Dr. Smith's ECG Blog

JUNE 17, 2018

A middle-aged patient with lung cancer had presented to clinic complaining of generalized malaise, cough, and chest pain. There is sinus tachycardia. Symptoms other than chest pain (malaise, cough in a cancer patient) 2. Sinus tachycardia, which exaggerates ST segments and implies that there is another pathology.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 26, 2010

This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 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 Tachycardia Stenosis 52

Dr. Smith's ECG Blog

MAY 16, 2023

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Here is his triage ECG: What do you think?

Chest Pain 52

Chest Pain Pericarditis Tachycardia STEMI 52

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.

Chest Pain 52

Chest Pain Physiology Blog Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Sinus tachycardia has many potential causes. This is especially true for the elderly patient with sinus tachycardia. What is the cause of the sudden tachycardia? It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

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

JUNE 11, 2011

Is this an anterior STEMI with LBBB? Explanation : The patient had a worrisome history: 59 yo with significant substernal chest pressure, so his pretest probability of MI (and even of STEMI) is reasonably high. Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion.

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

JULY 25, 2024

Just as important is pretest probability: did the patient report chest pain prior to collapse? Cardiac arrest #3: ST depression, Is it STEMI? Description of today's ECG findings ( Sinus tachycardia with diffuse ST depression and ST elevation in aVR ) — is diagnostic of DSI. Then assume there is ACS.

Cardiac Arrest 124

Cardiac Arrest Ischemia Tachycardia Defibrillator 124

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. He had no chest pain. Here is his ED ECG: There is sinus tachycardia. Is this acute STEMI? Is this an acute STEMI? -- Unlikely!

STEMI 52

STEMI Pulmonary Stent Stents 52

Dr. Smith's ECG Blog

OCTOBER 28, 2020

This ECG was texted to me with the implied question "Is this a STEMI?": I responded that it is unlikely to be a STEMI. Septal STEMI often has ST depression in V5, V6, reciprocal to V1. Then combine with clinical presentation and low pretest probability 2 Saddleback STEMIs A Very Subtle LAD Occlusion.T-wave wave in V1??

STEMI 52

STEMI Chest Pain Blog Tachycardia 52

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

Ken Grauer, MD

JUNE 14, 2024

Prompt cath is therefore advised if the post-ROSC shows an acute STEMI. The rhythm is regular — at a rate just over 100/minute = sinus tachycardia ( ie, the R-R interval is just under 3 large boxes in duration ). Continuing with assessment of ECG #1 in Figure-2: The rhythm is sinus tachycardia at ~110/minute.

Blog 159

Blog STEMI Cardiac Arrest Tachycardia 159

Dr. Smith's ECG Blog

MAY 19, 2022

Written by Pendell Meyers, edits by Smith and Grauer A man in his late 20s with history of asthma presented to the ED with a transient episode of chest pain and shortness of breath after finishing a 4-mile run. His symptoms of chest pain and shortness of breath were attributed to an asthma exacerbation during exercise.

Chest Pain 52

Chest Pain Exercise Pacemaker Coronary Angiogram 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. He later developed mild continuous chest pain, that he describes as the sensation of someone standing on his chest. This ECG was recorded: What do you think? There is widespread ST depression.

Chest Pain 118

Chest Pain Ischemia Echocardiogram Myocardial Infarction 118

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. It shows sinus tachycardia with right bundle branch block. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). When EMS found her, she was dyspneic and diaphoretic. Both were wrong.

Cardiogenic Shock 127

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 127

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 116

Chest Pain STEMI Echocardiogram Stent 116

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. The computer did read "STEMI". Additional case by Smith.

STEMI 52

STEMI Chest Pain Stent Stents 52

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 120

Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Ken Grauer, MD

MAY 28, 2024

Please N OTE: I divided my comments into 2 "parts" regarding the use of comparison tracings: i ) Comparison of one 12-lead ECG with another ( ie, including use of serial ECGs in a patient with chest pain — and how BEST to use a prior "baseline" tracing ) ; — and — ii ) Optimal use of comparison tracing with cardiac arrhythmias!

