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?

Chest Pain 135

Chest Pain Diabetes STEMI Blog 135

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.

Chest Pain 110

Chest Pain STEMI Ischemia Myocardial Infarction 110

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?

Chest Pain 100

Chest Pain STEMI Bradycardia Article 100

Dr. Smith's ECG Blog

SEPTEMBER 1, 2023

A 50-something male had onset of chest pain 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.

Chest Pain 128

Chest Pain STEMI Stenosis Myocardial Infarction 128

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.

Chest Pain 114

Chest Pain STEMI Atrial Flutter Ischemia 114

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.

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Chest Pain STEMI Blog 111

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.

Chest Pain 98

Chest Pain Cardiac Arrest STEMI Defibrillator 98

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.

Chest Pain 130

Chest Pain Tachycardia STEMI Blog 130

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.

Chest Pain 117

Chest Pain Pericarditis Aortic Echocardiogram 117

Dr. Smith's ECG Blog

JULY 7, 2024

Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain 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?

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Chest Pain STEMI Blog Arrhythmia 66

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

JANUARY 29, 2024

This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chest pain 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

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Chest Pain STEMI Blog Outcomes 96

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)?

Chest Pain 117

Chest Pain Myocardial Infarction Anatomy Angina 117

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.

Chest Pain 111

Chest Pain Myocardial Infarction Stents Stent 111

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 117

Chest Pain STEMI Aneurysm Stents 117

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 129

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 STEMI Bradycardia Ischemia 114

Dr. Smith's ECG Blog

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. 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.

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STEMI Heart Failure Stents Stent 123

Dr. Smith's ECG Blog

MARCH 27, 2025

Theres ST elevation in V3-4 which meets STEMI criteria, which could be present in either early repolarization, pericarditis or injury. Lets see what happens in the current STEMI paradigm. Emergency physician: STEMI neg but with elevated troponin = Non-STEMI The first ECG was signed off. Chest pain still persists.

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STEMI Chest Pain Pericarditis Ischemia 80

Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain 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?

Chest Pain 119

Chest Pain STEMI Outcomes Electrocardiogram 119

Dr. Smith's ECG Blog

AUGUST 6, 2024

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 ( Chest Pain ). 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.

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

MARCH 10, 2025

Written by Jesse McLaren A 50 year old presented to triage with one hour of chest pain, 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?

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Chest Pain Outcomes STEMI Electrocardiogram 89

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 115

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain 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.

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Chest Pain STEMI Pulmonary Embolism 73

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 Blog Ischemia 52

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.

Chest Pain 52

Chest Pain STEMI Blog Embolism 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 98

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Written by Jesse McLaren Two 70 year olds had acute chest pain 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.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JUNE 5, 2023

A 40-something male presented by ambulance with one hour of chest pain 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%.

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Chest Pain STEMI Physiology Research 96

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

MAY 31, 2023

A 67 yo f developed chest pain 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 chest pain.

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STEMI Chest Pain Myocardial Infarction Ischemia 96

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?

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Chest Pain STEMI Ischemia Document 52

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 70

Dr. Smith's ECG Blog

JANUARY 3, 2024

Written by Pendell Meyers A woman in her 70s had acute chest pain 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.

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STEMI Chest Pain Ischemia Outcomes 102

Dr. Smith's ECG Blog

OCTOBER 22, 2017

However, there are morphologies of Takotsubo that cannot be distinguished from STEMI. Takotsubo Typical Takotsubo, very unlikely to be ACS because of extremely long QT Presented with altered mental status, hypotension, and mild chest discomfort Peak trop 0.15 Comment Notice that I did not even put ACS on my differential?

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Chest Pain STEMI Cardiomyopathy Ultrasound 52

Dr. Smith's ECG Blog

JANUARY 8, 2024

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 chest pain and SOB. She had been sitting doing work when she experienced "waves of chest tightness". Sats were 88%.

Chest Pain 71

Chest Pain Pulmonary Embolism STEMI 71

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A healthy 45-year-old female presented with chest pain, with normal vitals. The patient was previously healthy, with no atherosclerotic risk factors, and developed chest pain after an episode of stress. The pain was crushing retrosternal, radiated to the arms and was associated with lightheadedness.

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Chest Pain Pericarditis SCAD STEMI 66