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 flutter waves can conceal or mimic ischemic repolarization findings, but here I don't see any obvious findings of OMI or subendocardial ischemia.

Chest Pain 52

Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The first task when assessing a wide complex QRS for ischemia is to identify the end of the QRS. How did the Queen of Hearts do on today's ECGs? The syncope lasted about 2-3 minutes according to his wife.

Cardiogenic Shock 128

Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 128

Ken Grauer, MD

MAY 20, 2023

NOTE: It's important to correlate ongoing circumstances at the time that a prior tracing was done ( ie, Was the patient stable and asymptomatic — or were they having chest pain, an exacerbation of heart failure, or some other ongoing process at the time the prior ECG was recorded? ).

Blog 145

Blog Chest Pain Ischemia STEMI 145

Dr. Smith's ECG Blog

JANUARY 9, 2024

Are you confident there is no ischemia? The heart rate is about 130 bpm. The heart rate could be compatible with that of a 2:1 conducted atrial flutter. Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? Do you agree with this strategy?

Tachycardia 119

Tachycardia Electrophysiology Atrial Flutter Ischemia 119

Dr. Smith's ECG Blog

JUNE 11, 2021

Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. On arrival, GCS was 13 and the patient complained of ongoing chest pain. Vitals were HR 58 BP 167/70 R20 sat 96%.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

JANUARY 1, 2024

His medical history includes hypertension, a decade-long battle with diabetes, ischemic heart disease, a coronary bypass graft surgery ten years ago, a diagnosis of congestive heart failure for the last five years, and a prior ICD implantation five years ago. There is some ST-segment elevation in DII, DIII, aVF, V4-6.

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. 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. No pericardial effusion. Alcohol intoxication?

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

DAIC

FEBRUARY 29, 2024

ET Murphy Ballroom 4 Comparison of an "Inclisiran First" Strategy with Usual Care in Patients With Atherosclerotic Cardiovascular Disease: Results From the VICTORION-INITIATE Randomized Trial Targeting Weight Loss to Personalize the Prevention of Type 2 Diabetes Once-weekly Semaglutide in Patients with Heart Failure With Preserved Ejection Fraction, (..)

Aortic valve 103

Aortic valve Myocardial Infarction Aortic Blood Pressure 103

Dr. Smith's ECG Blog

OCTOBER 18, 2023

The chest pain quickly subsided. Most such rhythms in the setting of ischemia are VF and will not convert without defibrillation. NT-pro-BNP peaked at 4831, consistent with heart failure. Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia.

Cardiac Arrest 122

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 122

MIBHS

OCTOBER 15, 2024

For example, if a coronary artery becomes blocked due to plaque buildup (a condition known as coronary artery disease), the heart muscle may not receive enough oxygen, leading to chest pain (angina) or, in more severe cases, a heart attack.

Circulation 52

Circulation Heart Attack Heart attacks Chest Pain 52

Dr. Smith's ECG Blog

OCTOBER 6, 2023

This is one case where it made a difference: Right Ventricular MI seen on ECG helps Angiographer to find Culprit Lesion Nevertheless, it is sometimes a fun academic exercise to try to predict the infarct artery: An elderly patient had onset of chest pain one hour prior. He called 911. Here is the prehospital ECG. What do you think?

Aneurysm 66

Aneurysm Chest Pain Cardiogenic Shock Blog 66

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.

Chest Pain 52

Chest Pain Critical Care Article Pacemaker 52

Dr. Smith's ECG Blog

MARCH 2, 2019

Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? Ischemia b. ST depression: is it ischemia? Does this patient have hypertension and/or heart failure that has worsened? Reference: Knotts RJ , Wilson JM, Kim E, Huang HD, Birnbaum Y.

Sickle Cell Disease 52

Sickle Cell Disease Ischemia Dysrhythmia Chest Pain 52

EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. LBBB may be the precipitating cause of the heart failure syndrome, or may portend high mortality when identified in preexisting heart failure.

Heart Failure 52

Heart Failure Myocardial Infarction Bradycardia Chest Pain 52

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This is the initial ECG: The QRS is widened with a regular cadence, and there are no discernable P waves.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

DECEMBER 27, 2018

But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI. All bets would be off if instead of no chest pain, this patient had worrisome new-onset symptoms. The Ratios of STE to S-wave: V1: 2.5/16 P EARL : Clinical correlation is KEY in this case.

Chest Pain 40

Chest Pain Hypertension STEMI Heart Disease 40

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. It appears that on occasion — J waves may be induced by ischemia ( thought to reflect an acute injury current from impending myocardial infarction ). But maybe not. Thelin et al.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

MARCH 15, 2023

This middle-aged patient has a remote history of cardiac surgery as a young child for a "heart murmur". She did notice something slightly wrong subjectively, but had no palpitations, chest pain, or SOB, or any other symptom. Exam was completely normal except for an irregular heart rate. She was on no medications.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 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. Heart failure leading to death was related to all subclasses of PVC.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

MARCH 6, 2020

This middle-aged man with no cardiac history but with significant history of methamphetamin and alcohol use presented with chest pain and SOB, worsening over days, with orthopnea. There is no evidence of infarction or ischemia. A cutoff of 1200 pg/ml for patients with a normal eGFR is very specific for heart failure.

Heart Failure 52

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy 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

MARCH 19, 2025

They end up with high mortality and needless heart failure. He was given two separate sprays of nitroglycerin sublingually, neither of which improved his pain but did cause him to become briefly hypotensive ( 600 ng/L. The patient has acute persistent refrectory chest pain and elevated troponin.

Chest Pain 116

Chest Pain STEMI Stents Stent 116

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

Scenario 1 : The patient presents with 24 hours of substernal chest pain. Denying patients the potential benefit of revascularization just because their symptoms have lasted a certain amount of time shows poor understanding of the pathophysiology of myocardial ischemia. He presented to the emergency department for evaluation.

Chest Pain 89

Chest Pain Pericarditis Myocardial Infarction Dementia 89

Dr. Smith's ECG Blog

MARCH 27, 2025

"Hi Steve wonder what you think of this ecg in a 60 yo woman w cp, known CAD" Presentation ECG (ECG 1): Here is her previous from one week prior when she presented with heart failure and trops were "negative" (ECG 2): My response: "They both look like active ischemia. The previous ECG also shows active ischemia."

Ischemia 106

Ischemia Chest Pain Cardiogenic Shock Heart Failure 106

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. She awoke in the morning with sharp chest pain which worsened throughout the morning. As her pain worsened, so did her dyspnea. This was written by Hans Helseth.

Tachycardia 74

Tachycardia Pulmonary Chest Pain Stenosis 74

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Written by Pendell Meyers A man in his 60s presented with acute chest pain. He was discharged home, but quickly bounced back 4 times within the next few months for worsening heart failure. This distinction is further complicated because marked LVH may at times mask the ST-T wave changes of acute ischemia.

Cardiac Arrest 86

Cardiac Arrest STEMI Blog Ischemia 86

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.

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75