Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.

Chest Pain 139

Chest Pain Embolism Pulmonary Tachycardia 139

Dr. Smith's ECG Blog

MAY 13, 2017

He complained of severe chest pain and was extremely agitated, so much so that he was throwing chairs in triage. Technically, the STE meets STEMI criteria because there is greater than 2.5 These kinds of cases were excluded from the study as obvious anterior STEMI. Case 1: The outcome of this case is at the far bottom.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 9, 2023

He has a history of STEMI and heart failure. The medics stated he had been nauseated and diaphoretic, but he did not have any chest pain or SOB. And especially suspect Old MI when the patient gives a history of MI and has no chest pain or SOB. A 50-something had syncope while driving. He had a prehospital ECG.

Aneurysm 115

Aneurysm Chest Pain Echocardiogram STEMI 115

Dr. Smith's ECG Blog

JUNE 11, 2024

Sent by anonymous A man in his 40s with no previous heart disease presented within 30 minutes of onset of acute chest pain that started while exercising. Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Chest pain and a computer ‘normal’ ECG.

Chest Pain 113

Chest Pain STEMI Blog Exercise 113

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. He had no chest pain. Is this acute STEMI? Is this an acute STEMI? -- Unlikely! Medications were aspirin, clopidogrel, metoprolol, and simvastatin.

STEMI 52

STEMI Pulmonary Stent Stents 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. Chest pain is squeezing or tight in nature.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

OCTOBER 26, 2010

This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He wrote most of it and I (Smith) edited.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stent 116

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. EMS gave 324 mg aspirin and 3 sublingual NTG, which the patient stated reduced the substernal chest pain from an 8/10 to 4/10. Pain better still. What do you think the echocardiogram shows? NTG drip started.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. He later developed mild continuous chest pain, that he describes as the sensation of someone standing on his chest. See this post: What do you think the echocardiogram shows in this case?

Chest Pain 119

Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

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. A patient with OMI can have a totally normal ECG!"

Myocardial Infarction 123

Myocardial Infarction Chest Pain STEMI Blood Pressure 123

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. 3 hours prior to calling 911 he developed typical chest pain. But it could be anterior STEMI. is likely anterior STEMI).

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His medical history is unremarkable except a similar pain occurred 4-5 times in the previous 3 months with less intensity, short duration, unrelated to exertion. He visited an outpatient clinic for it and an echocardiogram and exercise stress test was normal. The pain was completely resolved after coronary intervention.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

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? Do NOT use them.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 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? There was some SOB. Could it be acute (vs. Very unlikely.

STEMI 52

STEMI Myocardial Infarction Pericarditis Ultrasound 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

He reports significant chest pain at the base of his scapula on the right side along with new shortness of breath. Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE?

Chest Pain 116

Chest Pain Myocardial Infarction STEMI Pericarditis 116

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

JANUARY 28, 2023

Case 1 A middle aged woman presented with acute chest pain and shortness of breath, unclear time since onset, and likely with episodic symptoms off and on throughout the day. Only very slight STE which does not meet STEMI criteria at this time. The computer did read "STEMI". Additional case by Smith.

STEMI 52

STEMI Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

JULY 14, 2023

So we activated the Cath Lab Angiogram: Impression and Recommendations: Culprit for the patient's anterior ST segment myocardial infarction and out of hospital V-fib cardiac arrest is a thrombotic occlusion of the mid LAD The first troponin returned barely elevated at 36 ng/L (URL = 35) In our study of initial troponin in STEMI, 26.8%

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast. The patient was given opiates which improved his chest pain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

Chest Pain 120

Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

DECEMBER 29, 2015

What do you think of this ECG in a patient with chest pain? Case history A middle-aged woman with a history of HTN, but no prior CAD, presented to the ED with chest pain. The pain had been mild and intermittent for 2 weeks, but had become more intense on the night of presentation. Is the ST elevation due to LVH?

STEMI 40

STEMI Myocardial Infarction Chest Pain Aneurysm 40

Dr. Smith's ECG Blog

OCTOBER 22, 2024

He reported typical chest pain since 4H AM and arrived at our ED at 10h with ongoing chest pain. Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." The first ECG (10h14) showed TWI in inferior leads."

Chest Pain 66

Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). Echocardiogram was obtained and showed mild LVH without regional wall motion abnormality.

STEMI 116

STEMI Document Blog Ischemia 116

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. Formal echocardiogram showed normal EF, no wall motion abnormalities, no pericardial effusion.

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

Dr. Smith's ECG Blog

JUNE 18, 2013

This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion. His ECG was repeated at this point: This shows a well developed anterior STEMI. On echocardiogram, there was a 40% ejection fraction with anterior wall motion abnormality. The peak troponin I was over 100.

STEMI 52

STEMI Chest Pain Myocardial Infarction Webinar 52

Dr. Smith's ECG Blog

NOVEMBER 2, 2015

A middle-aged male called 911 for chest pain. Here was the first prehospital ECG with pain at 5/10: Computerized QTc is 418 ms. Serial ECGs demonstrated dynamic changes diagnostic of ACS (transient STEMI) 4. Finally, Transient STEMI should be taken emergently to the cath lab. Always look at prehospital ECGs 4.

STEMI 52

STEMI Myocardial Infarction Chest Pain Echocardiogram 52

Dr. Smith's ECG Blog

MARCH 2, 2009

Pain is similar, but associated with less SOB. A stat echocardiogram would have helped to make this diagnosis and facilitate timely reperfusion. Possibilities include: serial ECGs (which were done but still nondiagnostic), stat echocardiogram, or posterior ECG. The pain is very nitroglycerine responsive.

Heart Attack 52

Heart Attack Heart attacks STEMI Echocardiogram 52

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

Pericarditis 52

Pericarditis Chest Pain Stents Stent 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

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. The peak troponin I was 0.364 ng/ml.

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

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms.

Pericarditis 52

Pericarditis Chest Pain Aortic Blog 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. A rapid echocardiogram was performed, revealing an ejection fraction of 20% with thinning of the anterior-apical walls. That was also my initial concern.

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

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

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. See this case: what do you think the echocardiogram shows in this case?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52