Dr. Smith's ECG Blog

JANUARY 6, 2023

Submitted and written by Anonymous, edits by Meyers and Smith A 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache. Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 Abstract 556.

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Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

[link] A 30 year-old woman was brought to the ED with chest pain. She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying "I'm just an anxious person." This strongly suggests reperfusing RCA ischemia. Lobo et al.

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Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 5, 2024

The patient presented due to chest pain that was typical in nature, retrosternal and radiating to the left arm and neck. He denied any exertional chest pain. It is unclear if the patient was pain free at this time. The ECG does not show any definite signs of ischemia. The below ECG was recorded.

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Chest Pain Blog Cardiac Arrest Cardiomyopathy 122

Dr. Smith's ECG Blog

JANUARY 2, 2016

A middle aged male presented with chest pain. There may be ischemia present, but it is not evident on the ECG. In LVH, T-wave inversions are usually much more assymetric , like these (Figure 2): Acute Chest pain, but baseline ECG. Here is his ECG ( Figure 1 ): What do you think? All troponins were negative.

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Ischemia Chest Pain STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

A 70-year-old man calls 911 after experiencing sudden, severe chest pain. Computer read: "Non-specific ST abnormality, consider anterior subendocardial ischemia" There are very poor R-waves in V1-V4 suggesting old anterior MI. Firstly, subendocardial ischemia does not localize on 12-Lead ECG. Neth Heart J.

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Chest Pain Myocardial Infarction STEMI Ischemia 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.

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Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 4, 2023

Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chest pain radiating to the neck, associated with shortness of breath. Acute Q waves are a marker of severe ischemia and a predictor for delayed reperfusion. What do you think?

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Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

DECEMBER 16, 2019

This case was texted to me by one of our residency graduates, and with the outcome, so I don't know how I would have interpreted it blindly. A 50-something male who is healthy and active with no previous medical history presented with 5 hours of continuous worrisome chest pain. is worrisome! 21, 2015 post by Dr.

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Chest Pain Myocardial Infarction Stents Stent 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

None of these findings are diagnostic of ischemia, but they should give you a high index of suspicion and prompt serial ECGs at a minimum. He underwent PCI and had a good outcome. Ischemia comes and goes. mm of STE at 60 ms after the J-point in lead V3, 400 ms QTc, and 6 mm of R-wave amplitude in V4. Learning Points: 1.

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Chest Pain Cardiac Arrest Ischemia STEMI 52

Dr. Smith's ECG Blog

JUNE 30, 2023

These were texted to me only with "chest pain." It helps to know that the patient has active chest pain, as Wellen's is a post occlusion (reperfusion) state, with open artery and pain-free. Outcome: Patient ruled out for MI by troponins. And ECGs can change and evolve even when there is no ischemia.

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Chest Pain Blog Ischemia Document 52

Circulation: Cardiovascular Imaging

NOVEMBER 20, 2023

Risk ratios (RRs) and mean differences with 95% CIs were computed for binary and continuous outcomes, respectively.RESULTS:Five randomized controlled trials with a total of 5727 patients were included, of whom 51.1% of patients had evidence of ischemia on a prior functional test. were referred to CCTA and 22.5%

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Chest Pain Myocardial Infarction Cardiovascular Imaging Ischemia 40

Dr. Smith's ECG Blog

MARCH 27, 2025

After only 90 minutes of chest pain, the first troponin was unsurprisingly in the normal range at 11ng/L (normal <26 in males and <16 in females), so the emergency physician waited for repeat troponin. But it was interpreted as no acute ischemia and the patient was referred to cardiology as Non-STEMI. Cardiology aware.

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STEMI Chest Pain Pericarditis Ischemia 80

ECG Guru

JULY 24, 2023

The Patient: A 57-year-old man who complains of a sudden onset of "sharp" chest pain while on a long bike ride. The pain does not radiate, and nothing makes it worse or better. ST depression in the setting of acute transmural ischemia (STEMI) is almost ALWAYS due to reciprocal change. He is pale, cool, and diaphoretic.

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Chest Pain STEMI Ischemia Outcomes 98

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. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS.

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Chest Pain STEMI Myocardial Infarction Blog 98

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.”

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Chest Pain Plaque Coronary Artery Disease Ischemia 105

Dr. Smith's ECG Blog

MAY 31, 2023

A 67 yo f developed chest pain this morning." There is probably a trickle of flow which is why there is both subendocardial ischemia (ST depression) and early subepicardial ischemia (hyperacute T-waves). Opiates are associated with worse outcomes in Myocardial Infarction. Am Heart J. 2005;149:1043–1049.

