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.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

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. Patients with ACS and acute pulmonary edema 3. It was not relieved by anything.

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Chest Pain STEMI Aortic Pulmonary 52

Dr. Smith's ECG Blog

AUGUST 3, 2018

In the evening, a middle-aged man complained of chest pain at the nursing home. His chest pain was vague. He mentioned "cancer" and "chest". He mentioned "cancer" and "chest". There is a narrow complex tachycardia at a rate of 130. He was awake, with a pulse of 130 and BP of 50/30. Is is sinus?

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Chest Pain Tachycardia Atrial Flutter Ultrasound 40

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

It shows sinus tachycardia with right bundle branch block. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). In patients with narrow QRS ( not this patient), this pattern is highly suggestive of acute pulmonary embolism. Both were wrong.

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Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

Dr. Smith's ECG Blog

JUNE 11, 2011

Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion. Whenever you see tachycardia with bundle branch block, you should suspect that it is rate related BBB. However, he had a left bundle brach block with normal appropriate discordance on 3 EKGs. link] Shvilkin et al.

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Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

AUGUST 14, 2023

Written by Pendell Meyers, with some edits by Smith A man in his 40s with many comorbidities presented to the ED with chest pain, hypotension, dyspnea, and hypoxemia. The bedside echo showed a large RV (Does this mean there is a pulmonary embolism as the etiology?) An 80-something woman who presented with chest pain and dyspnea.

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Chest Pain Pulmonary Sickle Cell Disease Atrial Flutter 52

Dr. Smith's ECG Blog

APRIL 12, 2013

He had no chest pain. He was in acute distress from pulmonary edema, with a BP of 180/110, pulse 110. He had diffuse crackles on exam and B-lines on chest ultrasound, and chest x-ray also confirmed pulmonary edema. Here is his ED ECG: There is sinus tachycardia. The patient was transported to the ED.

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STEMI Pulmonary Stents Stent 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2015

They had already cardioverted at 120 J, then 200 J, which resulted in the following: Ventricular Tachycardia They then cardioverted at 200 J which r esulted in the same narrow complex rhythm shown above, at 185 beats per minute. This would treat both SVT or sinus tachycardia. I suggested esmolol if the heart rate did not improve.

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Tachycardia Chest Pain Pharmacology Myocardial Infarction 52

Ken Grauer, MD

AUGUST 16, 2024

I see the following: There is sinus tachycardia ( upright P wave with fixed PR interval in lead II ) — at the rapid rate of ~130/minute. Sinus Tachycardia and RAD — as already noted above. PEARL # 2: In the absence of associated heart failure ( cardiogenic shock ) — sinus tachycardia is not a common finding in acute MI.

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Blog Tachycardia Cardiogenic Shock Pulmonary 157

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.

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Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

Dr. Smith's ECG Blog

NOVEMBER 17, 2023

Ken (below) is appropriately worried about pulmonary embolism from the ECG. What I had not told him before he made that judgement is that the patient also had ultrasound B-lines of pulmonary edema. Finally, the presentation is dyspnea, not chest pain. What do you think? Also, we know the patient had a stent.

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Aneurysm Stent Stents Chest Pain 124

Dr. Smith's ECG Blog

JUNE 2, 2023

She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? She was awake, alert, well perfused, with normal mental status and overall unremarkable physical exam except for a regular tachycardia, possible rales at both bases, some mild RUQ abdominal tenderness.

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Tachycardia Cardiomyopathy Electrocardiogram Article 96

Dr. Smith's ECG Blog

MARCH 11, 2012

There was no pulmonary edema or hypoxia. Here was his initial ECG: Regular Wide Complex Tachycardia. Blood pressure was 180/80. Cardiac Echo showed excellent hyperdynamic function. The computer read the QRS duration as 160 ms. However, many toxins do not show up on tox screens. Sinus --Irregularly irregular?

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Tachycardia Chest Pain Pulmonary Blood Pressure 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

This 60-something with h/o COPD and HFrEF (EF 25%) presented with SOB and chest pain. Multifocal Atrial Tachycardia 2. P EARL # 4 — In “real life” — there is often NO distinct “cut-off” for differentiating between sinus tachycardia with multiple different-looking PACs vs MAT. Here is the ECG: What do you think?

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Atrial Fibrillation Tachycardia Arrhythmia Pulmonary 52

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. The CXR demonstrated no pulmonary edema. The fall was not a mechanical etiology. He denied any specific prodrome of gross palpitations, however did endorse feeling quite dizzy just before the event.

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Ischemia Stenosis Chest Pain Coronary Artery Disease 116

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

Chest trauma was suspected on initial exam. The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Gunshot wound to the chest with ST Elevation Would your radiologist make this diagnosis, or should you record an ECG in trauma? He was intubated for altered mental status.

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Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 115

Dr. Smith's ECG Blog

APRIL 15, 2019

Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. If a patient presents with chest pain and a normal heart rate, or with shockable cardiac arrest, then ischemic appearing ST elevation is STEMI until proven otherwise.

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Tachycardia STEMI Chest Pain Ischemia 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. CT angiogram showed extensive saddle pulmonary embolism. He had multiple cardiac arrests with ROSC regained each time.

