Dr. Smith's ECG Blog

MAY 19, 2022

Written by Pendell Meyers, edits by Smith and Grauer A man in his late 20s with history of asthma presented to the ED with a transient episode of chest pain and shortness of breath after finishing a 4-mile run. His symptoms of chest pain and shortness of breath were attributed to an asthma exacerbation during exercise.

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Chest Pain Exercise Pacemaker Coronary Angiogram 52

Dr. Smith's ECG Blog

APRIL 9, 2023

Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell Meyers A man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath.

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Chest Pain Ischemia Stenosis Pulmonary 52

Dr. Smith's ECG Blog

FEBRUARY 9, 2021

This ECG was texted to me with the words "Cocaine" and "Chest pain." This ECG was recorded at 82 minutes: No Evolution; this supports absence of OMI Troponin I (hs) were: 0 hour: 7 ng/L, 2 hour: 9 ng/L, 4 hour: 8 ng/L (Rules out Acute MI) Thus, the chest pain was non-ischemic. There are QS-waves in V1 and V2.

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Chest Pain STEMI Cardiomyopathy 40

American College of Cardiology

DECEMBER 10, 2024

A 63-year-old woman presents to the office for a second opinion on chronic chest pain and heart failure management. She has a medical history of mixed connective tissue disease, obstructive sleep apnea, hepatic steatosis, and long-standing hypertension diagnosed in her twenties.

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Chest Pain Cardiomyopathy Heart Failure Hypertension 49

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. She felt nauseous and lightheaded with no neurologic deficits.

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Chest Pain Ischemia Aortic Aortic valve 40

Dr. Smith's ECG Blog

JULY 5, 2023

The patient has acute chest pain. If not HCM — some unusual form of cardiomyopathy might explain the findings in today's ECG (ie, muscular dystrophy; infiltrative heart disease from amyloid or sarcoid; some unusual form of congenital heart disease, etc. ). This was texted to me in real time. What do you think?

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Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

OCTOBER 12, 2023

Takotsubo cardiomyopathy is also a possible explanation. An echo was done and decision was made to pursue cath lab the following day as the echocardiography was interpreted as consistent with Takotsubo Cardiomyopathy. Maybe it is T wave inversion of Takotsubo Cardiomyopathy ? There was never any severe chest pain.

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Cardiomyopathy Stenosis Chest Pain Hospital 110

European Journal of Heart Failure

FEBRUARY 27, 2024

Seventeen patients hospitalized for suspected hot-phase cardiomyopathy underwent both endomyocardial biopsy (EMB) and genetic testing: histological detection of apoptosis at EMB was frequent (77% of cases) and all patients that tested positive for pathogenic/likely pathogenic variants showed apoptosis at EMB.

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Cardiomyopathy Chest Pain Hospital Research 40

Dr. Smith's ECG Blog

SEPTEMBER 14, 2014

He presented with chest pain, not relieved by nitro, pain reproducible on exam and centered around the pacemaker insertion site. Here is his ECG one month prior, on admission for chest pain at that time also: Similar ratios. It is likely that severe cardiomyopathy and loading conditions result in false positives.

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Chest Pain Pacemaker Cardiomyopathy STEMI 52

EMS 12-Lead

MAY 20, 2022

She reports a known history of Hypertrophic Cardiomyopathy (HCM) with left ventricular outflow tract obstruction and is on daily beta blocker therapy. Cardiology felt her chest pain to be, most likely, the result of coronary supply-demand mismatch in the context of HCM endothelial remodeling (i.e. Below are two examples of this.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Frontiers in Cardiovascular Medicine

OCTOBER 7, 2024

BackgroundSigmoid Ventricular Septum (SVS) is a type of hypertrophic cardiomyopathy characterized by a reduced angle between the basal interventricular septum and the ascending aorta, and SVS can lead to dynamic Left Ventricular Outflow Tract obstruction (LVOTO) during hypercontractile states.

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Ablation Angina Chest Pain Echocardiogram 59

Dr. Smith's ECG Blog

JULY 25, 2024

Just as important is pretest probability: did the patient report chest pain prior to collapse? VF should make you think of ischemia, cardiomyopathy (especially scar from old MI), or one many other cardiac but non-ischemic etiologies. After cardiac arrest, I ALWAYS wait 15 minutes after an ECG like this and record another.

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Cardiac Arrest Ischemia Tachycardia Defibrillator 123

Dr. Smith's ECG Blog

OCTOBER 15, 2023

As noticed by the AI, if the patient presented with chest pain , then even this subtle ECG is diagnostic of OMI. What do you think? Here's what the Queen of Hearts thinks: Note that the Queen has "HIGH" confidence that this is OMI.

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Chest Pain Cardiomyopathy STEMI Blog 116

Dr. Smith's ECG Blog

OCTOBER 18, 2023

The chest pain quickly subsided. There was hyperkinesis of the basal segments and findings were interpreted as typical of takotsubo cardiomyopathy. An MRI was deemed unnecessary at the diagnosis of stress cardiomyopathy was concidered certain. Takotsubo cardiomyopathy is not a completely benign disorder.

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Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 121

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean.

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Stroke Strokes Chest Pain Cardiomyopathy 69

EMS 12-Lead

APRIL 9, 2024

There was no chest pain. V1 and V2 are probably placed too high on the chest given close morphological similarity to aVR. The fall was not a mechanical etiology. He denied any specific prodrome of gross palpitations, however did endorse feeling quite dizzy just before the event.

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Ischemia Stenosis Chest Pain Coronary Artery Disease 116

Dr. Smith's ECG Blog

JUNE 17, 2016

There were no injuries and no chest pain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear.

