Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. He described his chest pain as pleuritic and reported that it started the day prior while swinging a golf club. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive.

Chest Pain 60

Chest Pain Pericarditis Pacemaker STEMI 60

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. He had no chest pain. Is this acute STEMI? Is this an acute STEMI? -- Unlikely! The hypertension alone is the likely etiology of the pulmonary edema.

STEMI 52

STEMI Pulmonary Stents Stent 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. She is somewhat hypertensive, but her vital signs are otherwise normal. These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). In STEMI, they are generally upright and large in proportion to the QRS.

Chest Pain 52

Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

MAY 11, 2019

male was sitting at a work conference when he began having substernal chest pain with diaphoresis. He had a history of hypertension, but no history of heart problems. The pain was 7 out of 10 when this ECG was recorded: The QTc = 375 What do you think? Since the threshold for "STEMI" is 2.0 LAD occlusion.

Chest Pain 52

Chest Pain STEMI Stent Stents 52

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. When is it anterior STEMI? More on LVH.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 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. The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI?

Chest Pain 52

Chest Pain STEMI Aortic Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

Case submitted by Rachel Plate MD, written by Pendell Meyers A man in his 70s presented with chest pain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. He had history of prior MIs and CABG, as well as diabetes, hypertension, and hyperlipidemia.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart Attack 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

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. What About Lead V4?

Chest Pain 52

Chest Pain STEMI Stents Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

MAY 5, 2024

He learned more about the patient: A 77 year old female with a past medical history of hypertension and hyperlipidemia presented to the ED at around 0520 after waking up at 0400 with 10/10 chest heaviness radiating to both arms. The patient had continued to have chest pain.

EKG Technician 123

EKG Technician Chest Pain Blog STEMI 123

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

Written by Pendell Meyers, few edits by Smith A man in his 60s with history of stroke and hypertension but no known heart disease presented with chest pain that started on the morning of presentation at around 8am. Obvious inferoposterior STEMI. Here is his triage ECG when he presented at 1657: What do you think?

STEMI 52

STEMI Chest Pain Myocardial Infarction Document 52

Dr. Smith's ECG Blog

APRIL 2, 2014

A male in his 60's called 911 for chest pain. He had some cardiac risk factors including hypertension, on meds, but no previous coronary disease. His pain was intermittent and he was vague about when it was present and when it was resolved. Here is his prehospital ECG: Diagnosis?

STEMI 52

STEMI Ischemia Chest Pain Angioplasty 52

Dr. Smith's ECG Blog

OCTOBER 9, 2012

A middle-aged woman with a history of hypertension presented with typical chest pain. Here was her presenting ECG, with chest pain: Inferior leads show hyperacute T-waves and reciprocal STD in aVL, with a reciprocally hyperacute T-wave in aVL. Her BP was 160/80. This is all but diagnostic of inferior OMI.

Chest Pain 52

Chest Pain Bradycardia STEMI Hypertension 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast.

Chest Pain 119

Chest Pain Blog Hospital Tachycardia 119

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

AUGUST 30, 2020

The computer calls it a STEMI. If it was chest pain it would be more difficult to go with my gut on that." Never chest pain but had to treat as hypertensive emergency. In fact, severe hypertension by itself can lead to greatly increased oxygen demand and type 2 acute MI, sometimes with ST Elevation.

Diabetes 52

Diabetes Chest Pain Hypertension STEMI 52

Dr. Smith's ECG Blog

OCTOBER 15, 2022

As always, LAD OMI need not meet STEMI criteria and usually does NOT! A 50-something with cocaine chest pain and ST Elevation in V1 - V3 This one is very tough. Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6 Case 8. A 49 year old man with chest pain. Chest Pain and RBBB.

Chest Pain 52

Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Written by Willy Frick with edits by Ken Grauer A woman in her 70s with a history of hypertension presented with acute onset shortness of breath. The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI.

