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.

Chest Pain 124

Chest Pain Blood Pressure Ischemia STEMI 124

Dr. Smith's ECG Blog

DECEMBER 14, 2016

A middle aged male presented at midnight after 14 hours of constant, severe substernal chest pain, radiating to his throat and to bilateral jaws, and associated with diaphoresis. The pain was not positional, pleuritic, or reproducible. The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI?

Chest Pain 52

Chest Pain STEMI Aortic Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 27, 2023

I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI. The patient's nitro was dialed up to 100 mcg/min but the pain persisted. I was reading ECGs on the system, and saw this one: What do you think?

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

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 chest pain. The chest pain started about one hour prior to arrival while bike riding.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor STEMI 52

Dr. Smith's ECG Blog

JUNE 11, 2011

Is this an anterior STEMI with LBBB? Explanation : The patient had a worrisome history: 59 yo with significant substernal chest pressure, so his pretest probability of MI (and even of STEMI) is reasonably high. Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion.

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

APRIL 22, 2019

He then went on to say: "40-something with chest pain for one hour. Burning pain subxiphoid and into throat." Still does not meet STEMI criteria, but it is an obvious OMI And then another one became more obvious: Cath lab was activated and a 100% RCA occlusion was found. Sounds like reflux, right? Learning Points: 1.

Chest Pain 52

Chest Pain Arrhythmia Ischemia STEMI 52

Dr. Smith's ECG Blog

JULY 5, 2013

Right bundle branch block (RBBB) and left anterior fascicular block (LAFB) with very high voltage, consistent with RV hypertrophy (RVH) due to Tetralogy (remember there is a constricted outflow tract of the pulmonary artery, leading to RV hypertrophy.) There is no initial r-wave of the rSR' - there are initial Q-waves.

Chest Pain 52

Chest Pain STEMI Pulmonary 52

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. In patients with narrow QRS ( not this patient), this pattern is highly suggestive of acute pulmonary embolism. Of course it would also be nice to know about the patients oxygenation: in acute MI there is no hypoxia unless it results in pulmonary edema.

Cardiogenic Shock 126

Cardiogenic Shock Ultrasound Pulmonary Tachycardia 126

Dr. Smith's ECG Blog

MAY 10, 2014

A male in his late 30's to early 40's presented with 24 hours of intermittent typical chest pain. The following ECG was recorded: There is an obvious acute inferior STEMI. Whenever there is inferior STEMI, one should think about Right Ventricular STEMI (RVMI). and STE in lead III > STE in lead II.

STEMI 40

STEMI Chest Pain Pulmonary Ultrasound 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?

Chest Pain 115

Chest Pain Myocardial Infarction STEMI Pericarditis 115

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

large ASD, partial anomalous pulmonary venous return, significant tricuspid regurgitation, carcinoid valvular disease, etc,) 2) Conditions causing pressure overload of the RV. Any cause of pulmonary hypertension. Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). The LV EF was 57% at formal echo.

Pulmonary 115

Pulmonary Chest Pain Tricuspid Cardiogenic Shock 115

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. He later developed mild continuous chest pain, that he describes as the sensation of someone standing on his chest. Xray was consistent with pulmonary vascular congestion. 40 mg of furosemide was given.

Chest Pain 117

Chest Pain Ischemia Echocardiogram Myocardial Infarction 117

Dr. Smith's ECG Blog

APRIL 26, 2017

There was no chest pain or SOB at the tim of the ECG: Computerized QTc is 464 ms A previous ECG from 8 years prior was normal. This meets "STEMI criteria" However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4. The morphology is not right for STEMI. What do you think?

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. I wonder if this patient had pulmonary disease? Here is that ECG: Original ECG What do you think? All intervals ( PR-QRS-QTc ) are normal.

Hospital 76

Hospital Chest Pain Blog Pulmonary 76

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?

Ischemia 40

Ischemia Pulmonary STEMI Chest Pain 40

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

FEBRUARY 18, 2012

A 52 year old woman presented with chest pain. There was some pulmonary edema. This is typical for subendocardial ischemia, not STEMI, and often means left main ischemia or 3 vessel ischemia. Right sided ECGs are best recorded in the context of inferior STEMI. AT&T surprised me with their reach.

STEMI 52

STEMI Ischemia Chest Pain Stent 52

Dr. Smith's ECG Blog

JUNE 27, 2021

A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away. A chest X-ray was obtained: This was read by radiology as "Bilateral lower lobe interstitial opacities.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

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.

Pericarditis 52

Pericarditis Chest Pain Aortic Blog 52

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI. The ST/T ratio in V6, however, is slightly greater.

Pericarditis 52

Pericarditis Chest Pain Pulmonary STEMI 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." Chest x-ray was read as normal. CT pulmonary angiogram was negative for pulmonary embolism.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

MARCH 11, 2019

At some point he returned with chest pain, and all these findings were put into place. Many MI do not have chest pain 4. The computerized interpretation for this tracing was, “Sinus rhythm; Normal ECG” — and attention of acute care providers was apparently focused on attending to this patient’s pulmonary problems.

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

MARCH 30, 2014

Then the notes mention "cardiogenic shock" but without any reference to a cardiac echo or to a chest x-ray. Was there pulmonary edema? Now chest pain free. Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI. Then they were worried about sepsis as an etiology of hypotension.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

JUNE 20, 2020

The medics were worried about STEMI, as it meets STEMI criteria. He denied chest pain or dyspnea throughout. The troponins are NOT consistent with STEMI (OMI), which typically has a troponin I of at least 5 ng/mL. There was no prodrome and no associated symptoms such as SOB or CP. What do you think? There is LVH.

STEMI 52

STEMI Hospital Coronary Angiogram Dysrhythmia 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What do you see?

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

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.

Chest Pain 117

Chest Pain STEMI Myocardial Infarction Blog 117

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity. Which is true.

Chest Pain 120

Chest Pain STEMI Hypertension Blog 120

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.

Chest Pain 138

Chest Pain Embolism Pulmonary Tachycardia 138

Dr. Smith's ECG Blog

DECEMBER 22, 2022

On his physical examination, cardiac and pulmonary auscultation was completely normal. As his pain was very severe, emergency physicians concerned of aortic dissection and ordered a thoracic CT scan. Bi-phasic scan showed no dissection or pulmonary embolism. The pain was completely resolved after coronary intervention.

STEMI 52

STEMI Chest Pain Myocardial Infarction Echocardiogram 52

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

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? He had recently had a NonSTEMI.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

JULY 7, 2013

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. How old is this antero-inferior STEMI? There was some SOB. Could it be acute (vs. Very unlikely.

STEMI 52

STEMI Myocardial Infarction Pericarditis Ultrasound 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?

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 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. CT angiogram showed extensive saddle pulmonary embolism. He had multiple cardiac arrests with ROSC regained each time.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Ken Grauer, MD

JUNE 6, 2023

I've previously discussed the interesting correlation of a qR pattern in lead V1 in patients with RVH — as strongly suggesting associated pulmonary hypertension ( See ECG Blog #234 and Blog #248 ). But limitation of this ST elevation to a single lead is not consistent with any distribution of a STEMI.

Blog 78

Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52