Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He was given aspirin and sublingual nitro and the pain resolved. Conversely, pathological evaluation, as shown in Fig 2, will correctly identify the percentage of cross-sectional area occupied by plaque. He was started on nitro gtt.

Ischemia 121

Ischemia Plaque Stenosis Myocardial Infarction 121

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

Chest Pain 52

Chest Pain SCAD STEMI Blog 52

Ken Grauer, MD

FEBRUARY 3, 2024

Despite the absence of significant coronary stenosis on her post-arrest cath — the ECG in Figure-1 is clearly diagnostic of an extensive anterolateral STEMI ( presumably from acute LAD [ L eft A nterior D escending ] coronary artery occlusion). The rhythm in ECG #1 is regular and supraventricular at a rate of ~75/minute.

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Blog Cardiac Arrest STEMI Plaque 162

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 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

He did not state he had chest pain, but, then again, he couldn't remember anything. This is as clear a STEMI as you can get. So this is classic inferoposterior STEMI on the ECG but is NOT acute coronary syndrome! This 80 year old with a history of CABG had a cardiac arrest.

Cardiac Arrest 52

Cardiac Arrest STEMI Ultrasound Chest Pain 52

Dr. Smith's ECG Blog

JULY 31, 2013

A 20-something male presented from an outside facility with Chest pain. He came with this ECG from the outside facility, recorded 1 hour after pain onset: There is at least 2 mm of inferior ST elevation, with reciprocal ST depression in aVL, ST flattening in V4-V6, and T-wave inversion in V2. Vital signs were normal.

Chest Pain 52

Chest Pain Aneurysm STEMI Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. Here is the clinical story: A 40 year old male with no cardiac history presented with acute substernal chest pain that started 40 minutes prior to arrival. This ECG was texted to me with no other information. What did I say?

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STEMI Stenosis Plaque Chest Pain 130

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).

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Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. He described it as "10/10" intensity, radiating across his chest from right to left. This is written by Willy Frick, an amazing cardiology fellow in St.

Plaque 127

Plaque Angina Blog Stents 127

Dr. Smith's ECG Blog

JANUARY 5, 2024

The patient said his chest pain was 4/10, down from 8/10 on presentation. Although it is statistically unlikely, multiple plaque ruptures are possible. The PDA plaque was also bulky, but was not described as inflamed or ulcerated. The PDA plaque was also bulky, but was not described as inflamed or ulcerated.

Angina 120

Angina Plaque Document Stents 120

Dr. Smith's ECG Blog

FEBRUARY 20, 2009

Here is a case of an 89 year old woman who had syncope but no chest pain or shortness of breath. There was a ruptured plaque with thrombus in the LAD, with some flow still (accounting for the inverted T waves). Learning point: some EKGs represent STEMI no matter what the symptoms, until proven otherwise by angiography.

Chest Pain 52

Chest Pain STEMI Ischemia Plaque 52

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.

Chest Pain 82

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 82

Dr. Smith's ECG Blog

MAY 10, 2023

A 34 yo woman with a history of HTN, h/o SVT s/p ablation 2006, and 5 months post-partum presented with intermittent central chest pain and SOB. She had one episode of pain the previous night and two additional episodes early on morning the morning she presented. Deep breaths are painful and symptoms come and go.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), In Septal STEMI , transmural ischemia of the septum is recorded by the overlying lead V1 as ST Elevation. Lead III is also on the right and might manifest ST Elevation in Septal STEMI. with ADDED STE in III?

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Ischemia Pulmonary STEMI Chest Pain 40

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI.

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Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

MARCH 27, 2018

The chief complaint was "chest pain." Of course, it is actually clearly an acute inferior MI, even though (as is so frequent) it does not meet "STEMI criteria." Male patient: I went back to the room of the first patient and he stated that he had been having chest pain on and off for 3 days. Learning Points 1.

Chest Pain 52

Chest Pain Myocardial Infarction Plaque STEMI 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. Again, cath lab was not activated. Take Another Look at Figure-1.

