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. He was in cardiogenic shock requiring an impella for several days after cath.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart Attack 52

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Both were wrong.

Cardiogenic Shock 128

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

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. Troponin was ordered.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

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. Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). Post PCI the patient became gravely hypotensive and "shocky". The LV EF was 57% at formal echo.

Pulmonary 116

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 116

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

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. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What do you see?

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

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. When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. Here was his ED ECG, which was identical to the prehospital ECG. He did not get prehospital activation. What do you think?

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

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 Chest Pain 52

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." Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

AUGUST 13, 2020

This was my response: If it is the right clinical situation, such as acute chest discomfort, it looks like proximal left anterior descending occlusion with right bundle branch block and left anterior fascicular block. Because of the tachcardia, I would expect her to be very poor left ventricular function and maybe Cardiogenic shock.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Written by Pendell Meyers A man in his 40s called EMS for acute chest pain that awoke him from sleep, along with nausea and shortness of breath. Learning Points: Currently by definition, there is unfortunately no such thing as a formal diagnosis of STEMI or STEMI criteria in the setting of RBBB and LAFB.

Chest Pain 121

Chest Pain STEMI Cardiogenic Shock Heart Failure 121

Ken Grauer, MD

OCTOBER 25, 2024

The following are the KEY clinical and ECG features that establish the diagnosis of W ellens ' S yndrome : There should be a history of prior chest pain that has resolved at the time the defining ECG is obtained. The Chest Pain required for the definition of Wellens' Syndrome occurred at the time of coronary occlusion.

Blog 94

Blog Chest Pain STEMI Cardiogenic Shock 94

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 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. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

JULY 18, 2014

A man in his 60's presented after 4 days of chest pain, with some increase of pain on the day of presentation. Exact pain history was difficult to ascertain. Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? There was some SOB. How acute is it?

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 16, 2010

This 51 yo male complained of chest pain, then had a v fib arrest. He was in cardiogenic shock. As you will see, this results in the discovery of ST elevation in V2-V4 and I and aVL, diagnostic of anterolateral STEMI. The patient died 8 hours later of cardiogenic shock.

Tachycardia 52

Tachycardia Cardiogenic Shock Chest Pain STEMI 52

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 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

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. The patient arrived to the ED in cardiogenic shock but awake. Code STEMI was activated. What is the Diagnosis in this 70-something with Chest Pain? in-hospital mortality was 18.8%

Chest Pain 52

Chest Pain Cardiogenic Shock Tachycardia Ischemia 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

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

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. Also see these posts of Type II STEMI.

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73

Dr. Smith's ECG Blog

APRIL 9, 2025

A middle-age woman with no previous cardiac history called 911 for chest pain. The paramedics diagnosis was "Possible Anterolateral STEMI." More proof that a huge STEMI may have normal or near normal initial troponin. Taken together, these findings suggest an ongoing extensive antero-lateral STEMI.

Defibrillator 63

Defibrillator Cardiac Arrest Myocardial Infarction STEMI 63

Dr. Smith's ECG Blog

JANUARY 11, 2025

Written by Pendell Meyers An adult man presented with acute chest pain. See our other cases with similar patters, to burn this deep into your brain files: Smith : In my experience, these cases of LAD OMI with RBBB and LAFB are either about to arrest, post-arrest, and/or in cardiogenic shock. He appeared critically ill.

Cardiogenic Shock 137

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137