Dr. Smith's ECG Blog

MARCH 4, 2023

The ECG is rather classic for pulmonary embolism, and indeed this was a large acute PE. More on the ECG in pulmonary embolism: The ECG in this patient has both precordial T-wave inversions AND T-wave inversion in lead III. this is highly suggestive of pulmonary embolism. This is a classic S1Q3T3.

Chest Pain 52

Chest Pain Embolism Tachycardia Pulmonary 52

ECG Cases

MAY 10, 2023

In this ECG Cases blog we look at 10 cases of patients with chest pain, including false positive STEMI, false negative STEMI, and other causes to help hone your ECG interpretation skills in time-sensitive cases where those very ECG skills might save a life.

Chest Pain 52

Chest Pain STEMI Blog Pericarditis 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. 24 yo woman with chest pain: Is this STEMI?

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

DECEMBER 14, 2016

A middle aged male presented at midnight after 14 hours of constant, severe substernal chest pain, radiating to his throat and to bilateral jaws, and associated with diaphoresis. The pain was not positional, pleuritic, or reproducible. Patients with ACS and acute pulmonary edema 3. It was not relieved by anything.

Chest Pain 52

Chest Pain STEMI Aortic Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 14, 2023

Written by Pendell Meyers, with some edits by Smith A man in his 40s with many comorbidities presented to the ED with chest pain, hypotension, dyspnea, and hypoxemia. The bedside echo showed a large RV (Does this mean there is a pulmonary embolism as the etiology?) Here is his triage ECG: What do you think?

Chest Pain 52

Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

APRIL 9, 2023

Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell Meyers A man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath.

Chest Pain 52

Chest Pain Ischemia Stenosis Pulmonary 52

Dr. Smith's ECG Blog

JUNE 11, 2011

Explanation : The patient had a worrisome history: 59 yo with significant substernal chest pressure, so his pretest probability of MI (and even of STEMI) is reasonably high. Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion. Moreover, and importantly, there was sinus tach.

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

In patients with narrow QRS ( not this patient), this pattern is highly suggestive of acute pulmonary embolism. Although it was technically difficult and the quality therefore leaves a lot to be desired, you can still make out RV dilation and septal flattening which is much more suggestive of pulmonary embolism than OMI.

Cardiogenic Shock 118

Cardiogenic Shock Ultrasound Pulmonary Tachycardia 118

Dr. Smith's ECG Blog

NOVEMBER 17, 2023

Ken (below) is appropriately worried about pulmonary embolism from the ECG. What I had not told him before he made that judgement is that the patient also had ultrasound B-lines of pulmonary edema. Finally, the presentation is dyspnea, not chest pain. What do you think? Also, we know the patient had a stent.

Aneurysm 122

Aneurysm Stent Stents Chest Pain 122

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Written by Pendell Meyers and Peter Brooks MD A man in his 30s with no known past medical history was reported to suddenly experience chest pain and shortness of breath at home in front of his family. CT angiogram showed extensive saddle pulmonary embolism. He had multiple cardiac arrests with ROSC regained each time.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

EMS 12-Lead

APRIL 9, 2024

There was no chest pain. V1 and V2 are probably placed too high on the chest given close morphological similarity to aVR. The CXR demonstrated no pulmonary edema. This latter part has been implicated in embolic CVA. The fall was not a mechanical etiology.

Ischemia 116

Ischemia Stenosis Chest Pain Coronary Artery Disease 116

Dr. Smith's ECG Blog

APRIL 27, 2012

56 y/o male who presented with 12/10 severe chest pain starting at 3AM, radiating to his upper back. He had a history of pulmonary embolism but was no longer on coumadin and states the pain is different. The patient was very hypertensive and had back pain, so they did a CT of his chest to rule out dissection.

Chest Pain 52

Chest Pain Embolism Ischemia Pulmonary 52

Dr. Smith's ECG Blog

APRIL 26, 2017

There was no chest pain or SOB at the tim of the ECG: Computerized QTc is 464 ms A previous ECG from 8 years prior was normal. Absence of chest pain or SOB at the time of the ECG is important; had the patient had active chest pain, I would have recommended at least an emergency formal echo, if not cath lab activation.

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

MARCH 12, 2018

Notice I did not say "pulmonary embolism," because any form of severe acute right heart strain may produce this ECG. This includes, but is not limited to, PE, asthma/COPD exacerbation, hypoxic vasoconstriction from pneumonia, acute pulmonary hypertension exacerbation. What is the Diagnosis?