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STEMI Chest Pain Myocardial Infarction Ischemia 96

Dr. Smith's ECG Blog

JULY 31, 2013

A 20-something male presented from an outside facility with Chest pain. He came with this ECG from the outside facility, recorded 1 hour after pain onset: There is at least 2 mm of inferior ST elevation, with reciprocal ST depression in aVL, ST flattening in V4-V6, and T-wave inversion in V2. Vital signs were normal.

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Chest Pain Aneurysm STEMI Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. The following ECG was obtained.

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Chest Pain Myocardial Infarction Blog Stents 131

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. For now she can only say Not OMI.

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Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

AUGUST 28, 2020

This is ischemia until proven otherwise. A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock. I learned that the patient is on Sotalol for control of PVCs. This explains the long QT.

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Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Dr. Smith's ECG Blog

JULY 14, 2023

Non-randomized trials show better outcomes (neurologic survival) using this device; see this article in Resuscitation: Head and Thorax Elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Finally, head-up CPR (which was not used here), makes for better resuscitation.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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

SEPTEMBER 25, 2024

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 consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

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Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

MARCH 9, 2013

This male in his 40's had been having intermittent chest pain for one week. He awoke from sleep with crushing central chest pain and called ems. EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain. Ischemia may be so brief that Wellens' waves do not evolve 3. Lessons: 1.

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Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

JUNE 12, 2016

There was no chest pain or SOB, at least none reported by Dr. Lee. Answer : There is very abnormal T-wave inversion in aVL which is typical of subtle transmural/subepicardial (due to occlusion) ischemia to the inferior wall. Given that this patient has no chest pain, one must be skeptical of such a diagnosis.

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Chest Pain Ischemia STEMI Stents 52

Dr. Smith's ECG Blog

AUGUST 2, 2024

Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain. In this patient's case, the RV ischemia manifested as dramatic anterior hyperacute T waves. This degree of STE is a bit atypical for LAD ischemia. His ECG is shown below. 118.007305) from Heitner et al. ,

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STEMI Ischemia Blog Chest Pain 119

Dr. Smith's ECG Blog

JULY 14, 2024

Sent by anonymous, written by Pendell Meyers Case 1: A man in his 50s presented with acute chest pain. Click here to sign up for Queen of Hearts Access Case 2: A woman in her 60s presented with acute chest pain. Outcome of case 2? Normal vital signs. Here is his ECG at triage: What do you think? Normal vitals.

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AFIB Stents Stent Chest Pain 105

Dr. Smith's ECG Blog

JANUARY 3, 2024

Written by Pendell Meyers A woman in her 70s had acute chest pain and called EMS. The patient survived with unknown long term outcome. In this older woman with new chest pain — I find it difficult to justify not activating the cath lab. No further ECGs were recorded.

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STEMI Chest Pain Ischemia Outcomes 102

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. This is a case from many years ago that I discovered recently. He had been drinking 5 beers. No pericardial effusion.

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Myocardial Infarction Ischemia STEMI Pulmonary 40

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. Gottlieb SO, et al.

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Chest Pain Thrombosis Myocardial Infarction STEMI 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.

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Coronary Artery Disease Chest Pain Plaque Technology 59

Dr. Smith's ECG Blog

APRIL 2, 2014

A male in his 60's called 911 for chest pain. His pain was intermittent and he was vague about when it was present and when it was resolved. There is about 1 mm of STE in aVR I con sidered but rejected subendocardial ischemia. Is it subendocardial ischemia, or inferior MI? Here is his prehospital ECG: Diagnosis?

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STEMI Ischemia Chest Pain Angioplasty 52

DAIC

FEBRUARY 29, 2024

This year’s theme, “Advancing Cardiovascular Care for All” brings the latest practice-changing breakthroughs, along with top experts debating and discussing outcomes of highly-anticipated clinical trials. 24 from April 6 - 8, 2024 in Atlanta, GA at the Georgia World Congress Center. 24 and find out what it all means for your patients.

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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. Instead, antiarrhythmic drugs such as amiodarone or ß-blockers may be needed — and/or treatment targeted to correcting ischemia. Acute ischemia? Are you worried about OMI in this case?

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Cardiac Arrest Tachycardia Cardiomyopathy Bradycardia 122

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

There is normal R-wave progression in the precordial leads with no evidence of ischemia. 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. Here the image quality is enhanced using the PM Cardio app. What do you think?

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Pulmonary Tricuspid Chest Pain Cardiogenic Shock 116

Dr. Smith's ECG Blog

MARCH 30, 2014

Now chest pain free. After midnight (now day 3), she complains of shoulder pain and dyspnea. Outcome and Analysis: ECG 1 is diagnostic of inferior and right ventricular MI. Furthermore, there are T-wave changes in V2 and V3 which are highly suggestive of ischemia, but difficult to localize: anterior?

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Outcomes Cardiogenic Shock STEMI Chest Pain 52

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.

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Chest Pain STEMI Biomarkers Article 52