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 123

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. A single DES stent was placed, and the patient did well post-procedure.

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Chest Pain Ischemia Myocardial Infarction ICU 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.

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Chest Pain Physiology Stent Stents 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.

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Chest Pain STEMI Defibrillator Stent 52

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. Subendocardial ischemia does not localize. Finally the OMI was realized.

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Chest Pain Ischemia STEMI Arrhythmia 52

Dr. Smith's ECG Blog

SEPTEMBER 27, 2019

An elderly woman presented with chest pain that radiated to the back for several hours. The first troponin returned at 0.099 ng/mL (elevated, consistent with Non-Occlusion MI) Providers were concerned with aortic dissection, so they order a chest aorta CT. Here is here initial ECG: There is only a nonspecific flat T-wave in aVL.

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Chest Pain Blog Ischemia Article 52

Dr. Paddy Barrett

DECEMBER 5, 2023

The logic of stenting obstructed coronary arteries is simple. A stent unblocks the artery. Subscribe now Stenting stable coronary artery disease has not been convincingly proven to reduce the risk of future heart attacks or death 1. But coronary stenting is not the only way to reduce symptoms of angina. All is fixed.

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Stents Stent Angina Heart Attack 59

DAIC

APRIL 11, 2024

PCI is commonly used to open blocked arteries to treat significant myocardial ischemia , which occurs when the heart muscle does not get enough oxygenated blood. During PCI, an operator inserts a stent into a blocked artery through a catheter in the groin or arm.

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Plaque Heart attacks Heart Attack Coronary Artery Disease 111

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.

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Chest Pain Aneurysm STEMI Document 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.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

AUGUST 17, 2019

Chris Mondie of the Newark Beth Israel Emergency Medicine Residency sent this case A 50-something man presented with acute chest pain. It could at least say: "ST Elevation, consistent with normal variant," or "consistent with ischemia or normal variant," or "consistent with early repolarization." How do we do so?

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Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

JULY 11, 2019

Written and submitted by Ashley Mogul, with edits by Pendell Meyers and Steve Smith A man in his 40s with recent smoking cessation but otherwise no known past medical history presented due to chest pain since the previous evening. The pain has been constant and associated with vomiting and diaphoresis.

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Chest Pain STEMI Stents Stent 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, Pericarditis would be even more unlikely in someone without chest pain.

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

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. They agreed ischemia was likely in the setting of demand given DKA and infection.

Chest Pain 101

Chest Pain Ischemia Echocardiogram Myocardial Infarction 101

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient’s chest pain spontaneously resolved before he was evaluated and has a repeat ECG obtained at 22:12 obtained shown below. In context, of course, it is clear that the patient is reperfusing, as pain has dissipated and the diagnostic findings of OMI have become more nonspecific. This ECG is more difficult.

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Chest Pain STEMI Cardiogenic Shock Ischemia 52

Dr. Paddy Barrett

NOVEMBER 28, 2023

One of the most common questions I get is, “ Do I need a stent to treat my heart disease?” ” Typically, several of this person’s friends have had stents, so it seems natural to ask. First, we must understand what a stent is and why it is used. The stent ‘unblocks’ it. Flow is restored.

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Stent Stents Heart attacks Heart Attack 52

Dr. Smith's ECG Blog

MAY 5, 2024

He interprets here: "This EKG is diagnostic of right bundle branch block and transmural ischemia of the anterior wall, most likely from an occlusion of the proximal LAD. The patient had continued to have chest pain. There was a 100% proximal LAD occlusion that was opened and stented. The cath lab was activated.

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EKG Technician Chest Pain Blog STEMI 112

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

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.

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Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 86

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. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI.

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STEMI Chest Pain Myocardial Infarction Stent 117

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent.

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Triage EKG: What do you think?

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Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. Many health care providers will simply not attempt to assess ischemia in the presence of a wide QRS.

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Chest Pain Ischemia Pacemaker Stent 98

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 Stent 115

Dr. Smith's ECG Blog

OCTOBER 24, 2013

He underwent coronary stenting (uncertain which artery). There is no way to tell the difference between GI etiology of chest pain and MI. Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia.

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Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

A 60-something awoke with 10/10 crushing chest pain. I would expect TIMI-3 flow (normal flow, no persistent ischemia) with a culprit in the RCA (or possibly Circumflex). I would expect that a stent would be placed. The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented.

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Chest Pain STEMI Stent Stents 78

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

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. It would be a good topic for study.

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Echocardiogram Ischemia Chest Pain Blog 52

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. A stent was placed. Type B waves are deeper and symmetric. Lessons: 1.

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Myocardial Infarction Chest Pain 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

DAIC

MAY 14, 2024

The impact of this narrowing can ultimately result in angina (chest pain), which has been shown to double the risk of major cardiovascular events,1 as well as myocardial infarction ( heart attack ) or even death.

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Coronary Artery Disease Interventional Cardiology Innovation Physiology 111

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. So the RCA was stented.

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Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

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STEMI Ischemia Chest Pain Myocardial Infarction 52

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 106

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

A 50 something male was seen in the emergency room due to typical chest pain. The pain had started the same day about two hours prior to medical contact. The medical care providers ascribed the patient's chest pain to new onset atrial fibrillation with rapid ventricular response after having viewed the ECG.

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Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 89

Dr. Smith's ECG Blog

SEPTEMBER 6, 2011

Thus, there are some suspicious abnormalities, but no definite signs of ischemia. Because of persistent symptoms, another ECG was recorded 30 minutes later: There is only one new finding on this ECG which suggests ischemia. The difference is significant and highly suggests posterior ischemia. It is very subtle but real.

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Chest Pain Ischemia STEMI Stent 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

All of the patients presented with chest pain , and they are all in triage. The patient was referred immediately for cath which revealed RCA occlusion that was stented. Remember, in diffuse subendocardial ischemia with widespread ST-depression there may b e ST-E in lead s aVR and V1. There is ST depression in V1.

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Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 107