Blog 143

Blog Arrhythmia Tachycardia CME 143

Dr. Smith's ECG Blog

AUGUST 13, 2020

His previous echo one month prior shows the same thing: “consistent with old infarct in LAD vascular territory, with EF 45%” "I think there is something else causing his tachycardia which is exaggerating his EKG findings and mimicking an acute myocardial infarction." The patient spontaneously converted back to sinus tachycardia.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? This is the response he got: Interventionist: "No STEMI, no cath. After stabilizing the patient and recording more ECGs, he tried again: Interventionalist: "It isn't a STEMI." It is a STEMI equivalent. We don't know how many though.

STEMI 52

STEMI Hospital Blog Defibrillator 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. Chest pain was resolved upon arrival in the ED. In other words, after reperfusion therapy for STEMI, the appearance of AIVR is usually a good sign, meaning that the artery is reperfused. His previous ECG was normal.

Chest Pain 52

Chest Pain Ischemia Dysrhythmia STEMI 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

Although the patient reported experiencing mild pressure-like chest pain, there was suspicion among clinicians that this might be indicative of an older change. While the initial impression might not immediately suggest ventricular tachycardia (VT), a closer examination raises suspicion. What is the rhythm?

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

Ken Grauer, MD

FEBRUARY 18, 2023

The presenting complaint was chest pain — and the patient collapsed soon after arrival in the ED. The finding of a fairly regular, wide tachycardia without clear sign of atrial activity ( especially when seen in an acutely symptomatic patient ) — should immediately prompt a diagnosis of VT until proven otherwise.

Blog 78

Blog AFIB Chest Pain STEMI 78

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)? In addition to sinus tachycardia, the only abnormalities listed by the computer were "low voltage, precordial leads" and "anteroseptal infarct, old.Q

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

Ken Grauer, MD

MAY 20, 2023

NOTE: It's important to correlate ongoing circumstances at the time that a prior tracing was done ( ie, Was the patient stable and asymptomatic — or were they having chest pain, an exacerbation of heart failure, or some other ongoing process at the time the prior ECG was recorded? ).

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Blog Chest Pain Ischemia STEMI 145

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

JUNE 17, 2017

There is sinus tachycardia. The above is what I thought when I saw this, so I went to the chart and found this history: A type I diabetic aged approximately 35 years old presented with chest pain, nausea, vomiting and diffuse abdominal pain. The possibility of anterior STEMI was not noticed during patient care.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Stent 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms.

Pericarditis 52

Pericarditis Chest Pain Aortic Blog 52

Dr. Smith's ECG Blog

JULY 1, 2019

Case 2: sent by Dr. James Alva A man in his 50s with diabetes, hypertension, and hyperlipidemia presented to the ED with chest pain and shortness of breath off and on over the past three days, with associated vomiting. There is also much STE in V3-V6, especially V4-V6, that must be considered to be STEMI. Peak troponin was 3.21

Chest Pain 52

Chest Pain Ischemia STEMI Blog 52

Dr. Smith's ECG Blog

MARCH 11, 2019

In such cases, it is common for tachycardia to exaggerate the ST Elevation And, in fact, there was no new acute MI at this visit - troponins did not rise again. At some point he returned with chest pain, and all these findings were put into place. Many MI do not have chest pain 4.

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

EMS 12-Lead

JULY 21, 2022

If this was a tachycardia at a rate of 150, it might appear to be a narrow complex tachycardia, when in fact, it would be a wide complex tachycardia! Generally speaking, right bundle branch block does not mimic, or obscure, the ECG diagnosis of acute STEMI the way left bundle branch block does. An ECG is captured.

Bradycardia 52

Bradycardia Tachycardia STEMI Chest Pain 52

Dr. Smith's ECG Blog

JULY 24, 2024

22:25 — What if you have a regular SVT ( = narrow-complex tachycardia ) without obvious P waves? ( 2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”. ). 19:50 — Not appreciating statistical odds! ( The 4 common causes? — The most commonly overlooked cause? )

Arrhythmia 52

Arrhythmia Blog Tachycardia CME 52