Chest Pain, Ischemia and Thrombosis - Cardiovascular Update

ECG Blog #448 — A Young Man with Chest Pain.

Ken Grauer, MD

SEPTEMBER 21, 2024

For example, considering whatever symptoms that the patient may have had ( ie, chest pain, palpitations, shortness of breath, etc. ) — what this might mean in view of the ECG we are looking at. STEP #2 = Clinical Impression — in which we correlate our assessment that we made in Step #1 to the clinical situation at hand.

Chest Pain

Chest Pain Blog Thrombosis Tachycardia

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

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. The history is concerning ( This patient was awakened from sleep by chest pain that persisted for several hours — on a background of intermittent CP in recent weeks ).

Ischemia

Ischemia Plaque Stenosis Myocardial Infarction

Elder Male with Syncope

EMS 12-Lead

APRIL 9, 2024

There was no chest pain. V1 and V2 are probably placed too high on the chest given close morphological similarity to aVR. More detailed reviews of subendocardial ischemia, as well as acute ECG patterns that breach the typical presentation, can be found here: [link] [link] Imaging revealed no acute head, or spinal, injuries.

Ischemia

Ischemia Stenosis Chest Pain Coronary Artery Disease

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Bridging Innovation & Patient Care: The Growing Role of AI

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A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Dr. Smith's ECG Blog

JANUARY 9, 2023

No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. 24 yo woman with chest pain: Is this STEMI?

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Intravascular Imaging Can Improve Outcomes for Complex Stenting Procedures

DAIC

APRIL 2, 2025

The ECLIPSE trial shows that use of IVI to guide coronary stenting in severely calcified lesions prevents death, stent thrombosis, and unplanned repeat procedures in this high-risk patient population. The ECLIPSE trial results were presented at the American College of Cardiology Scientific Session (ACC.25)

Stent

Stent Stents Outcomes Coronary Angiogram

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

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). The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. He walked in to triage.

Chest Pain

Chest Pain STEMI Stent Stents

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

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. For now she can only say Not OMI.

Chest Pain

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

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. Gottlieb SO, et al.

Chest Pain

Chest Pain Thrombosis Myocardial Infarction STEMI

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Written by Pendell Meyers and Peter Brooks MD A man in his 30s with no known past medical history was reported to suddenly experience chest pain and shortness of breath at home in front of his family. Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain. It is also NOT the clinical scenario of takotsubo (a week of intermittent chest pain).

Plaque

Plaque Chest Pain Thrombosis Stenosis

Critical Left Main

EMS 12-Lead

JULY 24, 2023

But the symptoms returned with similar pattern – provoked by exertion, and alleviated with rest; except that on each occasion the chest pain was a little more intense, and the needed recovery period was longer in duration. It should be known that each category can easily manifest the generic subendocardial ischemia pattern.

Angina

Angina Ischemia Coronary Angiogram Stenosis

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia. Anything more on history? J Electrocardiol 2013;46:240-8 2.

Ischemia

Ischemia STEMI Stenosis Chest Pain

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

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.

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Case An elderly patient had acute chest pain and 911 was called. For this analysis, ACO was defined as angiographic evidence of coronary thrombosis with peak cardiac troponin-I (cTn-I) at least 10 ng/mL or cTn-T ≥ 1 ng/ mL. It is important for cardiologists to realize that a paramedic may see something they do not.

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This is the initial ECG: The QRS is widened with a regular cadence, and there are no discernable P waves.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

Acute Dyspnea in a Dialysis Patient. K is 6.3 mEq/L. Are ECG findings due to hyperkalemia, or even due to Type 2 MI?

Dr. Smith's ECG Blog

JANUARY 21, 2025

He denied chest pain. Time 7 hours lead reversal There is limb lead reversal (QRS in I and aVL are now inverted), but nevertheless one can see that the ischemia appears to have resolved. Negative trops and negative angiogram does not rule out coronary ischemia or ACS. Next day, with K = 4.6 The evidence of OMI is gone.

Chest Pain

Chest Pain STEMI Tachycardia Myocardial Infarction

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

It is possible there is microvascular dysfunction producing residual transmural ischemia. But this is most common when there is prolonged ischemia, and this patient had the fastest reperfusion imaginable! He had no chest pain, dyspnea, or any other anginal equivalent, and his vital signs were normal.

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

ECG Blog #448 — A Young Man with Chest Pain.

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Elder Male with Syncope

Webinars

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Intravascular Imaging Can Improve Outcomes for Complex Stenting Procedures

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Critical Left Main

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Hypertrophic Cardiomyopathy

Acute Dyspnea in a Dialysis Patient. K is 6.3 mEq/L. Are ECG findings due to hyperkalemia, or even due to Type 2 MI?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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