Dr. Smith's ECG Blog

AUGUST 24, 2012

A young otherwise healthy man presented with 4 hours of sharp 10/10 substernal chest pain. This ECG is diagnostic of anterior STEMI. But there was some doubt as to whether it might be pericarditis because of the ST elevation in I and II, without ST depression in III. It has been constant since then. BP was 160.

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Pericarditis STEMI Chest Pain Myocardial Infarction 52

ECG Cases

MAY 10, 2023

In this ECG Cases blog we look at 10 cases of patients with chest pain, including false positive STEMI, false negative STEMI, and other causes to help hone your ECG interpretation skills in time-sensitive cases where those very ECG skills might save a life.

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Chest Pain STEMI Blog Pericarditis 52

ECG Cases

NOVEMBER 16, 2021

Jesse McLaren guides us through 9 cases and explains how pericarditis is a diagnosis of exclusion through 3 simple steps: 1. Exclude more serious causes of chest pain, eg wraparound LAD occlusion, inferior OMI 2. Exclude complications of pericarditis, eg myocarditis, large pericardial effusion 3.

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Pericarditis Chest Pain Blog STEMI 52

Dr. Smith's ECG Blog

JUNE 17, 2018

A middle-aged patient with lung cancer had presented to clinic complaining of generalized malaise, cough, and chest pain. Symptoms other than chest pain (malaise, cough in a cancer patient) 2. PR depression, which suggests pericarditis 4. Here is that ECG: What do you think? There is sinus tachycardia.

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Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms.

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Pericarditis Chest Pain Aortic Blog 52

Dr. Smith's ECG Blog

AUGUST 4, 2024

Overall, this looks like one of the rare ECGs that is actually specific for pericarditis in my opinion. QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Pericarditis maybe." There was no prior ECG for comparison.

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Pericarditis Chest Pain Blog Aortic 103

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

This is a value typical for a large subacute MI, n ormal value 48 hours after myocardial infarction is associated with Post-Infarction Regional Pericarditis ( PIRP ). As already mentioned, this patient could have post-infarction regional pericarditis from a large completed MI. Sinus tachycardia has many potential causes. Hammill SC.

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Cardiogenic Shock Pericarditis Chest Pain Myocardial Infarction 109

Dr. Smith's ECG Blog

MAY 16, 2023

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Acute pain?" -(Dr. I immediately responded: "cool fake!

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Chest Pain Pericarditis Tachycardia STEMI 52

Dr. Smith's ECG Blog

APRIL 25, 2023

Healthy male under 25 years old with a pretty good story for acute onset crushing chest pain relieved with nitro. First, many on Twitter said "Pericarditis". This is NOT pericarditis, which virtually NEVER has ST depression any where except aVR. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

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Chest Pain Pericarditis Blog Cardiomyopathy 52

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. She was reportedly "pacing in her room while holding her chest". Clinician and EKG machine read of acute pericarditis.

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Pericarditis Chest Pain Blog Ultrasound 52

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.

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Chest Pain Embolism Pulmonary Tachycardia 141

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. 50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. Pericarditis?

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Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

JULY 19, 2019

Written by Pendell Meyers, with edits by Steve Smith A man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). But it does not meet STEMI criteria and it was not initially recognized.

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Chest Pain STEMI Aneurysm Pericarditis 52

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Here is his initial ED ECG: The R-wave in V4 extends to 33 mm, the computerized QTc is 372 ms The only available previous ECG is from one year ago, during the admission when he was diagnosed with pericarditis: 1 year ago ECG, with clinician and computer interpretatioin of pericarditis Normal 0 false false false EN-US X-NONE X-NONE What do you think?

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Pericarditis Chest Pain Pulmonary Embolism 52

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. 3 hours prior to calling 911 he developed typical chest pain. But it could be anterior STEMI. is likely anterior STEMI).

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Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. At midnight. The case continues. Worrall, C.,

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Myocardial Infarction Chest Pain STEMI Blood Pressure 127

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. Chest pain is squeezing or tight in nature.

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

JULY 18, 2014

A man in his 60's presented after 4 days of chest pain, with some increase of pain on the day of presentation. Exact pain history was difficult to ascertain. Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? There was some SOB. How acute is it?

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STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 10, 2020

He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain. It could also be due to pericarditis or myocarditis, but I always say that "you diagnose pericarditis at your peril." Pericarditis? Learning Points: 1. What happens then?

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Chest Pain Pericarditis Ultrasound Download 40

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

He reports significant chest pain at the base of his scapula on the right side along with new shortness of breath. Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE?

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Chest Pain Myocardial Infarction STEMI Critical Care 118

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Written by Pendell Meyers Two adult patients in their 50s called EMS for acute chest pain that started within the last hour. Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization."

