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. Successful drug-eluting stent placement opening up 95% mid RCA stenosis to 0% residual Nonobstructive left system disease. Chest pain and a computer ‘normal’ ECG.

Chest Pain 113

Chest Pain STEMI Blog Exercise 113

HeartRhythm

SEPTEMBER 8, 2024

An echocardiogram showed newly reduced left ventricular ejection fraction of 30-35%. He had minimal in-stent restenosis on angiography but had only minimal cardiac enzyme elevation and did not have antecedent chest pain before either of his events.

Defibrillator 40

Defibrillator Pacemaker Chest Pain Coronary Artery Disease 40

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. It was stented. This was a large OMI.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stents 116

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

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. The first hs troponin I returned at 1100 ng/L Angiogram Lesion on 1st Obtuse Marginal : Proximal subsection = 90% stenosis Stented. He had no h/o heart failure. Pre procedure TIMI III flow was noted.

STEMI 123

STEMI Heart Failure Stents Stent 123

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. mV compared to 0.05-0.1

Pericarditis 52

Pericarditis Chest Pain Stents Stent 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. A stent was placed. Type B waves are deeper and symmetric.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

MARCH 2, 2009

He continued to have worsening pain and diaphoresis, and associated left arm pain down to the fingers. reports MI in 2001 with a stent placed in the "marginal" artery. Pain is similar, but associated with less SOB. A stat echocardiogram would have helped to make this diagnosis and facilitate timely reperfusion.

Heart Attack 52

Heart Attack Heart attacks STEMI Echocardiogram 52

Dr. Smith's ECG Blog

JULY 11, 2024

No patient with chest pain should be sent home without troponin testing. An echocardiogram showed severely reduced global systolic function with an EF of 20-25% and an LV apical thrombus. All three lesions had TIMI 2 flow prior to stenting. An echocardiogram showed an EF of 20-25%.

Outcomes 112

Outcomes Stenosis Outpatient Echocardiogram 112

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 patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. Bedside echocardiogram showed hypokinesis of the mid to distal anterior wall and apex.

Plaque 66

Plaque Stents Stent Chest Pain 66

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The initial troponin I returned at 1500 ng/L and another ECG was recorded as the patient complained of 9/10 chest pain at 10 hours after the first Now the T-wave in III is fully upright, suggesting re-occlusion.

Chest Pain 52

Chest Pain Bradycardia Blog Critical Care 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

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. Another lesion in the proximal LAD with 80% stenosis was stented as well. Culprit lesion was reduced to 0% and stented. Additional case by Smith.

STEMI 52

STEMI Chest Pain Stents Stent 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. It was stented.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 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. His echocardiogram showed normal wall motion.

Plaque 127

Plaque Angina Blog Stents 127

Dr. Smith's ECG Blog

JULY 31, 2018

The lesion was stented. These are reperfusion T-waves (the same thing as Wellens' waves) Echocardiogram Regional wall motion abnormality-distal septum and apex. As emphasized by Dr. Smith — the best way to demonstrate acute ischemia is by identifying d ynamic S T- T wave c hanges in association with change in the nature of chest pain.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

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

FEBRUARY 4, 2022

A 40 something otherwise healthy man presented with substernal chest pain. They were stented. Formal Echocardiogram: The estimated left ventricular ejection fraction is 58 %. It had occurred once 3 days prior and resolved without any medical visit. What do you think? This ECG is DIAGNOSTIC of acute LAD Occlusion.

Chest Pain 52

Chest Pain STEMI Article Myocardial Infarction 52

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. Here are his publications.)

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40

Dr. Smith's ECG Blog

JUNE 23, 2024

Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. Echocardiogram showed LVEF 66% with normal wall motion and normal diastolic function. He did not remember whether he had experienced any chest pain. Two subsequent troponins were down trending.