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SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

This is why it is essential that the OMI/NOMI paradigm replace the STEMI/NonSTEMI paradigm. Under Non-STEMI, this patient would not have intervention until at least 20 hours (next day), after the infarct is completed. Acute MI due to plaque rupture does happen in young people, including young women. Learning Points: 1.

Chest Pain 52

Chest Pain Critical Care STEMI Plaque 52

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 She was having a transient STEMI, briefly. It did not progress to full STEMI with loss of the anterior wall, as in this case. Also, persistence of a pain free state does not guarantee an open artery.

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STEMI Chest Pain Hospital Risk Factors 40

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?

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. Values: STE60V3 = 2.0, It was stented.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

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.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

MARCH 19, 2025

Influenza-like illness can also trigger plaque rupture. STEMI criteria are only 43% sensitive for OMI. He was given two separate sprays of nitroglycerin sublingually, neither of which improved his pain but did cause him to become briefly hypotensive ( 600 ng/L. But in 34% there is persistent occlusion at next day angiogram.

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Chest Pain STEMI Stents Stent 116

Dr. Smith's ECG Blog

APRIL 13, 2025

A man in his early 30s was walking when he developed central chest pain which was non-radiating, then had a syncopal event with bowel incontinence, and when he woke up he had ongoing chest pain. Notes never having symptoms like this before, pain is so severe its causing SOB. He called 911. Embolism with lysis.

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Chest Pain Embolism STEMI Plaque 84

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

Written by Willy Frick A young woman with a history of paroxysmal nocturnal hemoglobinuria presented with acute substernal chest pain. The report describes heavy plaque in the proximal RCA by IVUS, but no lesions in the previously occluded RPL branch and no stent was deployed. It is consistent with an inferior LV aneurysm.

Chest Pain 66

Chest Pain Hospital Anatomy Aneurysm 66

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Case 1: 20-something woman with chest pain Case 2: 50-something man with chest pain Case 1 A 20-something yo woman presented in the middle of the night with severe crushing chest pain. They also recommended a NTG drip, after which she reported complete resolution of pain. She was a walk-in at triage.

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Chest Pain STEMI Aortic Ultrasound 105

Dr. Smith's ECG Blog

MARCH 1, 2025

A 50 something male presented in the evening to ED for evaluation of chest pain that started at 1600. Note: the 2022 ACC Expert consensus Chest pain guidelines state that "posterior STEMI-Equivalent" is a sign of acute coronary occlusion. The chest pain continued for hours. NSTEMI-OMI").

Chest Pain 121

Chest Pain STEMI Stents Stent 121

Dr. Smith's ECG Blog

MARCH 17, 2025

Written by Willy Frick A man in his 60s with a history of hypertension and 40 pack-year history presented to the ER with 1 day of intermittent, burning substernal chest pain radiating into both arms as well as his back and jaw. In the world of STEMI, we are incapable of recognizing the first ECG as a false negative.

STEMI 81

STEMI Chest Pain Myocardial Infarction Document 81

Dr. Smith's ECG Blog

JANUARY 21, 2025

He denied chest pain. This was attributed to a "Type 2 MI", which is acute MI that is not due to ruptured plaque, but rather due to "supply demand oxygen mismatch". Most MINOCA is due to ruptured plaque with thrombus that lyses and does not leave behind a visible culprit. See these posts: Dynamic OMI ECG.

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Chest Pain STEMI Tachycardia Myocardial Infarction 61

Dr. S. Venkatesan MD

JANUARY 22, 2025

The fear comes built in with the diagnosis often amplified by young felllows on call (& often times by senior consultants as well) It may appear real, from a clinical angle, but trust, when we deal with the whole gamut of so-called ACS (other than STEMI), there is indeed a benign face in many of them.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Anatomy Angina 52

Dr. Smith's ECG Blog

MARCH 8, 2025

He had no chest pain, dyspnea, or any other anginal equivalent, and his vital signs were normal. Mechanisms of plaque formation and rupture. Coronary plaque disruption. Just a few weeks ago, I took care of a patient who had ostial RCA OMI (TIMI 0 at cath) and his only complaint was syncope! link] Bentzon, J.

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75