Dr. Smith's ECG Blog

JULY 25, 2024

The ECG shows severe ischemia, possibly posterior OMI. But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. It takes time for that ischemia to resolve. Just as important is pretest probability: did the patient report chest pain prior to collapse?

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Cardiac Arrest Ischemia Tachycardia Defibrillator 124

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Sent by Drew Williams, written by Pendell Meyers A man in his 50s with history of hypertension was standing at the bus stop when he developed sudden onset severe pressure-like chest pain radiating to his neck and right arm, associated with dyspnea, diaphoresis, and presyncope. Is this Acute Ischemia? More on LVH.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

He was treated for infection and DKA and admission to hospital was planned. 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.

Chest Pain 119

Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

Dr. Smith's ECG Blog

DECEMBER 10, 2019

This is a previously healthy male teenager who was awoken by chest pain. He was seen at another hospital and found to have a slightly elevated troponin, then underwent a CT pulmonary angiogram (PE) protocol which revealed a right sided pneumonia. In the evening, he became diaphoretic and complained of 9/10 continuous chest pain.

Chest Pain 52

Chest Pain Pericarditis Ischemia Pediatrics 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. Ischemic Hyperacute T waves (Tall, round, symmetric, vs the “pointy” peaked-T’s of HyperK), are often a clue to ischemia. This was written by Sam Ghali ( @ EM_RESUS ), with a few edits by me. This case is tough.

Chest Pain 52

Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

APRIL 22, 2022

Written by Jesse McLaren, with comments from Smith and Grauer A 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. A prospective validation of the HEART score for chest pain patients at the emergency department. Backus BE, Six AJ, Kelder JC, et al.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. At this time he reported ongoing chest pain and was given aspirin and nitroglycerin. J Am Heart Assoc.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

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

DECEMBER 18, 2022

Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, Smith A woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. Ischemic ST depression includes posterior OMI and subendocardial ischemia.

Chest Pain 40

Chest Pain Ischemia Aortic Aortic valve 40

DAIC

JULY 23, 2024

Brittany Weber, MD, PhD , of Brigham and Women’s Hospital, is the 2024 YIA winner for her abstract, "The Frequency, Prevalence, And Outcomes Of Incidentally Detected Coronary Artery Calcium Using Artificial Intelligence Analysis Among Patients With Immune Mediated Inflammatory Diseases.”

Chest Pain 105

Chest Pain Plaque Coronary Artery Disease Ischemia 105

EMS 12-Lead

APRIL 9, 2024

His confusion progressively dissipated enroute to the hospital. There was no chest pain. More detailed reviews of subendocardial ischemia, as well as acute ECG patterns that breach the typical presentation, can be found here: [link] [link] Imaging revealed no acute head, or spinal, injuries. Type I ischemia.

Ischemia 116

Ischemia Stenosis Chest Pain Coronary Artery Disease 116

Circulation: Cardiovascular Imaging

NOVEMBER 20, 2023

of patients had evidence of ischemia on a prior functional test. 1.88];P=0.768), and cardiovascular hospitalizations (RR, 0.91 [95% CI, 0.59–1.39];P=0.669) PubMed, EMBASE, and Cochrane Central were searched for randomized controlled trials comparing the 2 strategies. were referred to CCTA and 22.5% In the follow-up ranging from 1 to 3.5

Chest Pain 40

Chest Pain Myocardial Infarction Cardiovascular Imaging Ischemia 40

Ken Grauer, MD

AUGUST 26, 2023

As discussed in many posts in this ECG Blog — despite not satisfying the millimeter-based definition of a STEMI — in this patient with new chest pain, the ECG findings in Figure-1 merit prompt cath lab activation without any need to wait for serum troponin to return elevated ( See ECG Blog #193 — regarding the new "OMI" paradigm ).

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Blog Chest Pain STEMI Ischemia 145

Ken Grauer, MD

DECEMBER 15, 2023

ECG #2 was actually done first, at the time the EMS unit arrived on the scene ( at which time the patient was having severe chest pain ). About 20 minutes later ( on the way to the hospital ) — the patient's CP resolved, and ECG #1 was recorded. Figure-2: Comparison between the 2 ECGs recorded in today's case.

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Blog STEMI Ischemia Chest Pain 151

Dr. Smith's ECG Blog

AUGUST 19, 2023

Because the patient had no chest pain or shortness of breath, they were initially diagnosed as gastroenteritis. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. Potassium was normal. Cardiology did not think it was "STEMI", but repeated the troponin. Take home 1.

Chest Pain 98

Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

She presented to an outside hospital after several days of malaise and feeling unwell. But in the other half of this 30% ( ie, in ~15% of all patients with MI ) — although these patients found on follow-up ECG to have had infarction did not have chest pain — they did have "something else" thought to be associated with their MI.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

He was admitted to the hospital for evaluation of these symptoms — but no ECG was done at that time. 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 proximal LAD is now widely patent.

