Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. The pain did not resolve with NTG, and so he went to emergent angiography: 1. LAD: severe in-stent restenosis in the mid (80%) and distal (90%) segment and diffuse disease distally.

Chest Pain 74

Chest Pain Stenosis Stent Stents 74

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 Stent 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

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.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 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 117

Chest Pain Ischemia Echocardiogram Myocardial Infarction 117

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.

Chest Pain 52

Chest Pain Blog Ischemia Article 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

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

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.

Chest Pain 52

Chest Pain STEMI Blog Stents 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?

Chest Pain 52

Chest Pain STEMI Blog Ischemia 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.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

DECEMBER 16, 2019

A 50-something male who is healthy and active with no previous medical history presented with 5 hours of continuous worrisome chest pain. Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated.

Chest Pain 52

Chest Pain Myocardial Infarction Stents Stent 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.

EKG Technician 123

EKG Technician Chest Pain Blog STEMI 123

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.

STEMI 79

STEMI Chest Pain Pericarditis Ischemia 79

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

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.

Chest Pain 129

Chest Pain Myocardial Infarction Blog Stent 129

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.

Chest Pain 111

Chest Pain Pacemaker Ischemia Stent 111

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.

Chest Pain 98

Chest Pain STEMI Stent Stents 98

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.

STEMI 120

STEMI Chest Pain Myocardial Infarction Blog 120

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 81

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.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

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

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!

Chest Pain 119

Chest Pain Blog Hospital Tachycardia 119

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.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 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.

Chest Pain 52

Chest Pain Ischemia STEMI Stents 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.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

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. The cath lab was activated, and then not cancelled, and the angiogram showed 99% TIMI 2 flow proximal LAD culprit lesion, stented in less than 90 minutes of arrival. Normal vital signs. Normal vitals. What do you think?

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AFIB Stent Stents Chest Pain 104

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.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. It was stented. This was a large OMI.

Chest Pain 115

Chest Pain STEMI Echocardiogram Stent 115

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.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

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.

Chest Pain 52

Chest Pain Ischemia STEMI Stent 52

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 85

Dr. Smith's ECG Blog

FEBRUARY 18, 2012

A 52 year old woman presented with chest pain. This is typical for subendocardial ischemia, not STEMI, and often means left main ischemia or 3 vessel ischemia. Perusal of her charts revealed that she had an LAD stent that was very close to the ostium of the circumflex. There was some pulmonary edema.

STEMI 52

STEMI Ischemia Chest Pain Stent 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. It was stented.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. She presented to the emergency department after a couple of days of chest discomfort. Are you confident there is no ischemia? Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)?

Tachycardia 118

Tachycardia Electrophysiology Atrial Flutter Ischemia 118

Dr. S. Venkatesan MD

FEBRUARY 25, 2024

It means either a percutaneous coronary intervention with a stent or CABG. Reference : Apart from the heavily quoted classics of COURAGE, BARI-2D, ISCHEMIA, ORBITA 1 etc. You may be. But I am not.You need to undergo some re-vascularisation procedure. What do you mean by that Doctor ? No we can’t.

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Chest Pain Plaque Stent Stents 59

Dr. Smith's ECG Blog

OCTOBER 26, 2011

This 42 yo diabetic male presented with cough and foot pain. In spite of aggressive questioning, he denied chest pain, but he did tell one triage nurse that he had had some chest burning, and so he underwent an ECG: There are deep Q-waves and QS-waves in precordial leads V2-V3, with a bit of R-wave left in V4.

STEMI 52

STEMI Chest Pain Myocardial Infarction Angioplasty 52