Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The patient continued having chest pain. Is there STEMI? Fortunately the patient was then taken for angiography.

Chest Pain 107

Chest Pain Arrhythmia Myocardial Infarction STEMI 107

Dr. Smith's ECG Blog

AUGUST 6, 2024

Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( Chest Pain ). In any case, the ECG is diagnostic of severe ischemia and probably OMI. All ECGs were recorded by EMS, and transferred to a PCI capable center for evaluation.

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Written by Jesse McLaren Four patients presented with chest pain. 4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6]

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Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity.

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Chest Pain STEMI Hypertension Blog 121

Dr. Smith's ECG Blog

MARCH 22, 2024

Written by Willy Frick A man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible.

Chest Pain 114

Chest Pain STEMI Bradycardia Ischemia 114

Dr. Smith's ECG Blog

JUNE 13, 2024

Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chest pain that started 2-3 hours earlier while sitting on a porch swing. V1 sits over both the RV and the septum, so transmural ischemia of either one with give OMI pattern in V1 and reciprocal STD in V5 and V6.

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Chest Pain Document STEMI Defibrillator 92

ECG Cases

DECEMBER 20, 2022

Jesse McLaren discusses some key aspects of cocaine chest pain ECG interpretation in this month's blog including: Patients with cocaine-associated chest pain require benzodiazepines +/- nitroglycerine for symptom relief, aspirin and ECG to look for signs of occlusion and reperfusion.

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Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

MAY 20, 2024

A 63 year old man with a history of hypertension, hyperlipidemia, prediabetes, and a family history of CAD developed chest pain, shortness of breath, and diaphoresis after consuming a large meal at noon. He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.

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Chest Pain Blood Pressure Ischemia STEMI 126

Dr. Smith's ECG Blog

MAY 31, 2023

A 67 yo f developed chest pain this morning." Cath lab declined as it is not a STEMI." There is probably a trickle of flow which is why there is both subendocardial ischemia (ST depression) and early subepicardial ischemia (hyperacute T-waves). See this case: A man his 50s with chest pain.

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STEMI Chest Pain Myocardial Infarction Ischemia 96

Dr. Smith's ECG Blog

JANUARY 25, 2017

A 20-something male drank heavily of ethanol and used cocaine, then was involved in a stressful verbal altercation, at which time he developed chest pain. 911 was called and the medics recorded this ECG (unfortunately, leads V4-V6 are missing) Due to marked ST Elevation, the computer read was STEMI What do you think?

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 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. OMI or STEMI? What do you think?

Chest Pain 52

Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

JANUARY 3, 2024

Written by Pendell Meyers A woman in her 70s had acute chest pain and called EMS. Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Ongoing OMI.

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STEMI Chest Pain Ischemia Outcomes 103

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He was given aspirin and sublingual nitro and the pain resolved. Another ECG was recorded after the nitroglycerine and now without pain: All findings are resolved. This confirms that the pain was ischemia and is now resovled.

Ischemia 122

Ischemia Plaque Stenosis Myocardial Infarction 122

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

MARCH 1, 2023

Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms. During active chest pain an ECG was recorded: Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF.

Chest Pain 52

Chest Pain Ischemia Tachycardia Stenosis 52

Dr. Smith's ECG Blog

MARCH 27, 2025

Theres ST elevation in V3-4 which meets STEMI criteria, which could be present in either early repolarization, pericarditis or injury. Lets see what happens in the current STEMI paradigm. Emergency physician: STEMI neg but with elevated troponin = Non-STEMI The first ECG was signed off. Chest pain still persists.

STEMI 52

STEMI Chest Pain Pericarditis Ischemia 52

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.

STEMI 121

STEMI Chest Pain Myocardial Infarction Blog 121

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. LVH and the diagnosis of STEMI - how should we apply the current guidelines? In LVH, T-wave inversions are usually much more assymetric , like these (Figure 2): Acute Chest pain, but baseline ECG.

Ischemia 52

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.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

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 Lupu L, et al.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

MARCH 27, 2023

I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI. Here is the history: A 40-something male had intermittent chest discomfort until 90 minutes prior to presentation, when it became constant.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 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. These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). Ischemic Hyperacute T waves (Tall, round, symmetric, vs the “pointy” peaked-T’s of HyperK), are often a clue to ischemia.

Chest Pain 52

Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This is another case written by Pendell Meyers (who is helping to edit the blog and has many great recent posts) Case A 45 year old man was driving to work when he experienced acute onset sharp left sided chest pain with paresthesias of the left arm. A repeat ECG was recorded with pain 2/10: Not much change.

Chest Pain 52

Chest Pain STEMI Defibrillator Blog 52

Dr. Smith's ECG Blog

MAY 23, 2014

This case shows a CT image of subendocardial ischemia. This patient presented with a mechanical fall and had chest pain. His chest pain increased and this ECG was recorded: Now there is increasing inferior ST elevation. This is all but diagnostic of inferior-posterior STEMI. There is ST depression in V4-V6.

Ischemia 52

Ischemia Chest Pain STEMI Outpatient 52

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. If it is STEMI, it would have to be RBBB with STEMI. Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. Only 5-18% of ED patients with chest pain have a myocardial infarction of any kind. Ischemia/infarction.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. It was signed off by an emergency physician as “STEMI negative” because it did not meet STEMI criteria.

Chest Pain 52

Chest Pain STEMI Ischemia Stenosis 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chest pain with diaphoresis. The ECG was incorrectly interpreted as no signs of ischemia. The Importance of the History: As noted above — the onset of chest pain in today's case was acute. His vitals were within normal limits.

Chest Pain 52

Chest Pain Physiology Blog Stents 52

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 ). ECG Blog #184 — illustrates the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL ( featured in Audio Pearl #2 in this blog post ).

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Blog STEMI Ischemia Chest Pain 152

Dr. Smith's ECG Blog

MARCH 8, 2019

A previously healthy middle-aged male presented shortly after the acute onset of chest pain very shortly before calling 911. On arrival, he was pain free: What do you think? Jerry Jones commented: "Any ST depression on the ECG of a patient with chest pain credible for ACS represents a reciprocal change until proved otherwise."

Chest Pain 52

Chest Pain STEMI Plaque Ischemia 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). Because the patient had no chest pain or shortness of breath, they were initially diagnosed as gastroenteritis. Potassium was normal. Take home 1.

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Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

JULY 30, 2023

Written by Pendell Meyers A woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. The STD maximal in V1-V4 is diagnostic of acute transmural posterior wall ischemia, most likely due to posterior OMI. It does not meet STEMI criteria. Subendocardial ischemia does not localize.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 52

Ken Grauer, MD

AUGUST 26, 2023

These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ). Figure-2: Comparison between the 2 ECGs recorded in today's case.

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Blog Chest Pain STEMI Ischemia 145

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

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.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 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. Is this Acute Ischemia? When is it anterior STEMI?

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

ECG Cases

SEPTEMBER 23, 2019

In EM Cases' first ECG Cases blog we review 7 examples of ECGs of patients presenting to the ED with chest pain, who's ECG were read as normal by the computer. And guess what.they all show acute ischemia!

Ischemia 52

Ischemia Chest Pain Blog STEMI 52

Ken Grauer, MD

DECEMBER 8, 2023

For full discussion of this case — See ECG Blog #292 — == The 2 ECGs shown in Figure-1 were obtained from a man in his 30s — who presented to the ED ( E mergency D epartment ) with chest pain that began several hours earlier. ECG #2 was recorded 1 hour after ECG #1. Initial troponin was negative.

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Blog Chest Pain STEMI Ischemia 164