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. And ECGs can change and evolve even when there is no ischemia. First: 2nd: What was my response? It was indeed.

Chest Pain 52

Chest Pain Blog Ischemia Document 52

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. But it was interpreted as no acute ischemia and the patient was referred to cardiology as Non-STEMI. Cardiology aware.

STEMI 80

STEMI Chest Pain Pericarditis Ischemia 80

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Triage EKG: What do you think?

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

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.

Chest Pain 131

Chest Pain Myocardial Infarction Blog Stents 131

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. Learning Points: 1.

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 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. Stress echocardiogram ruled out myocardial ischemia.

Chest Pain 40

Chest Pain Echocardiogram Document Ischemia 40

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. Our patient had a Brugada Type 1 pattern elicited by an elevated core temperature, which is also a documented phenomenon.

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

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. Gottlieb SO, et al.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

OCTOBER 12, 2024

or basilar ischemia. 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.” (!!!)

STEMI 116

STEMI Document Blog Ischemia 116

Dr. Smith's ECG Blog

JANUARY 9, 2024

Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Do you agree with this strategy?

Tachycardia 119

Tachycardia Electrophysiology Atrial Flutter Ischemia 119

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. Perhaps they indicate an open artery with minimal flow and severe subendocardial ischemia, but not total subepicardial ischemia. Here is one case of a patient I saw. But we find that this is unusual.

Chest Pain 52

Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

JUNE 27, 2021

A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away. persistent pain despite medical Rx brought emergently to Cath lab." He had been drinking 5 beers.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 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. There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

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.

Chest Pain 52

Chest Pain STEMI Document Ischemia 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. Resolution of pain, by itself, is not reliable enough to be certain of resolution of ischemia.

Chest Pain 52

Chest Pain STEMI Ischemia Aortic 52

Dr. Paddy Barrett

AUGUST 1, 2023

Share Chest Pain Symptoms There is no role for CT Calcium Scoring in the setting of someone with chest pain symptoms suspected to be from a narrowed coronary artery. Regardless, if you present with chest pain and get a stress test instead of a CTCA, you are arguably getting an inferior test. I would say yes.

Coronary Angiogram 52

Coronary Angiogram Plaque Coronary Artery Disease Chest Pain 52

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. Figure-1: Initial ECG, obtained pre-hospital from this 40-ish year old woman with new-onset chest pain ( See text ). See P.S. below ) == P.S. : I believe I found another example of ischemia-induced J waves ( See Oct. She called 911. The proposed mechanism is complex.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 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. To EMPHASIZE: We are not told the circumstances under which ECG #2 was obtained. What Do We Learn from ECG #3 ?

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Document 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. TnI peaked at 67.10

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 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. For coronary anatomy, see here: [link] This is the post intervention ECG: All ST Elevation is gone (more proof that it was all a result of ischemia) Formal Echo: Normal estimated left ventricular ejection fraction - 55%.

Chest Pain 52

Chest Pain Pericarditis Stents Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Sent by anonymous, edited by Pendell Meyers A man in his 50s with history only of hypertension presented with acute chest pain that started 45 minutes prior to presentation while doing yard work. Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10."

STEMI 78

STEMI Myocardial Infarction Ischemia Academic 78

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.

Chest Pain 40

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

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? It is posterior OMI until proven otherwise.

STEMI 52

STEMI Chest Pain Myocardial Infarction Document 52

Dr. Smith's ECG Blog

APRIL 15, 2019

If a patient presents with chest pain and a normal heart rate, or with shockable cardiac arrest, then ischemic appearing ST elevation is STEMI until proven otherwise. CLICK HERE — for the ESC/ACC/AHA/WHF 2018 Consensus Document on the 4th Universal Definition of MI, in which these concepts are discussed and illustrated.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

JANUARY 30, 2019

It was from a patient with chest pain: Note the obvious Brugada pattern. Our patient had a Brugada Type 1 pattern elicited by an elevated core temperature, which is also a documented phenomenon. The elevated troponin was attributed to either type 2 MI or to non-MI acute myocardial injury. There is no further workup at this time.

Heart Rhythm 52

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? This patient was reported to have distant heart sounds but was not hypotensive and did not have JVD according to documentation. She was noted to be tachycardic and her heart sounds were distant on physical exam.

Tachycardia 40

Tachycardia Pericarditis Ultrasound Blood Pressure 40

Dr. Smith's ECG Blog

AUGUST 8, 2020

Weren't you taught that "new tall T wave in V1" is concerning for ischemia, and so this is the opposite? Weren't you taught that concave morphology favors pericarditis? There is also new flattening of the T wave in V1 compared to prior.

Pericarditis 52

Pericarditis STEMI Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. Most recent echo showed EF of 60%. He also had a history of chronic kidney disease, stage III.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

APRIL 8, 2015

Check : [vitals, SOB, Chest Pain, Ultrasound] If the patient has Abdominal Pain, Chest Pain, Dyspnea or Hypoxemia, Headache, Hypotension , then these should be considered the primary chief complaint (not syncope). Evidence of acute ischemia (may be subtle) vii. Left BBB vi. Pathologic Q-waves viii.

Arrhythmia 52

Arrhythmia Outcomes Chest Pain Risk Factors 52

Dr. Smith's ECG Blog

DECEMBER 31, 2024

Written by Pendell Meyers A woman in her 70s with known prior coronary artery disease experienced acute chest pain and shortness of breath. The chest pain was described as severe pressure radiating to both shoulders. Here is her ECG within 30 minutes of PCI: Improved, but still with ischemia. hours since onset.

Ischemia 119

Ischemia Tachycardia Chest Pain STEMI 119

Dr. Smith's ECG Blog

JANUARY 13, 2025

A 50-something male presented to triage with chest pain for one day. A Chest X-ray showed infiltrates. Thus, another etiology of chest pain is found, and the fever suggests "fever-induced Brugada." Unexplained cardiac arrest or documented VF/polymorphic VT: +3 3. Ischemia or infarction. Hypothermia.

Chest Pain 71

Chest Pain Cardiac Arrest Ischemia Sudden Cardiac Death 71

Dr. Smith's ECG Blog

FEBRUARY 12, 2025

She did not even need to ask in this case, because even if the patient presented with chest pain, she would call it NEGATIVE. The emergency physician does cautiously (correctly) note that the ECG meets STEMI criteria in V3 and V4, but goes on to document absence of ACS symptoms.

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Chest Pain STEMI Electrocardiogram Blog 82

Dr. Smith's ECG Blog

MARCH 25, 2025

Written by Willy Frick A woman in her 60s with very severe hyperlipidemia (LDL >200 mg/dL) presented with acute onset chest pain. She described the pain as moderate in severity, and said it had come and gone several times over the next few hours before ultimately resolving. Her symptoms began while getting off the bus.

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Chest Pain Ischemia Plaque Stents 63

Dr. Smith's ECG Blog

MARCH 8, 2025

It is possible there is microvascular dysfunction producing residual transmural ischemia. But this is most common when there is prolonged ischemia, and this patient had the fastest reperfusion imaginable! He had no chest pain, dyspnea, or any other anginal equivalent, and his vital signs were normal. Galiuto, L.,

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75