Chest Pain 40

Chest Pain Pulmonary Embolism Tachycardia 40

Dr. Smith's ECG Blog

MAY 10, 2023

A 34 yo woman with a history of HTN, h/o SVT s/p ablation 2006, and 5 months post-partum presented with intermittent central chest pain and SOB. She had one episode of pain the previous night and two additional episodes early on morning the morning she presented. Deep breaths are painful and symptoms come and go.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 25, 2017

Written by Pendell Meyers, edits by Smith: Case A 72 year old female with hypertension and COPD presented with sudden shortness of breath and chest pain. A new right bundle branch block in a sick patient with chest pain and/or shortness of breath is a worrisome finding concerning for LAD occlusion or significant pulmonary embolism.

Chest Pain 52

Chest Pain Pericarditis Embolism Stents 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

My answer: "This is classic for PE, but it can also be present in any hypoxia due pulmonary hypoxic vasoconstriction and resulting acute pulmonary hypertension and acute right heart strain. The ECG of most patients with longstanding pulmonary disease show more r wave progression than I see in ECG #1. This is NOT Wellens.

Chest Pain 52

Chest Pain Pulmonary Tachycardia Embolism 52

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

DECEMBER 6, 2024

A 50-something man presented with worsening severe exertional chest pain which was just resolving as he had an ECG recorded in triage. By itself seeing this ECG pattern does not necessarily mean that the patient has a pulmonary embolism. Are the T-waves in leads I and II hyperacute? Hard to tell. How can we know?

Coronary Artery Bypass Graft 106

Coronary Artery Bypass Graft Ischemia Stenosis Chest Pain 106

Dr. Smith's ECG Blog

DECEMBER 20, 2013

He said that his pain does not feel like his previous episode of pericarditis, and is not related to meals. He denied chest pain, shortness of breath, nausea, fever, chills, rashes, cough, and leg pain. Does subsegmental pulmonary embolism matter? The ST/T ratio in V6, however, is slightly greater.

Pericarditis 52

Pericarditis Chest Pain Pulmonary Embolism 52

MIBHS

OCTOBER 31, 2024

Chronic Pulmonary Disease Lung diseases like chronic obstructive pulmonary disease (COPD) can lead to pulmonary hypertension, which in turn can cause the right side of the heart to enlarge, a condition known as cor pulmonale.

Blood Pressure 52

Blood Pressure Blood Clot Heart Valves Heart Rhythm 52

Dr. Smith's ECG Blog

JANUARY 12, 2023

Written by Pendell Meyers, edits by Smith Two patients presented with acute chest pain/pressure. Chest x-ray was read as normal. CT pulmonary angiogram was negative for pulmonary embolism. Two patients with chest pain. She had an acute LAD OMI in the process of reperfusion, see case below.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 22, 2022

On his physical examination, cardiac and pulmonary auscultation was completely normal. As his pain was very severe, emergency physicians concerned of aortic dissection and ordered a thoracic CT scan. Bi-phasic scan showed no dissection or pulmonary embolism. He has 40 packs-year of smoking history.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MAY 10, 2014

A male in his late 30's to early 40's presented with 24 hours of intermittent typical chest pain. This is known as McConnell's sign, and is described for Pulmonary Embolism ; here we see it in right ventricular MI. The following ECG was recorded: There is an obvious acute inferior STEMI.

STEMI 40

STEMI Chest Pain Pulmonary Ultrasound 40

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 (ECG on the left) was a 45 year-old male, and patient 2 (ECG is on the right) was a 70 year-old male. But ECG #1 is not "normal".

Chest Pain 108

Chest Pain STEMI Myocardial Infarction Blog 108

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). Aortic Dissection, Valvular (especially Aortic Stenosis), Tamponade.

Arrhythmia 52

Arrhythmia Outcomes Risk Factors Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

Written by Pendell Meyers A woman in her 40s presented with acute chest pain and shortness of breath. Smith : This is classic for pulmonary embolism (PE). Acute pulmonary embolism was confirmed on CT angiogram: The patient did well. Chest pain, SOB, Precordial T-wave inversions, and positive troponin.

Chest Pain 99

Chest Pain Embolism Pulmonary Tachycardia 99

Dr. Smith's ECG Blog

OCTOBER 27, 2024

This was submitted by a paramedic, Hailey Kennedy A late 50s male called 911 following 2 hours of chest pain that started while working at his desk. He reported the crushing chest pain radiated down his left arm. He presented to the ED for evaluation chest pain. Pain was improved but not gone upon arrival.

STEMI 123

STEMI Chest Pain Myocardial Infarction Aneurysm 123