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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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.

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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

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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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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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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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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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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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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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 Attack Heart attacks Coronary Artery Disease 111

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 87

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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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 117

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 Stents 103

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 Stents Stent 82

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 Stents 121

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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Dr. Anish Koka

MAY 16, 2023

This means that at every age, the probability a man complaining of chest pain has significant underlying coronary disease as a cause of this chest pain is much higher than a woman complaining of chest pain. Thanks for reading Dr. The data is overwhelming every way you can possibly look at it.

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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. 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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Plaque Chest Pain Stents Stent 59

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.

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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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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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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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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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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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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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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. Paddy Barrett

AUGUST 1, 2023

Share Chest Pain Symptoms There is no role for CT Calcium Scoring in the setting of someone with chest pain symptoms suspected to be from a narrowed coronary artery. Regardless, if you present with chest pain and get a stress test instead of a CTCA, you are arguably getting an inferior test. I would say yes.

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Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The initial troponin I returned at 1500 ng/L and another ECG was recorded as the patient complained of 9/10 chest pain at 10 hours after the first Now the T-wave in III is fully upright, suggesting re-occlusion.

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Dr. Smith's ECG Blog

MARCH 9, 2017

Case A 42-year-old lady presented to the ED with complaints of intermittent episodes of chest pain associated with shortness of breath for the last 2 days. This was her ECG (it is unclear if this was with or without pain): Computerized ECG Read: “Normal sinus rhythm. This case was written by Sam Ghali: ( @EM_RESUS ). Normal ECG.”

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Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain.

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STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Case A 47 year old male called 911 for severe chest pain. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. It was opened and stented.

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Dr. Smith's ECG Blog

MARCH 19, 2023

It was opened and stented. The reason the initial ECG is so concerning — is that it already suggests high likelihood of OMI ( = O cclusion-based MI ) in this 50-ish year old man who presents with a 2-hour history of new chest pain. Formal bubble contrast echo: The estimated left ventricular ejection fraction 57%.

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Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

Troponin profile The patient underwent angiography and had a 90% thrombotic proximal LAD lesion that was stented. This patient's ischemia was so brief that it did not cause any myocardial stunning. This patient's ischemia was so brief that it did not cause any myocardial stunning. The QTc is normal. R wave progression is normal.

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Dr. Smith's ECG Blog

MARCH 20, 2023

Angiogram soon after (around 4 hrs after presentation) showed multi vessel CAD, with culprit lesion total occlusion of the first obtuse marginal branch (OM1), which was stented. For clarity in Figure-1 — I've reproduced the initial ECG in today's case, together with the mirror -image of the chest leads to the right in this Figure.

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Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). Later on during the night of his admission he had a short episode of chest pain that resolved with sublingual nitroglycerin. His vitals were initially normal.

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