Dr. Smith's ECG Blog

AUGUST 11, 2024

Written by Jesse McLaren A healthy 75 year old developed 7/10 chest pain associated with diaphoresis and nausea, which began on exertion but persisted. Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. What do you think?

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Chest Pain STEMI Bradycardia Stents 74

Dr. Smith's ECG Blog

APRIL 6, 2024

A young woman presented with acute chest pain. In fact, it read: ** **ACUTE MI / STEMI ** ** The physicians caring for the patient activated the cath lab for "STEMI". In fact, it read: ** **ACUTE MI / STEMI ** ** The physicians caring for the patient activated the cath lab for "STEMI".

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Chest Pain STEMI Hospital 104

Dr. Smith's ECG Blog

MARCH 31, 2024

The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation. The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). mm STE in the posterior leads.

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Chest Pain STEMI Ischemia Myocardial Infarction 91

Dr. Smith's ECG Blog

AUGUST 16, 2024

Written by Pendell Meyers A man in his 60s presented with acute chest pain and normal vital signs. Its hard to measure the STE in I exactly with the moving baseline, but there is almost certainly not enough STE to meet STEMI criteria. Here is his triage ECG: What do you think? They are symmetric, fat, convex on both sides, etc.

Chest Pain 101

Chest Pain STEMI Blog 101

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

Written by Jesse McLaren A 45 year old presented with two weeks of recurring non-exertional chest pain, now constant for an hour. Because of the ECG changes in a patient with chest pain, and with inferolateral hypokinesis on POCUS, the cath lab was activated. Below is old and then new ECG (old on top; new below).

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Chest Pain STEMI Ischemia Anatomy 88

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

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Chest Pain Defibrillator STEMI Coronary Artery Disease 130

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 Embolism 52

ECG Cases

DECEMBER 20, 2022

Jesse McLaren discusses some key aspects of cocaine chest pain ECG interpretation in this month's blog including: Patients with cocaine-associated chest pain require benzodiazepines +/- nitroglycerine for symptom relief, aspirin and ECG to look for signs of occlusion and reperfusion.

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Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The patient continued having chest pain. Is there STEMI? Fortunately the patient was then taken for angiography.

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Chest Pain Arrhythmia Myocardial Infarction STEMI 85

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Written by Jesse McLaren A 65 year old with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented with 3 days of fluctuating chest pain, which was ongoing at triage. So a patient with high pretest probability (prior CABG with new chest pain), had new ECG changes showing posterior OMI.

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Chest Pain STEMI Atrial Flutter Ischemia 112

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

I came to work one day and one of my partners said, "Hey, Steve, we had a STEMI this afternoon!" Of course he said: "Yes, it was a 60 year old diabetic with Chest pain." That is not a STEMI. They had activated the cath lab and the interventionalist did not notice that it was not a STEMI/OMI. He said: "What?

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Chest Pain Diabetes STEMI Blog 129

Dr. Smith's ECG Blog

JUNE 21, 2023

Sent by Magnus Nossen MD, written by Pendell Meyers A man in his 50s, previously healthy, developed acute chest pain. The primary care physician there evaluated this patient and deemed the chest pain to be due to gastrointestinal causes. In this case, the EMS provider was routed to the urgent care facility.

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Chest Pain Cardiac Arrest STEMI Defibrillator 95

Dr. Smith's ECG Blog

APRIL 4, 2023

Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chest pain radiating to the neck, associated with shortness of breath. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI?

Chest Pain 52

Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

JUNE 13, 2024

Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chest pain that started 2-3 hours earlier while sitting on a porch swing. See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6. Also seen in inferior + RV OMI.)

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Chest Pain Document STEMI Defibrillator 90

Dr. Smith's ECG Blog

MARCH 9, 2024

Written by Willy Frick A 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. Due to the chest pain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. He had associated nausea, vomiting, and dyspnea.

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Chest Pain Pericarditis Aortic Echocardiogram 110

Dr. Smith's ECG Blog

AUGUST 10, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLaren A 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram.

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Chest Pain STEMI Ischemia Nursing 86

Dr. Smith's ECG Blog

DECEMBER 29, 2023

Written by Jesse McLaren A previously healthy 50 year-old presented with 24 hours of intermittent exertional chest pain, radiating to the arms and associated with shortness of breath. In a previously healthy patient with new and ongoing chest pain, this is concerning for acute occlusion of the first diagonal artery.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 73

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. He described his chest pain as pleuritic and reported that it started the day prior while swinging a golf club. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive.

