Dr. Smith's ECG Blog

APRIL 4, 2023

Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chest pain radiating to the neck, associated with shortness of breath. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome.

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Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin.

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Chest Pain STEMI Stents Stent 52

Dr. Smith's ECG Blog

MAY 16, 2023

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Anxiety is a common cause of chest pain with tachycardia.

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Chest Pain Pericarditis Tachycardia STEMI 52

Dr. Smith's ECG Blog

JULY 19, 2019

Written by Pendell Meyers, with edits by Steve Smith A man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). The patient was still with ongoing chest pain at the time ECG #1 was done.

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Chest Pain STEMI Aneurysm Pericarditis 52

Dr. Smith's ECG Blog

JUNE 14, 2017

There was apparently no syncope and he had no bony injuries, but he did complain of left sided chest pain. His chest was tender. A bedside cardiac ultrasound was normal. An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD IVCD type rhythm ??

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Chest Pain Congenital Heart Disease Article Congenital 52

Dr. Smith's ECG Blog

JUNE 30, 2023

These were texted to me only with "chest pain." It helps to know that the patient has active chest pain, as Wellen's is a post occlusion (reperfusion) state, with open artery and pain-free. Smith and Meyers containing thousands of tracings with documentation of cardiac catheterization results. It was indeed.

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Chest Pain Blog Ischemia Document 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? Up until recently — all computerized ECG interpretation programs that I am aware of used standard millimeter-based STEMI critieria as the basis for determining which chest pain patients should "qualify" for prompt cath with PCI. This was sent to me by a friend.

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Chest Pain STEMI Blog Academic 52

Dr. Smith's ECG Blog

MARCH 7, 2024

. = I had a previous case of an adolescent with trauma and chest pain who also had AIVR: An adolescent with trauma, chest pain, and a wide complex rhythm From this blog post: "AIVR is NOT common in otherwise healthy children.

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Hemorrhage Chest Pain AFIB Article 125

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. The following ECG was obtained.

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Chest Pain Myocardial Infarction Blog Stents 130

Dr. Smith's ECG Blog

MARCH 27, 2025

After only 90 minutes of chest pain, the first troponin was unsurprisingly in the normal range at 11ng/L (normal <26 in males and <16 in females), so the emergency physician waited for repeat troponin. Chest pain still persists. Paged cardiology 0800: patient complains of chest pain. Cardiology aware.

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STEMI Chest Pain Pericarditis Ischemia 80

Frontiers in Cardiovascular Medicine

OCTOBER 7, 2024

Case 2: A 57-year-old female was admitted to the hospital due to recurrent chest pain after physical activity for more than four years. Additionally, septum decreased from 16 to 13 mm after ten months, and the morphological changes associated with SVS also disappeared.

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Ablation Angina Chest Pain Echocardiogram 59

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

We documented that the majority of stenotic lesions had compensatory enlargement and thus exhibited remodeling. 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 ).

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Ischemia Plaque Stenosis Myocardial Infarction 121

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. The pain initially started the day prior to presentation. The ST elevation from today is ~0.2

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Pericarditis Chest Pain Stents Stent 52

Circulation

NOVEMBER 11, 2024

Advanced cardiac imaging especially in atypical presentations, can aid in early diagnosis.Case:A 59 year-old man with history of biopsy-proven pulmonary sarcoidosis presented with non exertional chest pain for 2 months. EKG, cardiac enzymes, and Initial echocardiogram(TTE) was unremarkable.

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Chest Pain Echocardiogram Document Ischemia 40

Open Heart

AUGUST 4, 2023

The most frequently documented symptoms were dyspnoea (64%), oedema (62%) and palpitations (57%). We identified six symptom clusters: generally symptomatic, dyspnoea and oedema, chest pain, anxiety, fatigue and palpitations, and asymptomatic (reference). female, 58% white).

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Atrial Fibrillation Ablation Chest Pain Document 52

Dr. Smith's ECG Blog

MARCH 4, 2024

Algorithm: Veritas (on Mortara machines) The Queen gets it right Case 2 A middle-aged woman with chest pain and a "normal" ECG in triage. Algorithm is either Glasgow or Marquette 12 SL The Queen gets it right Case 7 Chest pain relieved by Maalox and viscous lidocaine. The OMI was not seen and she arrested in triage.

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STEMI Blog Chest Pain Webinar 127

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

The British Journal of Cardiology

JUNE 11, 2024

Manifestations of CVDs, such as chest pain, abnormal serum markers, unstable angina, myocardial infarction (MI), myocarditis, and new-onset hypertension, were documented. The most common symptom was left hemithorax and interscapular pain (317 patients, 46%).