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STEMI Chest Pain Hospital Blog 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

(In other words, the artery was occluded but has sponteneously reperfused, resulting in pain relief) It is important to monitor patients with Wellens' syndrome for re-occlusion, which is usually, but not always, associated with recurrent chest pain. The patient remained pain free. Chest Pain scores can be misleading.

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Chest Pain Angina Ischemia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. He has "ischemic cardiomyopathy" and "congestive heart failure." He had no h/o heart failure. Here is the next day ECG: Some posterior reperfusion T-waves (slightly larger upright T-waves in V2 and V3).

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STEMI Heart Failure Stents Stent 122

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

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours.

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Chest Pain STEMI Document Ischemia 52

Dr. Sanjay Gupta

DECEMBER 19, 2022

She asked me why I felt she had had a heart attack and I explained to her that she had had chest pains and the blood test indicating damage to the heart was elevated and that was all we needed to say that she had had a heart attack. On the basis of these findings we told her that she had suffered a heart attack.

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Heart Attack Heart attacks Blood Clot Chest Pain 40

Ken Grauer, MD

FEBRUARY 3, 2024

As discussed in detail in ECG Blog #228 — this seemingly qualifies as a “ Silent ” MI ( Approximately half of those MIs not accompanied by CP — have some other associated symptom such as syncope, which substitutes as a “chest pain equivalent” ). Longterm prognosis of patients with MINOCA clearly depends on the underlying etiology.

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Blog Cardiac Arrest STEMI Plaque 163

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. As shown in Figure-2 — there are other entities to consider!

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Blog Chest Pain Cardiac Arrest Hemorrhage 122

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

DAIC

FEBRUARY 29, 2024

12:15 p.m.

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Aortic valve Myocardial Infarction Aortic Blood Pressure 103

Ken Grauer, MD

JANUARY 13, 2024

On the other hand — the ST elevation seen in lead V1 is perfectly consistent with LVH and LV "strain" ( ie, The shape of this ST-T wave in lead V1, in association with the deep S wave in this lead — is a mirror-image opposite picture of the typical expected appearance of LVH with "strain" in a lateral chest lead ).

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Blog Ischemia AFIB Hypertension 159

Dr. Anish Koka

JANUARY 1, 2023

The diagnosis was made based on classic findings of inflammation on an electrocardiogram associated with acute chest pain. 2-3 days after this he developed the same sharp chest pain and shortness of breath with elevated inflammatory markers (CRP) as well as typical findings of pericarditis seen on ECG.

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COVID-19 Pericarditis Chest Pain Biomarkers 52

Wellnest

DECEMBER 31, 2023

Yes, COVID-19 symptoms can resemble a heart attack, including chest pain, shortness of breath, and changes in echocardiogram or EKG. It serves as an initial assessment, and an MRI may be considered if other signs of cardiomyopathy are present. Can COVID-19 symptoms mimic a heart attack?

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COVID-19 Heart Attack Heart attacks Exercise 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

The patient's chest pain had resolved by the time of the ECG 2. But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. He presents with an episode of brief, new-onset chest pain that had resolved by the time E CG # 1 was obtained.

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Angina Stents Stent Aneurysm 52

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. ( It may also occur in patients with underlying coronary disease, cardiomyopathy, and/or with digoxin toxicity. Th e patient was hemodynamically stable in association with this rhythm.

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Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

JUNE 28, 2023

RVOT VT: A 40-something without past history presents with wide complex tachycardia and crushing chest pain Regular Wide Complex Tachycardia. No , this requires inferior axis and LBBB morphology. There is no inferior axis. What is the Diagnosis? Figure-1: The initial ECG that was recorded in the ED.

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Tachycardia Ultrasound Heart Disease Atrial Fibrillation 98

Ken Grauer, MD

JULY 15, 2023

Subsequent testing supported the presumption of apical cardiomyopathy as the cause of this patient's sustained VT. ie, Severe subendocardial ischemia from sustained VT in a patient severe apical cardiomyopathy resulted in a peak troponin >31,000 ng/L in today's case ). CT coronary angiogram showed no obstructive coronary disease.

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Dr. Smith's ECG Blog

JANUARY 9, 2024

While fully acknowledging that "Sometimes ya gotta be there!" — in order to optimally assess the patient — the clinical definition of hemodynamic stability is for the patient to be without significant symptoms such as chest pain, shortness of breath, hypotension and/or mental status changes — as a direct result of the fast heart rate.

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Tachycardia Electrophysiology Atrial Flutter Ischemia 118

Dr. Smith's ECG Blog

JULY 1, 2019

Case 2: sent by Dr. James Alva A man in his 50s with diabetes, hypertension, and hyperlipidemia presented to the ED with chest pain and shortness of breath off and on over the past three days, with associated vomiting. M y T HOUGHTS on E CG # 1 — The patient in Case #1 was a 60-something woman with acute dyspnea, but no chest pain.

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Chest Pain Ischemia STEMI Blog 52

Dr. Smith's ECG Blog

JULY 31, 2018

Troponins may be negative with very rapid reperfusion, or measured too late, or chronically elevated due to cardiomyopathy or renal failure. While ST coving in V1 is not necessarily abnormal — the presence of ST elevation in association with ST-T wave abnormalities in V2,V3 in a patient with chest pain is clearly cause for concern.

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SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. He described it as "10/10" intensity, radiating across his chest from right to left. This is written by Willy Frick, an amazing cardiology fellow in St.

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Plaque Angina Blog Stents 126