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STEMI Chest Pain Blog Pericarditis 124

Dr. Smith's ECG Blog

JANUARY 17, 2018

A physician caring for his new arrival, a 50-something with acute chest pain and dyspnea and syncope, texted me this initial ED ED ECG. Let's look at the ED ECG more closely: Sinus rhythm There is ST Elevation in anterior leads: V2-V6 There is ST elevation in I, II, aVL Why is this not STEMI? No active chest pain 2.

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Pericarditis Chest Pain STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Apparently he denied chest pain. As always, takotsubo cardiomyopathy and focal pericarditis can mimic OMI, but takotsubo almost never mimics posterior MI, and both are diagnoses of exclusion after a negative cath. JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain.

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Dr. Smith's ECG Blog

OCTOBER 5, 2011

T-wave to ST ratio is greater than 4 in lead V6, making pericarditis unlikely (also there were no symptoms of pericarditis). It turns out that this was a 27 yo African American male who presented with pressure-like (non-pleuritic) chest pain and dyspnea. Would you be certain that it is not STEMI? mm in V3, 2.5

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Dr. Smith's ECG Blog

OCTOBER 17, 2022

In fact, there was no chest pain either. If you were thinking that this is not anterior OMI because there is no reciprocal ST depression , it is important to remember that half of anterior STEMI do NOT have any reciprocal ST depression. Pericarditis? P.S.: Acute pericarditis may produce diffuse ST elevation.

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Pericarditis Chest Pain Blog Arrhythmia 52

Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. Haven't you been taught that this favors pericarditis? Weren't you taught that concave morphology favors pericarditis? This is a high troponin (most STEMI are above 10 ng/mL for troponin I). There is no STE or STD in III an aVF.

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Pericarditis STEMI Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

MARCH 3, 2023

Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO). At each step, you will also find active links to the original publications.

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Dr. Smith's ECG Blog

JANUARY 28, 2018

The STD in V2-V4 is almost certainly reciprocal STD, reciprocal to STEMI in the posterior wall; this is evident because it is maximal in V2-V4, not in V4-V6. In patients with suspicion of acute MI who have any ST elevation, aVL is also a very useful lead to differentiate between pericarditis and MI. mm ST depression in aVL.

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Dr. Smith's ECG Blog

MARCH 11, 2016

A middle-aged woman had intermittent angina for 48 hours, then onset of constant, crushing chest pain for 1.5 cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." of AMI patients and is often preceded by postinfarction regional pericarditis (PIRP).

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Dr. Smith's ECG Blog

NOVEMBER 13, 2022

A 50 something-year-old man with a history of newly diagnosed hypertension and diabetes, for which he did not take any medication, presented a non-PCI-capable center with a vague, but central chest pain. Such an out-of-proportion STE is virtually never seen in pericarditis. STE in lead I and II are more subtle.

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Chest Pain Myocardial Infarction Blog Pericarditis 52

Dr. Smith's ECG Blog

MARCH 11, 2019

You do NOT see this in normal variant STE, nor in pericarditis. At some point he returned with chest pain, and all these findings were put into place. Many MI do not have chest pain 4. Smith noted in his Learning Points about this Case that, “Many MIs do not have chest pain”.

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Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 12, 2023

Written by Pendell Meyers, edits by Smith Two patients presented with acute chest pain/pressure. ECG read as: "Shows T wave inversions in the inferior leads and less than 1mm STE in V2, without STEMI criteria." Two patients with chest pain. She had an acute LAD OMI in the process of reperfusion, see case below.

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Chest Pain STEMI Blog Stenosis 52

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. Chest pain, SOB, Precordial T-wave inversions, and positive troponin. What is the Diagnosis? Now another, with ultrasound.

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Dr. Smith's ECG Blog

FEBRUARY 29, 2016

He denied fevers and chills, abdominal pain, chest pain, or SOB. It is uncommon in the age of reperfusion therapy, as most STEMI get treated reasonably early, before transmural infarct. Patients with completed, transmural infarct are also at risk for post-infarction regional pericarditis and myocardial rupture.

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Dr. Smith's ECG Blog

JANUARY 17, 2024

Written by Jesse McLaren Two patients presented with acute chest pain, and below are the precordial leads V1-6 for each. Patient 1 Patient 2 STEMI criteria is based only ST elevation millimeter criteria measured in isolation from the QRS and stratified by age/sex, so this is the only information provided above.

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Chest Pain STEMI Myocardial Infarction Blog 108

Dr. Smith's ECG Blog

NOVEMBER 30, 2024

Written by Jesse McLaren, with edits from Meyers Four patients presented with chest pain or shortness of breath, and ECGs labeled ‘inferior STEMI’. Less concavity associated with hyperacuity This can help identify false negative STEMI, or STEMI(-)OMI, at risk for delayed reperfusion. More asymmetry 3.

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