Dr. Smith's ECG Blog

DECEMBER 29, 2023

Written by Jesse McLaren A previously healthy 50 year-old presented with 24 hours of intermittent exertional chest pain, radiating to the arms and associated with shortness of breath. In a previously healthy patient with new and ongoing chest pain, this is concerning for acute occlusion of the first diagonal artery.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 70

Dr. Smith's ECG Blog

JUNE 17, 2023

Written by Pendell Meyers A middle aged man called EMS for acute chest pain. I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 Physician accuracy in interpreting potential ST-segment elevation myocardial infarction electrocardiograms. I said "Not OMI. Carley et al. Emerg Med J.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch.

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.

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STEMI Chest Pain Myocardial Infarction Blog 121

Dr. Smith's ECG Blog

MARCH 10, 2017

A 61 year-old with chest pain arrived to the ED by ambulance with resolving chest pain. Safety of Computer Interpretation of Normal Triage Electrocardiograms. The chest pain is resolving, so if these are resolving hyperacute T-waves, then followup ECGs should show their size diminishing.

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STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

A 70-year-old man calls 911 after experiencing sudden, severe chest pain. The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! But if there is none - then you are looking at least at an Isolated Posterior STEMI until proven otherwise.

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Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2017

This was sent to me by a former resident from a community hospital: A middle-aged woman complained of chest pain and was seen in triage. Comment This paper has received some press recently: Safety of Computer Interpretation of Normal Triage Electrocardiograms The algorithm used was also the GE Marquette 12 SL. Normal ECG."

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Chest Pain Bradycardia Technology Electrocardiogram 52

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.

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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.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria.

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Chest Pain STEMI Blog Academic 52

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

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STEMI Article Chest Pain Blog 52

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. International Journal of Cardiology Heart & Vasculature Case A 40-year-old man presents with excruciating back pain which has started 1 hour ago. Turk Kardiyol Dern Ars.

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STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MARCH 13, 2013

A 36 yo male smoker presented to the ED with chest pain. It had started the night before as "indigestion" and had progressed to 8/10 substernal chest pressure radiating to the right shoulder/jaw associated with diaphoresis, nausea, and SOB. of patients with anterior STEMI, ST elevation of greater than or equal to 3.0

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STEMI Myocardial Infarction Electrocardiogram Chest Pain 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. He had been awakened by cough at 3 AM 2 days earlier.

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STEMI Chest Pain Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. This is a case I had quite a while back. See the explainability : She sees large T-waves in V2, V3.

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Chest Pain Bradycardia Blog Electrocardiogram 116

Dr. Smith's ECG Blog

OCTOBER 9, 2018

The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction. link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. They did not find one STEMI on their triage ECGs (no surprise!

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Chest Pain STEMI Cardiac Arrest Blog 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.

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STEMI Ischemia Chest Pain Myocardial Infarction 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. Induced Brugada-type electrocardiogram, a sign for imminent malignant arrhythmias. PM Cardio digitized version.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

Dr. Smith's ECG Blog

MARCH 8, 2021

This was just published in JAMA Internal Medicine: The de Winter Electrocardiogram Pattern Evolving From Hyperacute T Waves It reminded me that many believe, due to the assertions in the original de Winter's article, that de Winter's waves are stable. He was a 30-something with chest pain. Here is one case of a patient I saw.

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Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

JUNE 12, 2017

This was sent by : Jacob Smith, DO Emergency Medicine Resident Ohio Health Doctors Hospital Emergency Residency Christopher Lloyd, DO, FACEP Director of Clinical Education, USACS Midwest Case A 30 year old patient presents to triage with chest pain. This is diagnostic of inferior MI, though does not meet millimeter criteria for "STEMI."

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MARCH 3, 2023

can cause ST-segment elevation (STE) on electrocardiogram (ECG), the distinction between them may be hard and complicated. Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO). At each step, you will also find active links to the original publications.

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Chest Pain STEMI Download Blog 52

Dr. Smith's ECG Blog

MARCH 6, 2019

A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath. This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline."

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STEMI Chest Pain Ischemia Myocardial Infarction 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. Patel DJ, et al.

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Chest Pain Thrombosis Myocardial Infarction STEMI 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. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

An initial electrocardiogram (ECG) is provided below. Although the patient reported experiencing mild pressure-like chest pain, there was suspicion among clinicians that this might be indicative of an older change. The patient was promptly admitted to the hospital for further evaluation. What do you think? What is the rhythm?

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Tachycardia Blog Heart Failure Ischemia 112

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?

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Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

He was asked multiple times about chest pain or dyspnea, but repeatedly denied any such symptoms. Patient denied chest pain on initial review of symptoms. Was now endorsing chest pain which began 30 minutes ago. Upon further questioning, he states that he has had intermittent chest pain since yesterday.

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Myocardial Infarction Chest Pain Cardiogenic Shock STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

She went on to describe her chest pain as a "buffalo sitting on my chest" and a "weird" sensation in her jaw for 1 hour prior to arrival, associated with lightheadedness and diaphoresis. The patient was given fentanyl initially for chest pain with minimal effect and then vomited which was followed by zofran and famotidine.

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Chest Pain Critical Care Article Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

A 40 something otherwise healthy man presented with substernal chest pain. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. These include about 60 occlusion MI (OMI) with clear ST segment elevation (none of which would be called “Normal” by the computer) and about 165 Non-STEMI.

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Chest Pain STEMI Article Myocardial Infarction 52

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. Cardiology felt her chest pain to be, most likely, the result of coronary supply-demand mismatch in the context of HCM endothelial remodeling (i.e.

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Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

DECEMBER 27, 2018

A Deep Neural Network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation. But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI. I do research on Cardiologs' algorithm: Smith SW et al. What an honor.

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Chest Pain Hypertension STEMI Heart Disease 40

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The patient contacted EMS after a few hours of chest pain that started 5:30 AM. The pain was described as 6/10 radiating to the right shoulder. The chest pain was described as both sharp and pressure like. Below is the post -PCI electrocardiogram. He is otherwise healthy.

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Chest Pain Blog Ischemia Risk Factors 60

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

male with a history of HTN and ETOH developed squeezing epigastric abdominal pain with associated vomiting and diaphoresis, followed by a syncopal episode which lasted about 10 seconds. When medics arrived, he denied any chest pain, shortness of breath, or palpitations prior to the syncopal episode.

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Chest Pain Ischemia Angina Electrocardiogram 40

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." hours when she called 911. LV Thrombus , 1.5 0 0 1 95 544 MMRF 4 1 638 14.0 GUSTO-I Investigators.

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Myocardial Infarction Pericarditis Angina STEMI 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. Bicarb 20, Lactate 4.2,

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Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

JANUARY 17, 2024

Written by Jesse McLaren Two patients presented with acute chest pain, and below are the precordial leads V1-6 for each. Patient 1 Patient 2 STEMI criteria is based only ST elevation millimeter criteria measured in isolation from the QRS and stratified by age/sex, so this is the only information provided above.

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Chest Pain STEMI Myocardial Infarction Blog 118