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COVID-19 Cardiovascular Disease Angina Chest Pain 40

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. Smith's ECG Blog

SEPTEMBER 22, 2023

Here is the clinical story: A 40 year old male with no cardiac history presented with acute substernal chest pain that started 40 minutes prior to arrival. In spite of a relatively short QTc of 376 ms, the very low R-wave amplitude in V4 and the ST Elevation at 60 ms after the J-point in lead V3 contribute to a high final value.

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Dr. Smith's ECG Blog

JANUARY 5, 2024

Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." The following ECG was obtained.

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Angina Plaque Document Stents 120

Dr. Smith's ECG Blog

MARCH 8, 2021

He was a 30-something with chest pain. A male in his 30's complained of sudden severe substernal chest pain. This is the longest lasting I have ever documented a hyperacute T wave without going "up" or "down." Shoulder pain after lifting a heavy box de Winter's -- they remained stable for 30 minutes with many ECGs.

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Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

OCTOBER 12, 2024

The providers documented concern for ST elevation in the precordial and lateral leads as well as a concern for hyperkalemic T waves in the setting of succinylcholine administration. Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) Potassium resulted as 4.9,

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STEMI Document Blog Ischemia 115

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.

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Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

JUNE 4, 2019

A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH. In a patient with new-onset chest pain — this is diagnostic of acute OMI until you prove otherwise.

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Chest Pain STEMI Ischemia Aortic 52

Dr. Smith's ECG Blog

MARCH 19, 2023

The reason the initial ECG is so concerning — is that it already suggests high likelihood of OMI ( = O cclusion-based MI ) in this 50-ish year old man who presents with a 2-hour history of new chest pain. What Do We Learn from ECG #3 ? Q waves are now present in each of the inferior leads in ECG #3.

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Chest Pain STEMI Myocardial Infarction Document 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

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. She was reportedly "pacing in her room while holding her chest". The source of this case is anonymous.

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Pericarditis Chest Pain Blog Ultrasound 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

A 50 something-year-old man with a history of newly diagnosed hypertension and diabetes, for which he did not take any medication, presented a non-PCI-capable center with a vague, but central chest pain. His vitals were normal and his first ECG was as shown below: There is obvious ST segment elevation (STE) in anterior leads.

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Chest Pain Myocardial Infarction Blog Pericarditis 52

Dr. Smith's ECG Blog

JULY 31, 2020

Meyers, Weingart and Smith published their OMI Manifesto — in which they extensively document the critically important concept that management of acute MI by separation into a “STEMI” vs “non-STEMI” classification is an irreversibly flawed approach. ST depression that is maximal in leads V2-to-V4.

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STEMI Article Chest Pain Blog 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. The day prior to presentation (about 12 hours prior to presentation) he described sudden onset chest pain and shortness of breath while gardening in his back yard. He had no further pain and went to bed that night with no complaints.

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Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

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

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

And some similar ECGs from Pulmonary Embolism: A young woman with altered mental status and hypotension An elderly woman transferred to you for chest pain, shortness of breath, and positive troponin - does she need the cath lab now? Finally — Note that the S1Q3T3 pattern is missing in ECG #2 , despite documentation of a massive PE.

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Chest Pain Pulmonary Tachycardia Embolism 52

Dr. Smith's ECG Blog

JULY 26, 2023

The combination of absence of chest pain and history of LV aneurysm made it easy to assess that this patient does not have acute OMI. In view of the History with the current admission ( ie, presenting to the ED for vertigo — with no new chest pain ) — I interpreted ECG #1 as no OMI.

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Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

Written by Pendell Meyers, few edits by Smith A man in his 60s with history of stroke and hypertension but no known heart disease presented with chest pain that started on the morning of presentation at around 8am. Here is his triage ECG when he presented at 1657: What do you think?

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STEMI Chest Pain Myocardial Infarction Document 52

Dr. Smith's ECG Blog

JUNE 28, 2019

60-something with h/o MI and stents presented with chest pain radiating to the back and nausea/vomiting. In this patient with documented coronary disease — these q waves could reflect prior lateral infarction ( especially in view of the Q in lead aVL ). Time zero What do you think? There is inferior ST elevation. Pericarditis?

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Chest Pain Pericarditis Stents Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

Written by Willy Frick A 40 year old woman was at home cooking when she developed chest pain. The operator documented thoughtful consideration of risks and benefits of stent placement. Unfortunately, a few hours later the patient complained of recurrent chest pain. She took an oxycodone and called EMS.

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Plaque Stents Stent Chest Pain 66