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The patient was a middle-aged female who had acute chestpain of approximately 6 hours duration. The pain was still active at the time of evaluation. Angiogram reportedly showed acute thrombotic occlusion of the first obtuse marginal which was stented. Peak troponin was not recorded. Long term follow up is unavailable.
A 56 year old male with PMHx significant for hypertension had chestpain for several hours, then presented to the ED in the middle of the night. He reported chestpain that developed several hours prior to arrival and was 5/10 in intensity. The pain was located in the mid to left chest and developed after riding his bike.
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 ( ChestPain ). 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.
Written by Jesse McLaren A healthy 75 year old developed 7/10 chestpain associated with diaphoresis and nausea, which began on exertion but persisted. Below is the first ECG recorded by paramedics after 2 hours of chestpain, interpreted by the machine as “possible inferior ischemia”. What do you think?
This was interpreted by the treating clinicians as not showing any evidence of ischemia. Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. He did not remember whether he had experienced any chestpain. Two subsequent troponins were down trending.
A 63 year old man with a history of hypertension, hyperlipidemia, prediabetes, and a family history of CAD developed chestpain, 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.
A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chestpain. 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.
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 chestpain. 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.
Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chestpain with diaphoresis. The ECG was incorrectly interpreted as no signs of ischemia. The Importance of the History: As noted above — the onset of chestpain in today's case was acute. His vitals were within normal limits.
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 chestpain with paresthesias of the left arm. A repeat ECG was recorded with pain 2/10: Not much change.
While in the ED, patient developed acute dyspnea while at rest, initially not associated with chestpain. He later developed mild continuous chestpain, 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.
Written by Pendell Meyers A woman in her 50s presented with acute chestpain 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.
52-year-old lady presents to the Emergency Department with 2 hours of chestpain, 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.
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.
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.
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 chestpain. There was a 100% proximal LAD occlusion that was opened and stented. The cath lab was activated.
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 chestpain. The chestpain started about one hour prior to arrival while bike riding.
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 chestpain.
A 50-something male who is healthy and active with no previous medical history presented with 5 hours of continuous worrisome chestpain. Chestpain 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.
The patient’s chestpain 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.
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.
On the day of presentation she complained of typical chestpain, 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.
As discussed in many posts in this ECG Blog — despite not satisfying the millimeter-based definition of a STEMI — in this patient with new chestpain, 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 ).
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 chestpain radiating to the left arm, associated with nausea. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI.
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 chestpain relieved by rest. This episode of chestpain began 3 hours ago and was persistent even at rest. Troponin was ordered.
A 60-something awoke with 10/10 crushing chestpain. 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.
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 chestpain. So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent.
Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chestpain 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?
He underwent coronary stenting (uncertain which artery). There is no way to tell the difference between GI etiology of chestpain 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 chestpain are nearly diagnostic of ischemia.
On the second morning of his admission, he developed 10/10 chestpain and some diaphoresis after breakfast. The patient was given opiates which improved his chestpain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chestpain. She is usually incredibly good at recognizing them!
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.
All of the patients presented with chestpain , 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.
Sent by anonymous, written by Pendell Meyers Case 1: A man in his 50s presented with acute chestpain. 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?
The impact of this narrowing can ultimately result in angina (chestpain), which has been shown to double the risk of major cardiovascular events,1 as well as myocardial infarction ( heart attack ) or even death.
A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chestpain. 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.
There was no chestpain 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 chestpain, one must be skeptical of such a diagnosis.
This male in his 40's had been having intermittent chestpain for one week. He awoke from sleep with crushing central chestpain 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.
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 chestpain while chopping wood around noon. It was stented. This was a large OMI.
Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chestpain and collapsed, and had bystander CPR. On arrival, GCS was 13 and the patient complained of ongoing chestpain. So the RCA was stented.
A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chestpain 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.
A 50 something male was seen in the emergency room due to typical chestpain. The pain had started the same day about two hours prior to medical contact. The medical care providers ascribed the patient's chestpain to new onset atrial fibrillation with rapid ventricular response after having viewed the ECG.
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.
This means that at every age, the probability a man complaining of chestpain has significant underlying coronary disease as a cause of this chestpain is much higher than a woman complaining of chestpain. Thanks for reading Dr. The data is overwhelming every way you can possibly look at it.
Written by Pendell Meyers A man in his 60s presented with acute chestpain. Total proximal LAD occlusion was found and stented at angiography soon after the ECG above. This distinction is further complicated because marked LVH may at times mask the ST-T wave changes of acute ischemia. There is sinus rhythm with clear LVH.
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