Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Of course this depends on many factors: 1) duration of occlusion, 2) whether full or near occlusion with zero flow or some flow -- the flow in the artery is the critical factor, measured by "TIMI" flow, 3) presence of collateral circulation and others. Upon questioning patient, he denies having any chest pain or chest tightness of any sort.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

DECEMBER 6, 2010

He had no previous history of CAD, and presented with very typical waxing and waning chest pain, much worse with exertion but also present at rest and on presentation, though his pain was minimal at the time of the ECG. This is all suggestive of posterior STEMI, but not definitely diagnostic. Blood pressure was 150/80.

STEMI 52

STEMI Chest Pain Ultrasound Blood Pressure 52

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. Circulation 1999;99(15):1972-7.

STEMI 52

STEMI Chest Pain Myocardial Infarction Angioplasty 52

Ken Grauer, MD

FEBRUARY 3, 2024

Despite the absence of significant coronary stenosis on her post-arrest cath — the ECG in Figure-1 is clearly diagnostic of an extensive anterolateral STEMI ( presumably from acute LAD [ L eft A nterior D escending ] coronary artery occlusion). The rhythm in ECG #1 is regular and supraventricular at a rate of ~75/minute.

Blog 163

Blog Cardiac Arrest STEMI Plaque 163

Dr. Smith's ECG Blog

JANUARY 2, 2016

A middle aged male presented with chest pain. LVH and the diagnosis of STEMI - how should we apply the current guidelines? In LVH, T-wave inversions are usually much more assymetric , like these (Figure 2): Acute Chest pain, but baseline ECG. How about diagnosing anterior STEMI in the setting of LVH?

Ischemia 52

Ischemia Chest Pain STEMI Myocardial Infarction 52

Ken Grauer, MD

MARCH 7, 2023

But, in a patient who presents to the ED for new chest pain — seeing these subtle findings that are localized to leads V2- thru -V4 should at the least make you consider acute posterior OMI ( O cclusion-based MI ) — until you prove otherwise. To EMPHASIZE: These are subtle findings. What do YOU think?

Blog 78

Blog Chest Pain STEMI Ischemia 78

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

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. So the RCA was stented.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He was given aspirin and sublingual nitro and the pain resolved. The history is concerning ( This patient was awakened from sleep by chest pain that persisted for several hours — on a background of intermittent CP in recent weeks ).

Ischemia 122

Ischemia Plaque Stenosis Myocardial Infarction 122

Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. Step 1 to missing posterior MI is relying on the STEMI criteria. But it is still STEMI negative. What do you think? A 15 lead ECG was done (below).

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

MARCH 2, 2009

By definition, this is a non-STEMI because there is not 1 mm of ST elevation in 2 consecutive leads. However, ST elevation is only an imperfect surrogate for complete acute persistent occlusion of an epicardial coronary artery without collateral circulation. The pain is very nitroglycerine responsive.

Heart Attack 52

Heart Attack Heart attacks STEMI Echocardiogram 52

Dr. Smith's ECG Blog

MARCH 9, 2013

This male in his 40's had been having intermittent chest pain for one week. He awoke from sleep with crushing central chest pain and called ems. EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain. Type B waves are deeper and symmetric.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Plan was for admission for chest pain workup. Jernberg T, et al.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

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. There was no OMI.

Stroke 70

Stroke Strokes Chest Pain Cardiomyopathy 70

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

JANUARY 1, 2024

Although the patient reported experiencing mild pressure-like chest pain, there was suspicion among clinicians that this might be indicative of an older change. There is some ST-segment elevation in DII, DIII, aVF, V4-6. Due to the observed ST-segment elevation, the medical team expressed immediate concern.

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. Circulation. Circulation, 137(19), p.e523. Hayes, S.N.,

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The patient continued having chest pain. Is there STEMI? Circulation Research , 56 (2), 184–194. link] Fesmire, F.

Chest Pain 107

Chest Pain Arrhythmia Myocardial Infarction STEMI 107

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Case A 39-year-old male without prior medical history presents with chest pain that started 2 hours prior to presentation. He says that the pain intensity was 10/10 at home but now about 4/10. Despite the clinical stability and decreasing pain, this patient needs an immediate angiogram. Circulation 2002; 105(4): 539-42.

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40

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. Circulation.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

AUGUST 10, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLaren A 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram.

Chest Pain 98

Chest Pain STEMI Ischemia Nursing 98

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. Circulation , 130 (25). At midnight.

Myocardial Infarction 123

Myocardial Infarction Chest Pain STEMI Blood Pressure 123

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

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 Most recent echo showed EF of 60%. If the patient is at 1.8,

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

JULY 7, 2013

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. How old is this antero-inferior STEMI? Circulation 1993;88(3):896-904. There was some SOB.

STEMI 52

STEMI Myocardial Infarction Pericarditis Ultrasound 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? Circulation 1993;88(3):896-904.

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 27, 2024

COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab. N Engl J Med [Internet] 2019;Available from: [link] Should all patients with shockable arrest be taken to angiography regardless of STEMI or No STEMI?

Defibrillator 113

Defibrillator Cardiac Arrest STEMI Chest Pain 113

Dr. Smith's ECG Blog

DECEMBER 6, 2022

A 65 year old with diabetes presented with a syncopal episode while sitting, associated with weakness but no chest pain or shortness of breath. So they took the patient urgently to cath: 100% occlusion of inferior obtuse marginal branch of the circumflex, with collateral circulation. What do you think?

Chest Pain 52

Chest Pain STEMI Diabetes Circulation 52

Dr. Smith's ECG Blog

JULY 22, 2023

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. Circulation, 117, 1890–1893. [3]: See below for PM Cardio digitized version of this. PM Cardio digitized version.

Chest Pain 91

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 91

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 40

STEMI Chest Pain Cardiac Arrest Stents 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. 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

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 11, 2016

A middle-aged woman had intermittent angina for 48 hours, then onset of constant, crushing chest pain for 1.5 cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." Circulation 1993; 88:896-904. Circulation 1995; 91:1659-1668. LV Thrombus , 1.5

Myocardial Infarction 52

Myocardial Infarction Pericarditis STEMI Angina 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. It was from a patient with chest pain: Note the obvious Brugada pattern. Circulation, 117, 1890–1893. [3]:

Heart Rhythm 52

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 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