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 He had 50% stenosis of the LAD which was deemed not culprit, and all other vessels were normal. I said "Not OMI. No intervention.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

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.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Blog 52

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, 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?

Chest Pain 52

Chest Pain STEMI Blog Stenosis 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.

Chest Pain 52

Chest Pain Ischemia Stenosis Tachycardia 52

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. It was signed off by an emergency physician as “STEMI negative” because it did not meet STEMI criteria.

Chest Pain 52

Chest Pain STEMI Ischemia Stenosis 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. 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 ACC/AHA guidelines mandate less than 2 hours cath for patients with ACS with refractory pain, pulmonary edema, or electrical or hemodynamic instability.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

Chest Pain 52

Chest Pain SCAD STEMI Blog 52

Dr. Smith's ECG Blog

JUNE 11, 2024

Sent by anonymous A man in his 40s with no previous heart disease presented within 30 minutes of onset of acute chest pain that started while exercising. Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Chest pain and a computer ‘normal’ ECG.

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Chest Pain STEMI Blog Exercise 112

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. At this time he reported ongoing chest pain and was given aspirin and nitroglycerin.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. Chest pain is squeezing or tight in nature.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Blog Pericarditis 52

Dr. Smith's ECG Blog

JUNE 28, 2018

He had suffered a couple bouts of typical chest pain in the last 24 hours. This ECG (ECG #3) was recorded immediately after the last episode of pain spontaneously resolved. The pain had lasted about one hour. So you are going to get to see what the ECG would have shown had you recorded one during pain! Am Heart J.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

Chest Pain 52

Chest Pain STEMI Stent Stents 52

Ken Grauer, MD

FEBRUARY 3, 2024

BUT — Cardiac catheterization done a little later did not reveal any significant stenosis. Despite the absence of significant coronary stenosis on her post-arrest cath — the ECG in Figure-1 is clearly diagnostic of an extensive anterolateral STEMI ( presumably from acute LAD [ L eft A nterior D escending ] coronary artery occlusion).

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Blog Cardiac Arrest STEMI Plaque 163

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

A 60-something awoke with 10/10 crushing chest pain. The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. Quiz : What percent of full blown STEMI have an open artery with normal flow at angiogram? But the patient's chest pain continues and so you order a 2nd ECG (ECG 2 here).

Chest Pain 98

Chest Pain STEMI Stent Stents 98

Dr. Smith's ECG Blog

MAY 2, 2019

Written by Pendell Meyers I received this prehospital ECG (we receive prehospital ECGs by telemetry from EMS in a large area around our hospital) and was told that there was a patient in her 50s with chest pain who was headed to an outside hospital (which happens to be a catheterization center). Here is the ECG: What do you think?

STEMI 52

STEMI Hospital Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He was given aspirin and sublingual nitro and the pain resolved. Because the pathologist determines the degree of stenosis by dividing the lumen area by the total area, the degree of stenosis will be overestimated.

Ischemia 121

Ischemia Plaque Stenosis Myocardial Infarction 121

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. 3 hours prior to calling 911 he developed typical chest pain. But it could be anterior STEMI. is likely anterior STEMI).

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He wrote most of it and I (Smith) edited.

Chest Pain 115

Chest Pain STEMI Echocardiogram Stent 115

Dr. Smith's ECG Blog

JULY 31, 2013

A 20-something male presented from an outside facility with Chest pain. He came with this ECG from the outside facility, recorded 1 hour after pain onset: There is at least 2 mm of inferior ST elevation, with reciprocal ST depression in aVL, ST flattening in V4-V6, and T-wave inversion in V2. Vital signs were normal.

Chest Pain 52

Chest Pain Aneurysm STEMI Ischemia 52

Dr. Smith's ECG Blog

JANUARY 28, 2023

Case 1 A middle aged woman presented with acute chest pain and shortness of breath, unclear time since onset, and likely with episodic symptoms off and on throughout the day. Only very slight STE which does not meet STEMI criteria at this time. Another lesion in the proximal LAD with 80% stenosis was stented as well.

STEMI 52

STEMI Chest Pain Stent Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. Here is the clinical story: A 40 year old male with no cardiac history presented with acute substernal chest pain that started 40 minutes prior to arrival. This ECG was texted to me with no other information. What did I say?

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STEMI Stenosis Plaque Chest Pain 129

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

NOVEMBER 15, 2023

A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

SEPTEMBER 14, 2014

He presented with chest pain, not relieved by nitro, pain reproducible on exam and centered around the pacemaker insertion site. is very specific for STEMI , and there is some evidence, as well as rationale, that a paced rhythm behaves similarly. Here is one case of anterior STEMI in a paced rhythm.

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Chest Pain Cardiomyopathy STEMI Pacemaker 52

Dr. Smith's ECG Blog

OCTOBER 10, 2024

Written by Pendell Meyers A man in his early sixties with no significant medical history (including a "negative cardiac workup a few years ago" for unclear indication) called 911 for acute chest pain constantly for the past 5 hours. However, this patient has active chest pain, and thus this this is inferior-posterior OMI.

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Chest Pain STEMI Blog Stenosis 108

Dr. Smith's ECG Blog

AUGUST 28, 2020

This can only be due to STEMI. Here I annotate it: This shows 100% occluded circumflex (red arrow) and a 90% stenosis of the LAD (Yellow arrow). The LAD was thought to be not thrombotic, but a chronic tight stenosis. The LAD was thought to be not thrombotic, but a chronic tight stenosis. I said "activate the cath lab."

Cardiogenic Shock 40

Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast. The patient was given opiates which improved his chest pain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

Chest Pain 119

Chest Pain Blog Hospital Tachycardia 119

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

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. The pain initially started the day prior to presentation. The ST elevation from today is ~0.2

Pericarditis 52

Pericarditis Chest Pain Stent Stents 52

Dr. Smith's ECG Blog

MAY 23, 2014

This patient presented with a mechanical fall and had chest pain. However, there are also Q-waves inferiorly and the inferior T-waves are inverted, suggesting that this is an old MI with persistent ST elevation, or, alternatively, a subacute or partially reperfused, inferior STEMI. His first troponin I returned at 0.10

Ischemia 52

Ischemia Chest Pain STEMI Outpatient 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.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

MARCH 6, 2023

If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation? However, in the context of the first ECG and the waning chest pain, this is diagnostic of reperfusion. Due to the severity of the pain and the high BP, they obtained an aortic dissection CT.

Chest Pain 52

Chest Pain STEMI Stenosis Blog 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain. It is also NOT the clinical scenario of takotsubo (a week of intermittent chest pain).

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

COPD, Idiopathic PAH, acute or chronic PE, pulmonary valve stenosis, etc) 3) Conditions affecting RV myocardial contractility, such as ARVD or RV infarction The ECGs does not really show any signs of chronic RV dilation or hypertrophy. 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

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours.

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Chest Pain STEMI Document Ischemia 52