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Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

MARCH 12, 2018

Notice I did not say "pulmonary embolism," because any form of severe acute right heart strain may produce this ECG. This includes, but is not limited to, PE, asthma/COPD exacerbation, hypoxic vasoconstriction from pneumonia, acute pulmonary hypertension exacerbation. Differences of Pulmonary Embolism T-waves from Wellens' T-waves: 1.

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Chest Pain Pulmonary Embolism Tachycardia 40

Circulation

NOVEMBER 11, 2024

Advanced cardiac imaging especially in atypical presentations, can aid in early diagnosis.Case:A 59 year-old man with history of biopsy-proven pulmonary sarcoidosis presented with non exertional chest pain for 2 months. Repeat TTE and EKG then noted newly enlarged left atrium and atrial tachycardia.

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Chest Pain Echocardiogram Document Ischemia 40

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

My answer: "This is classic for PE, but it can also be present in any hypoxia due pulmonary hypoxic vasoconstriction and resulting acute pulmonary hypertension and acute right heart strain. Tachycardia (or nearly) 2. An ECG was texted to me (Smith) without any clinical information: What did I say? This is NOT Wellens.

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Chest Pain Pulmonary Tachycardia Embolism 52

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.

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Coronary Angiogram Chest Pain Stenosis STEMI 52

Ken Grauer, MD

MARCH 27, 2024

No chest pain. In the context of today's case — these P waves are diagnostic of RAE = P Pulmonale ( See ECG Blog #75 ) and almost certain associated pulmonary hypertension. Retrospectively — I interpret this 1:1 retrograde conduction as diagnostic of a reentry SVT rhythm as the etiology of the initial tachycardia.

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Blog Congenital Heart Disease Congenital Heart Disease 187

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

MARCH 11, 2019

In such cases, it is common for tachycardia to exaggerate the ST Elevation And, in fact, there was no new acute MI at this visit - troponins did not rise again. At some point he returned with chest pain, and all these findings were put into place. Many MI do not have chest pain 4. Troponin I greater than 1.0

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Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 28, 2023

There was some dyspnea but no chest pain. Further ultrasound showed no B-lines (no pulmonary edema). A young man presented with continuous prolonged generalized weakness, lightheadedness, and presyncope. Here is his ECG. This shows LVH, with high voltage. The heart rate is too fast for this poor filling.

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Preserved Ejection Fraction Sudden Cardiac Death Heart Failure Chest Pain 57

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? It is difficult to tell if there is collapse during diastole due to the patient’s tachycardia. MY Thoughts on the ECG in Figure-1: The rhythm in ECG #1 — is sinus tachycardia at ~125/minute.

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Tachycardia Pericarditis Ultrasound Blood Pressure 40

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. See here for management of Polymorphic Ventricular Tachycardia , which includes Torsades. Most recent echo showed EF of 60%. He appeared to be in shock.

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STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 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. The patient was transported to the CCU for further medical optimization where a pulmonary artery catheter was placed.

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Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

AUGUST 9, 2019

His comments/questions are inserted below the ECG: A 50-something woman presented with 3 days of intermittent chest pain that became worse on the day of presentation, with diaphoresis and radiation to the left arm, as well as abdominal pain. This is her ECG: An obvious STEMI, but which artery?

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Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

APRIL 8, 2015

Check : [vitals, SOB, Chest Pain, Ultrasound] If the patient has Abdominal Pain, Chest Pain, Dyspnea or Hypoxemia, Headache, Hypotension , then these should be considered the primary chief complaint (not syncope). Aortic Dissection, Valvular (especially Aortic Stenosis), Tamponade.

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Arrhythmia Outcomes Risk Factors Chest Pain 52

Wellnest

JULY 19, 2023

When a person experiences a heart attack or myocardial infarction, they may feel chest pain and other symptoms in different parts of their body. The abnormal heart rhythms can further lead to death because of ventricular tachycardia and ventricular fibrillation. So, how do you recognize a heart attack?

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Heart Attack Heart attacks Blood Pressure Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

Written by Pendell Meyers A woman in her 40s presented with acute chest pain and shortness of breath. Smith : This is classic for pulmonary embolism (PE). Acute pulmonary embolism was confirmed on CT angiogram: The patient did well. Chest pain, SOB, Precordial T-wave inversions, and positive troponin.

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Chest Pain Embolism Pulmonary Tachycardia 113

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. She awoke in the morning with sharp chest pain which worsened throughout the morning. As her pain worsened, so did her dyspnea. This was written by Hans Helseth.

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Tachycardia Pulmonary Chest Pain Stenosis 74

Dr. Smith's ECG Blog

MARCH 6, 2025

Smith comments : Wide complex tachycardia. The differential diagnosis of WCT is: 1) Sinus tachycardia with "aberrancy" (in this case RBBB and LAFB), but there are no P-waves and the QRS morphology is not typical of simple RBBB/LAFB. Also, if the rate is constant, not wavering up and down, it is highly unlikely to be sinus tachycardia.

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Tachycardia Dysrhythmia ICU Pulmonary 96

Dr. Smith's ECG Blog

JANUARY 21, 2025

He denied chest pain. Bedside POCUS showed very poor LV function and a few pulmonary B lines. A Chest X-ray did not show pulmonary edema. This ECG was recorded: It is difficult to appreciate P-waves, but I believe this is sinus tachycardia. He was put on BiPAP. And here the lines show the offset.

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Chest Pain STEMI Tachycardia Myocardial Infarction 62