Chest Pain 120

Chest Pain Blog Hospital Tachycardia 120

Ken Grauer, MD

APRIL 5, 2024

As a result, the ST elevation ( with especially tall, peaked T wave in lead V2) — is not indication of acute ischemia. Today's patient is a middle-aged woman who presented with low back pain, shortness of breath and marked hypertension — but no chest pain. A picture is worth 1,000 words.

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Blog Ischemia Chest Pain Hypertension 94

Ken Grauer, MD

JANUARY 13, 2024

My written interpretation on a tracing such as this one would read, "Marked LVH and 'strain' and/or ischemia — with need for clinical correlation." BOTTOM Line: Today's patient presented with a 2-3 day history of chest pain and the ECG shown in Figure-1. Please see ECG Blog #73 for additional details ).

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Blog Ischemia AFIB Hypertension 159

Dr. Smith's ECG Blog

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. Smith's ECG Blog — Interpretation of a post-resuscitation ECG can be extremely challenging. Finally — The ECG of patient's with cardiac arrest is often exceedingly abnormal, if not bizarre.

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Dr. Smith's ECG Blog

MARCH 17, 2024

He also complained of intermittent mild chest pain radiating into into both shoulders and his back, as well as occasional unexplained sweating. Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive ). He had no further chest pain.

Angina 71

Angina Chest Pain Blog Ischemia 71

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%.

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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. Author continued : STE in aVR is often due to left main coronary artery obstruction (OR 4.72), and is associated with in-hospital cardiovascular mortality (OR 5.58).

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

OCTOBER 15, 2024

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 arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. Patient 1 remained in the hospital overnight.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

OCTOBER 18, 2023

A few days into her hospital stay she developed chest discomfort and the following ECG was recorded. The ECG below was on file and was taken a few days earlier, on the day of admission to the hospital. The chest pain quickly subsided. She is healthy with no known cardiac disease. What do you think?

Cardiac Arrest 122

Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 122

Dr. Smith's ECG Blog

JANUARY 9, 2024

Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Do you agree with this strategy?

Tachycardia 119

Tachycardia Electrophysiology Atrial Flutter Ischemia 119

Dr. Smith's ECG Blog

JUNE 18, 2011

3 hours prior to calling 911 he developed typical chest pain. When flow is restored, wall motion may completely recover so that echocardiogram does not detect the previous ischemia. Pain was typical for MI (substernal, not postional or sharp, resolved with NTG) b. This is not pericarditis because: a.

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

DAIC

JANUARY 3, 2024

Traditional methods of non-invasive ischemia testing (stress EKG , stress echo, SPECT , PET , direct-to-cath) can result in false negatives 20-30 percent of the time, which can lead to undetected disease, and false positives over 50 percent of the time, which can lead to unnecessary invasive procedures. 2021 ACC/AHA Chest Pain Guidelines.

Coronary Artery Disease 59

Coronary Artery Disease Chest Pain Plaque Technology 59

Dr. Smith's ECG Blog

DECEMBER 19, 2018

A middle-aged woman had an acute onset of chest pain and dyspnea. The pain had almost resolved by the time an ECG was obtained in the ED: Here is the computer diagnosis What do you think? This confirms that there were dynamic signs of ischemia on the initial ECG. The ST depression in aVL is also resolved.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 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.

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Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

MARCH 8, 2021

He was a 30-something with chest pain. A male in his 30's complained of sudden severe substernal chest pain. Perhaps they indicate an open artery with minimal flow and severe subendocardial ischemia, but not total subepicardial ischemia. Interventionalist at the Receiving Hospital: "No STEMI, no cath.

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Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

MARCH 11, 2019

The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." Here is the patient's troponin I profile: These were interpreted as due to demand ischemia, or type II MI. ng/mL is seldom a result of demand ischemia (type 2 MI). First was 2.9

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

The patient was promptly admitted to the hospital for further evaluation. 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 rapidly regained consciousness, reporting no residual pain.

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

Ken Grauer, MD

JULY 22, 2023

The message is clear — If, in a patient with new chest pain — ST-T wave depression is maximal in leads V2 , V3 and/or V4 — consider acute posterior MI until proven otherwise. The C ASE C ontinues : En route to the hospital — another tracing was done 2 minutes after ECG #1.

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Blog Chest Pain STEMI AFIB 78

Dr. Smith's ECG Blog

AUGUST 26, 2019

She did not report any chest pain or pressure. She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? The morphology of STE is not diagnostic of being due to acute transmural ischemia.

Chest Pain 52

Chest Pain STEMI Biomarkers Article 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? ST depression. Myocardial Contusion?

Tachycardia 115

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia. Anything more on history? J Electrocardiol 2013;46:240-8 2.

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Ischemia STEMI Stenosis Chest Pain 52