Dr. Smith's ECG Blog

OCTOBER 30, 2024

All of the patients contacted EMS due to acute onset chest pain. The above ECG is from a 70 something male with chest pain. ECG #2 Case 2 : The above ECG was obtained from a diabetic 45 year old smoker with chest pain. Following the improvement in the ECG the patient's pain too improved drastically.

Chest Pain 93

Chest Pain Aortic Myocardial Infarction STEMI 93

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. Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis.

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Chest Pain STEMI Aneurysm Stents 107

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.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Ischemia 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

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.

Chest Pain 113

Chest Pain STEMI Bradycardia Ischemia 113

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 90

Chest Pain Ischemia Pericarditis Tachycardia 90

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 118

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. Another ECG was recorded while awaiting the cath team: Now there is STEMI Let's look at that first (prehospital ECG) again: Very subtle! It was opened and stented. So I uncrumpled it: What do you think?

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Chest Pain Critical Care STEMI Stents 111

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 117

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

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".

Chest Pain 93

Chest Pain STEMI Blog Stents 93

Dr. Smith's ECG Blog

JANUARY 6, 2023

Submitted and written by Anonymous, edits by Meyers and Smith A 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache. A single DES stent was placed, and the patient did well post-procedure.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 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 83

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 Stents Stent 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

Case submitted by Rachel Plate MD, written by Pendell Meyers A man in his 70s presented with chest pain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. He also noted a bilateral "odd feeling" in his arms. He stated it was similar to prior heart attacks.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart attacks 52

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, Pericarditis would be even more unlikely in someone without chest pain.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

MAY 11, 2019

male was sitting at a work conference when he began having substernal chest pain with diaphoresis. The pain was 7 out of 10 when this ECG was recorded: The QTc = 375 What do you think? Since the threshold for "STEMI" is 2.0 mm, this ECG actually meets STEMI criteria. Since the threshold for "STEMI" is 2.0

Chest Pain 52

Chest Pain STEMI Stents Stent 52

Ken Grauer, MD

OCTOBER 25, 2024

P.S.: Cardiac cath was performed — and showed a distal LA D "culprit" lesion that was successfully stented. The following are the KEY clinical and ECG features that establish the diagnosis of W ellens ' S yndrome : There should be a history of prior chest pain that has resolved at the time the defining ECG is obtained.

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Blog Chest Pain Cardiogenic Shock STEMI 95

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. There is an obvious inferior posterior STEMI(+) OMI. Angiogram: Culprit Lesion (s): Thrombotic occlusion of the proximal RCA -- stented. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity?

Chest Pain 87

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 87

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This is another case written by Pendell Meyers (who is helping to edit the blog and has many great recent posts) Case A 45 year old man was driving to work when he experienced acute onset sharp left sided chest pain with paresthesias of the left arm. A repeat ECG was recorded with pain 2/10: Not much change.

Chest Pain 52

Chest Pain STEMI Defibrillator Stents 52

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. of such ‘high risk Non-STEMI’ patients get angiography within 2 hours.[2] But does this matter?

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STEMI Chest Pain Myocardial Infarction Stents 120

Dr. Smith's ECG Blog

AUGUST 17, 2019

Chris Mondie of the Newark Beth Israel Emergency Medicine Residency sent this case A 50-something man presented with acute chest pain. So there is definitely no STEMI, and the STE is normal. But after reading this blog, you all know that most OMI do NOT meet STEMI criteria. 100% proximal LAD successfully stented.

Chest Pain 52

Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

JULY 19, 2019

Written by Pendell Meyers, with edits by Steve Smith A man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). But it does not meet STEMI criteria and it was not initially recognized.

Chest Pain 52

Chest Pain STEMI Aneurysm Pericarditis 52

Dr. Smith's ECG Blog

JULY 30, 2023

Written by Pendell Meyers A woman in her 50s presented with acute chest pain and lightheadedness since the past several hours. It does not meet STEMI criteria. Luckily, 45 minutes later, with ongoing pain and a troponin I that resulted at 136 ng/L, the ECG was repeated: What do you think now? Anyway, she does say OMI.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 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 Stents Stent 52

Dr. Smith's ECG Blog

JULY 11, 2019

Written and submitted by Ashley Mogul, with edits by Pendell Meyers and Steve Smith A man in his 40s with recent smoking cessation but otherwise no known past medical history presented due to chest pain since the previous evening. The pain has been constant and associated with vomiting and diaphoresis.

Chest Pain 52

Chest Pain STEMI Article Stents 52

Dr. Smith's ECG Blog

DECEMBER 22, 2022

The lesion was successfully stented. The pain was completely resolved after coronary intervention. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. Here is the post-intervention angiogram and post-PCI ECG. In OMI/NOMI paradigm you search a clue for acute coronary occlusion (ACO). Turk Kardiyol Dern Ars.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 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.

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Chest Pain Blood Pressure Ischemia STEMI 125

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.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). In STEMI, they are generally upright and large in proportion to the QRS. So this argues against acute STEMI.

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Chest Pain Aneurysm STEMI Document 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 Pulmonary 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Triage EKG: What do you think? 1] Wereski, R.,

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 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.

Chest Pain 113

Chest Pain STEMI Blog Exercise 113

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!

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

A 60-something awoke with 10/10 crushing chest pain. I would expect that a stent would be placed. 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? He walked in to triage.

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Chest Pain STEMI Stents Stent 88

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

A 60-something woman called EMS for chest pain. link] Clinical Course I don't know if the medics noticed these ECG findings or not, but if not, they recognized the value of serial ECGs in a patient with chest pain. The medics administered aspirin (no Nitroglycerine), and the pain resolved. #5: mm in V2 and 0.65

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Chest Pain STEMI Stents Stent 121