Cardiogenic Shock 126

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 126

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. This meets "STEMI criteria" However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4. The morphology is not right for STEMI. What do you think?

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours.

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

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. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

Any cause of pulmonary hypertension. Just the fact of chest pain and highly elevated troponin is enough to activate the cath lab, but here you can see just how subtle hyperacute T-waves can be. Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). Post PCI the patient became gravely hypotensive and "shocky".

Pulmonary 115

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 115

Dr. Smith's ECG Blog

AUGUST 26, 2019

Written by Pendell Meyers A woman in her 70s with diabetes, hypertension, and hyperlipidemia suddenly developed nausea, diaphoresis, and brief syncope while eating at a restaurant. She did not report any chest pain or pressure. This one likely does meet STEMI criteria in II, III, and aVF. Let me know what happens."

Chest Pain 52

Chest Pain STEMI Biomarkers Article 52

Dr. Smith's ECG Blog

DECEMBER 29, 2018

Written by Pendell Meyers A male in his 50s with history of HTN, DM, HLD presented with chest pain of less than one hour duration. Here is a repeat ECG 45 minutes later with persistent chest pain: Obviously progressing into a clear STEMI. Meets formal STEMI criteria in V2-V3.

Chest Pain 52

Chest Pain STEMI Diabetes Hypertension 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.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Sent by anonymous, edited by Pendell Meyers A man in his 50s with history only of hypertension presented with acute chest pain that started 45 minutes prior to presentation while doing yard work. Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI").

STEMI 77

STEMI Myocardial Infarction Ischemia Academic 77

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest. Troponin was ordered.

Chest Pain 81

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 81

Dr. Smith's ECG Blog

OCTOBER 8, 2018

Steffen writes this case: "A few weeks ago I was able to recognize a STEMI because of what I had seen on your blog." "I I have enclosed the ECG from a 50-something year old male who complained of chest pain. He had no further risk factors for atherosclerosis besides hypertension. The rhythm is ventricular bigeminy.

STEMI 52

STEMI Chest Pain Blog Atherosclerosis 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

A middle-aged man presented with 7-8/10 non-radiating chest tightness to the left chest wall, associated with nausea but no diaphoresis, that began while walking approximately 40 minutes prior to arrival at the ED. The pain resolved as he arrived to the emergency department. The patient remained pain free.

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. He went inside and sat down, and the pain slowly subsided over the course of about 30 minutes.

Chest Pain 40

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

Dr. Smith's ECG Blog

FEBRUARY 14, 2020

Crushing Chest pain, but the ECG is not obvious; later there is both RBBB and LBBB 35 yo woman with LAD occlusion manifesting with only hyperacute Ts and inferior ST depression, also missed by computer The pain increased within the first 15 minutes and this repeat ECG was obtained: What is this?

Chest Pain 52

Chest Pain STEMI Anatomy Risk Factors 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain. I need to innoculate you against the subsequent opinions below. From Gue at al.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Case submitted and written by Mazen El-Baba MD, with edits from Jesse McLaren and edits/comments by Smith and Grauer A 90-year old with a past medical history of atrial fibrillation, type-2 diabetes, hypertension, dyslipidemia, presented with acute onset chest/epigastric pain, nausea, and vomiting. link] Harhash AA et al.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JUNE 27, 2021

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. persistent pain despite medical Rx brought emergently to Cath lab." It was not a STEMI) 1.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 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 111

Tachycardia Blog Ischemia Heart Failure 111

Dr. Smith's ECG Blog

JULY 1, 2019

Case 2: sent by Dr. James Alva A man in his 50s with diabetes, hypertension, and hyperlipidemia presented to the ED with chest pain and shortness of breath off and on over the past three days, with associated vomiting. There is also much STE in V3-V6, especially V4-V6, that must be considered to be STEMI.

Chest Pain 52

Chest Pain Ischemia STEMI Blog 52