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2 middle aged males presented with chestpain. Which had the more severe chestpain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chestpain at the time the ECG was recorded. 414 patients were included in the analysis.
Written by Jesse McLaren A 45-year-old presented with 24 hours of intermittent chestpain. On it’s own this is nonspecific, but in the right context this could be diagonal occlusion (if active chestpain) or infero-posterior reperfusion (if resolved chestpain). #2 Can you guess the sequence?
Written by Pendell Meyers A man in his 40s called EMS for acute chestpain that awoke him from sleep, along with nausea and shortness of breath. Learning Points: Currently by definition, there is unfortunately no such thing as a formal diagnosis of STEMI or STEMI criteria in the setting of RBBB and LAFB.
Written by Jesse McLaren, with a very few edits by Smith A 60-year-old presented with chestpain. The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. But STEMI criteria is only 43% sensitive for OMI.[1]
A young woman presented with acute chestpain. 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".
In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chestpain. The post ECG Cases 49 – ECG and POCUS for Dyspnea and ChestPain appeared first on Emergency Medicine Cases.
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 chestpain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.
Written by Pendell Meyers Two patients with acute chestpain. Patient 1: Patient 2: Patient 1: A man in his 40s with minimal medical history presented with acute chestpain radiating to his R shoulder. Two patients with chestpain. Do either, neither, or both have OMI and need reperfusion?
Written by Jesse McLaren A 45 year old presented with two weeks of recurring non-exertional chestpain, now constant for an hour. Because of the ECG changes in a patient with chestpain, and with inferolateral hypokinesis on POCUS, the cath lab was activated. Below is old and then new ECG (old on top; new below).
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 Chestpain." 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?
The patient was a middle-aged female who had acute chestpain 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.
Written by Jesse McLaren A healthy 75 year old developed 7/10 chestpain associated with diaphoresis and nausea, which began on exertion but persisted. Below is the first ECG recorded by paramedics after 2 hours of chestpain, interpreted by the machine as “possible inferior ischemia”. What do you think?
A 50-something male had onset of chestpain 1 hour prior to ED arrival. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. It was tested on a large database of known outcomes and was more than twice as senstivity as STEMI criteria and much better than cardiologists.
Written by Pendell Meyers A man in his 60s presented with acute chestpain 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.
Sent by Magnus Nossen MD, written by Pendell Meyers A man in his 50s, previously healthy, developed acute chestpain. The primary care physician there evaluated this patient and deemed the chestpain to be due to gastrointestinal causes. In this case, the EMS provider was routed to the urgent care facility.
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 chestpain and nausea. The patient continued having chestpain. Is there STEMI? Fortunately the patient was then taken for angiography.
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 chestpain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.
Written by Willy Frick A 67 year old man with a history of hypertension presented with three days of chestpain radiating to his back. Due to the chestpain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. He had associated nausea, vomiting, and dyspnea.
Written by Jesse McLaren A 50 year old presented to triage with one hour of chestpain, and the following ECG labeled normal by the computer (GE Marquette SL) algorithm. Smith comment: we showed that the first troponin, even in full-blown STEMI, is negative 25% of the time. What do you think?
Written by Jesse McLaren A previously healthy 60 year old developed exertional chestpain with diaphoresis, and called EMS. So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. What do you think?
Written by Jesse McLaren Four patients presented with chestpain. 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]
This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chestpain The tech came running with the ECG as the computer called "STEMI!" So signed it NO STEMI and triaged him OK to not be in RESUS." What do you think? Sam sent this to me and asked: "What do you think, Steve?" My answer: --Tough one! --But
A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chestpain 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)?
The patient presented to an outside hospital An 80yo female per triage “patient presents with chestpain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. HPI: Abrupt onset of substernal chestpain associated with nausea/vomiting 30 min PTA.
Written by Jesse McLaren, comments by Smith A 55 year old with a history of NSTEMI presented with two hours of exertional chestpain, with normal vitals. See these posts: ChestPain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab? So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion.
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 chestpain 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?
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 chestpain and diaphoresis. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0.
A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chestpain. Here is his most recent previous ECG: This was recorded after intervention for inferior STEMI (with massive ST Elevation, see below), and shows inferior Q-waves with T-wave inversion typical of completed inferior OMI.
Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chestpain 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.)
Written by Jesse McLaren Three patients presented with acute chestpain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. What do you think?
Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( ChestPain ). It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. The ECG shows ST depression in lead V3.
I was working at triage when the medics brought this patient who is 65 yo and has had chestpain 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!
Written by Jesse McLaren Two patients in their 70s presented to the ED with chestpain and RBBB. Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. Do either, both, or neither have occlusion MI? Vitals were normal.
Jesse McLaren discusses some key aspects of cocaine chestpain ECG interpretation in this month's blog including: Patients with cocaine-associated chestpain require benzodiazepines +/- nitroglycerine for symptom relief, aspirin and ECG to look for signs of occlusion and reperfusion.
In this ECG Cases blog we look at 10 cases of patients with chestpain, 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.
Written by Pendell Meyers A man in his early 40s experienced acute onset chestpain. The chestpain 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".
Written by Jesse McLaren Two 70 year olds had acute chestpain with nausea and shortness of breath, and called paramedics. There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD.
A 40-something male presented by ambulance with one hour of chestpain that was improving after sublingual nitroglycerine and 325 mg of aspirin, chewed. Here it is: Obvious Inferior Posterior STEMI (+) OMI. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%.
He experienced a sudden onset of substernal chestpain, 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.
A 67 yo f developed chestpain this morning." Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. See this case: A man his 50s with chestpain.
Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chestpain 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?
Written by Jesse McLaren A previously healthy 50 year-old presented with 24 hours of intermittent exertional chestpain, radiating to the arms and associated with shortness of breath. In a previously healthy patient with new and ongoing chestpain, this is concerning for acute occlusion of the first diagonal artery.
Written by Pendell Meyers A woman in her 70s had acute chestpain and called EMS. Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Ongoing OMI.
Let me tell you about her hospitalization, discharged 1 day prior, but it was at another hospital (I wish I had the ECG from that hospitalization): The patient is 40 years old and presented to another hospital with chestpain and SOB. She had been sitting doing work when she experienced "waves of chest tightness". Sats were 88%.
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