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. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. How would one tell?

Chest Pain 81

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 81

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. Symptoms other than chest pain (malaise, cough in a cancer patient) 2. Inclusion criteria were chest pain, at least 2 serial cTnI in 24 hours, sinus rhythm , and at least 1 ECG.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 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 126

Chest Pain Blood Pressure Ischemia STEMI 126

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.

Chest Pain 139

Chest Pain Embolism Pulmonary Tachycardia 139

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

MAY 13, 2024

Chest Pain – Benign Early Repol or OMI? Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain.

Chest Pain 111

Chest Pain STEMI Ultrasound Heart Attack 111

Dr. Smith's ECG Blog

JANUARY 10, 2020

He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain. Here is the parasternal short axis, performed by a real expert in emergency department point of care cardiac ultrasound: There does not appear to be an anterior wall motion abnormality.

Chest Pain 52

Chest Pain Pericarditis Ultrasound Download 52

Dr. Smith's ECG Blog

JUNE 14, 2017

There was apparently no syncope and he had no bony injuries, but he did complain of left sided chest pain. His chest was tender. A bedside cardiac ultrasound was normal. Is there STEMI? An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD IVCD type rhythm ??

Chest Pain 52

Chest Pain Congenital Heart Disease Article Congenital 52

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. He had diffuse crackles on exam and B-lines on chest ultrasound, and chest x-ray also confirmed pulmonary edema.

STEMI 52

STEMI Pulmonary Stent Stents 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

MAY 10, 2014

A male in his late 30's to early 40's presented with 24 hours of intermittent typical chest pain. The following ECG was recorded: There is an obvious acute inferior STEMI. Whenever there is inferior STEMI, one should think about Right Ventricular STEMI (RVMI). and STE in lead III > STE in lead II.

STEMI 52

STEMI Chest Pain Pulmonary Ultrasound 52

Dr. Smith's ECG Blog

JULY 18, 2014

A man in his 60's presented after 4 days of chest pain, with some increase of pain on the day of presentation. Exact pain history was difficult to ascertain. Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? There was some SOB. How acute is it?

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 1, 2023

A man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. He had active chest pain at the time of triage at 0137 at night, with this triage ECG: What do you think? Gallbladder ultrasound was negative for stones.

Stent 129

Stent Stents STEMI Physiology 129

Dr. Smith's ECG Blog

JUNE 11, 2021

Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

DECEMBER 6, 2010

He had no previous history of CAD, and presented with very typical waxing and waning chest pain, much worse with exertion but also present at rest and on presentation, though his pain was minimal at the time of the ECG. This is all suggestive of posterior STEMI, but not definitely diagnostic. Blood pressure was 150/80.

STEMI 52

STEMI Chest Pain Ultrasound Blood Pressure 52

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

SEPTEMBER 20, 2011

He did not state he had chest pain, but, then again, he couldn't remember anything. We did a bedside cardiac ultrasound. This is as clear a STEMI as you can get. So this is classic inferoposterior STEMI on the ECG but is NOT acute coronary syndrome! This 80 year old with a history of CABG had a cardiac arrest.

Cardiac Arrest 52

Cardiac Arrest STEMI Ultrasound Chest Pain 52

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 103

Coronary Angiogram Plaque Thrombosis STEMI 103

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

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

JUNE 27, 2021

A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away. A bedside ultrasound was done, with dozens of clips, and was even done with Speckle Tracking.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Pulmonary 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 Coronary Artery Disease 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. Values: STE60V3 = 2.0, It was stented.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 52

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. Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 Lupu L, et al.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

APRIL 20, 2018

female with HTN, HLD, diabetes, ESRD on dialysis is brought in by EMS with sudden onset, left -sided chest pain for the past four hours. While she was in her bed at home, she had sudden onset of left sided chest pain that radiated to her shoulder. The pain was pleuritic, without nausea or diaphoresis.

Chest Pain 52

Chest Pain Ultrasound Risk Factors Diabetes 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), In Septal STEMI , transmural ischemia of the septum is recorded by the overlying lead V1 as ST Elevation. Lead III is also on the right and might manifest ST Elevation in Septal STEMI. with ADDED STE in III?

Ischemia 52

Ischemia Pulmonary STEMI 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

APRIL 24, 2020

A middle aged man had off and on chest pain for 2 weeks, then 2 hours of more severe and constant pain. When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. Here was his ED ECG, which was identical to the prehospital ECG. He did not get prehospital activation. What do you think?

Ischemia 52

Ischemia Chest Pain Stenosis Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 24, 2013

There is no way to tell the difference between GI etiology of chest pain and MI. Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. An emergency cardiac ultrasound could be very useful.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? This is the initial ED ECG of a 46 year old male with chest pain: The QTc was 420 ST Elevation at 60 ms after the J-point in lead V3 = 2.5

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. EMS gave 324 mg aspirin and 3 sublingual NTG, which the patient stated reduced the substernal chest pain from an 8/10 to 4/10. This was a point of care ultrasound, not a bubble contrast echo. Is this OMI?

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. Case 3 : Male in 30's with chest pain, cough, and fever. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think?

STEMI 52

STEMI Chest Pain Cardiac Arrest Stent 52

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion.

Arrhythmia 116

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 116

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Case A 47 year old male called 911 for severe chest pain. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. The ST depression may be the most visibly obvious sign of STEMI. Some are STEMI-equivalents.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 To, me these look like anterior wall motion abnormality, but I showed them to one of our ultrasound fellows who is very interested in this. She was having a transient STEMI, briefly. She called 911.

STEMI 52

STEMI Chest Pain Hospital Risk Factors 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. His ED cardiac ultrasound (which is not at all ideal for detecting wall motion abnormalities, and is also very operator dependent for this finding) was significant for depressed global EF. Later on during the night of his admission he had a short episode of chest pain that resolved with sublingual nitroglycerin.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

The patient said his chest pain was 4/10, down from 8/10 on presentation. On intravascular ultrasound (IVUS), the mid RCA plaque was described as "cratered, inflamed, and bulky," and the OM plaque was described as "bulky with evidence of inflammation and probably ulceration." Repeat hsTnI was 183 ng/L, up from 26 ng/L.

Angina 109

Angina Plaque Document Stent 109