options for this rhythm, when all else fails?

Guess the culprit with ST Elevation in posterior leads

Should we activate the cath lab? A Quiz on 5 Cases.

Critical Left Main

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

Chest discomfort and a dilated right ventricle. What's going on?

What is the infarct artery? What does the post PCI ECG show? What does the convalescent ECG show?

American College of Cardiology ACC.24 Late-breaking Science and Guidelines Session Summary

How does Acute Total Left Main Coronary occlusion present on the ECG?

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

The ECG told the whole story, but no one listened: ECG interpretation skills are critical to patient outcomes.

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