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Chest Pain Pericarditis Pacemaker STEMI 62

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.

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Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

MARCH 22, 2024

Written by Willy Frick A man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chest pain and diaphoresis. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0.

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Chest Pain Bradycardia STEMI Ischemia 111

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA.

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Chest Pain Myocardial Infarction Stents Stent 89

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Written by Jesse McLaren Four patients presented with chest pain. 4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6]

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Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

APRIL 22, 2024

A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chest pain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest. At times the pain does go to his left neck. What do you think the prehospital ECG showed (with pain)?

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Chest Pain Myocardial Infarction Anatomy Angina 118

Dr. Smith's ECG Blog

JULY 23, 2024

I was working at triage when the medics brought this patient who is 65 yo and has had chest pain for 12 hours. The pain had been intermittent until an hour before arrival, when he called 911. Another ECG was recorded while awaiting the cath team: Now there is STEMI Let's look at that first (prehospital ECG) again: Very subtle!

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Chest Pain Critical Care STEMI Stents 106

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. Barely any STE, and thus not meeting STEMI criteria.

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Chest Pain STEMI Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.

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Chest Pain Tachycardia STEMI Blog 118

Dr. Smith's ECG Blog

JUNE 17, 2023

Written by Pendell Meyers A middle aged man called EMS for acute chest pain. I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 Learning Points: False positive STEMI activations are unfortunately common. I said "Not OMI. Others probably thought lead V4 has a hyperacute T wave.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

Written by Jesse McLaren, comments by Smith A 55 year old with a history of NSTEMI presented with two hours of exertional chest pain, with normal vitals. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab? So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion.

Chest Pain 101

Chest Pain STEMI Aneurysm Stents 101

Frontiers in Cardiovascular Medicine

JANUARY 2, 2024

Background Despite the crucial role of Chest pain centers (CPCs) in acute myocardial infarction (AMI) management, China's mortality rate for ST-segment elevation myocardial infarction (STEMI) has remained stagnant. Conclusion CPC quality control metrics affect STEMI mortality based on Killip class.

Myocardial Infarction 59

Myocardial Infarction Chest Pain COVID-19 Catheterization Laboratory 59

Dr. Smith's ECG Blog

APRIL 21, 2023

Written by Jesse McLaren, with comments from Smith A 50-year old patient on the medical wards developed acute chest pain, with an ECG labeled (see computer interpretation at the top) and confirmed as normal. In the STEMI paradigm, patients with ischemic symptoms and ECGs that don’t meet STEMI criteria get serial ECGs.

Chest Pain 52

Chest Pain STEMI Cancer Hemorrhage 52

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you manage the patient?

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Chest Pain Blog STEMI 128

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chest pain with diaphoresis. Diagnosis: Acute non-ST segment elevation MI (Non-STEMI, or NSTEMI) Second troponin returned at around 0200: 15,894 ng/L 0245 (unclear if ongoing pain or not) Inferoposterior (and lateral V5-6) reperfusion findings.

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Chest Pain Physiology Stents Stent 52

ECG Guru

DECEMBER 23, 2023

He experienced a sudden onset of substernal chest pain, nausea & vomiting, and dizziness. He states the pain is a 5 on 1-10 scale. The Patient: A 60-year-old man at work. No cardiac history or current medications. The ECGs: The first ECG , taken at 12:30:05, shows a sinus rhythm with ventricular bigeminy.

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STEMI Chest Pain 105

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Sent by Drew Williams, written by Pendell Meyers A man in his 50s with history of hypertension was standing at the bus stop when he developed sudden onset severe pressure-like chest pain radiating to his neck and right arm, associated with dyspnea, diaphoresis, and presyncope. When is it anterior STEMI? Is this Acute Ischemia?

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Chest Pain STEMI Blog Stenosis 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. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). No pericardial effusion on ultrasound."

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Chest Pain Pericarditis Blog Cardiomyopathy 52

Dr. Smith's ECG Blog

MARCH 1, 2023

Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms. During active chest pain an ECG was recorded: Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF.

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Chest Pain Ischemia Stenosis Tachycardia 52

Dr. Smith's ECG Blog

MAY 23, 2023

Written by Pendell Meyers A man in his early 40s experienced acute onset chest pain. The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. And yet it still says "normal".

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Chest Pain STEMI Blog Stents 86