Chest Pain 118

Chest Pain Cardiac Arrest Sudden Cardiac Death Blog 118

Dr. Smith's ECG Blog

DECEMBER 11, 2023

See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. This is different from nitroglycerin which produces vasodilation and can improve by pain improving myocardial perfusion. Here is the angiogram after stent placement. See this case: A man his 50s with chest pain. At midnight.

Myocardial Infarction 123

Myocardial Infarction Chest Pain STEMI Blood Pressure 123

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

JUNE 19, 2023

The patient’s chest pain spontaneously resolved before he was evaluated and has a repeat ECG obtained at 22:12 obtained shown below. In context, of course, it is clear that the patient is reperfusing, as pain has dissipated and the diagnostic findings of OMI have become more nonspecific. This ECG is more difficult.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

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. Successful primary angioplasty of the mid-circumflex artery towards the main marginal branch with the implantation of a drug-eluting stent. You must record frequent serial ECGs for patients with chest pain.

Chest Pain 66

Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. I think a good start would be a posterior EKG and a high quality contrast echocardiogram read by an expert. His inpatient clinicians did not think that an urgent angiogram was warranted given that he was chest pain free, his EKG appeared nondiagnostic, and serial troponins were not elevating beyond 2 ug/L.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 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 lesion was successfully stented. Aspirated thrombotic material.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 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. Formula value is now down to a very low value of 19.352 A 90% thrombotic LAD lesion was found and stented. There is nondiagnostic ST elevation in V1-V4. Most ST elevation is resolved.

STEMI 52

STEMI Myocardial Infarction Chest Pain Echocardiogram 52

DAIC

APRIL 8, 2024

“At that time, the damage to the heart muscle was greater than we see today, and we didn’t have the possibility to revascularize patients with percutaneous coronary intervention and stents like we do today,” Yndigegn said. Half were randomly assigned to receive long-term beta blocker medications and the rest did not take beta blockers.

Heart attacks 52

Heart attacks Heart Attack Heart Failure Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 10, 2024

Written by Pendell Meyers An elderly female called EMS with acute chest pain. Rather, they tell you what has been going on in the last several hours: 1) Echocardiogram -- The myocardium remains stunned and hypokinetic after reperfusion. Her vitals were within normal limits, and here is her EMS ECG: What do you think?

Chest Pain 108

Chest Pain Ischemia Echocardiogram Stents 108

Dr. Smith's ECG Blog

JANUARY 5, 2025

Written by Willy Frick A man in his 60s with hypertension and prior stroke presented with three days of crushing chest pain. He reported intermittent chest pain for the last few months, but never lasting this long. The cardiology consultant notes that pain is "almost resolved." There is active infarction.

Chest Pain 77

Chest Pain Ischemia Angina Echocardiogram 77

Dr. Smith's ECG Blog

FEBRUARY 16, 2025

This is a very bold statement in a type 1 diabetic with very concerning sounding chest pain. The patient was treated with aspirin and a GI cocktail, which did not help the pain. Echocardiogram was finally performed five hours after the first diagnostic ECG. Echocardiogram showed LVEF 33% with akinesis of the lateral wall.

STEMI 72

STEMI Pericarditis Chest Pain Echocardiogram 72

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

Written by Pendell Meyers, few edits by Smith A woman in her 70s was woken from sleep by midsternal chest pain radiating to left arm with nausea. Echocardiogram: EF 42% Moderate hypokinesis of the mid anterolateral and apical lateral myocardium Final diagnosis by the cardiologist was "STEMI" despite never meeting STEMI criteria.

STEMI 81

STEMI Chest Pain Echocardiogram Stents 81

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Written by Pendell Meyers A man in his 60s presented with acute chest pain. Total proximal LAD occlusion was found and stented at angiography soon after the ECG above. Here is his triage ECG: What do you think? There is sinus rhythm with clear LVH. Here are some images: Next morning ECG: Reperfusion findings are clear.

Cardiac Arrest 86

Cardiac Arrest STEMI Blog Ischemia 86