Chest Pain and Thrombosis - Cardiovascular Update

ECG Blog #448 — A Young Man with Chest Pain.

Ken Grauer, MD

SEPTEMBER 21, 2024

For example, considering whatever symptoms that the patient may have had ( ie, chest pain, palpitations, shortness of breath, etc. ) — what this might mean in view of the ECG we are looking at. STEP #2 = Clinical Impression — in which we correlate our assessment that we made in Step #1 to the clinical situation at hand.

Chest Pain

Chest Pain Blog Thrombosis Tachycardia

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

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.

Chest Pain

Chest Pain STEMI Aneurysm Stent

Severe Chest Pain on ED Arrival, after Wellens' waves Seen on Prehospital ECG

Dr. Smith's ECG Blog

MARCH 13, 2023

A 40-something woman called 911 in the middle of the night for Chest pain that was intermittent. On arrival, she complained of severe pain. The medics had recorded this ECG and were uncertain whether it was recorded during chest pain: Let's get a better image with use of the PM Cardio app : What do you think?

Chest Pain

Chest Pain Myocardial Infarction Angioplasty Thrombosis

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A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Dr. Smith's ECG Blog

JANUARY 9, 2023

No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. 24 yo woman with chest pain: Is this STEMI?

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Intravascular Imaging Can Improve Outcomes for Complex Stenting Procedures

DAIC

APRIL 2, 2025

The ECLIPSE trial shows that use of IVI to guide coronary stenting in severely calcified lesions prevents death, stent thrombosis, and unplanned repeat procedures in this high-risk patient population. The ECLIPSE trial results were presented at the American College of Cardiology Scientific Session (ACC.25)

Stent

Stent Stents Outcomes Coronary Angiogram

Abstract 4137144: Return to Cath Lab: Chest Pain Resolution after Right Coronary Artery Chronic Total Occlusion Intervention

Circulation

NOVEMBER 11, 2024

Introduction:Subacute stent thrombosis (ST) is related to high rates of cardiac reinfarction. The patient’s chest pain (CP) was not alleviated with initial revascularization of his left circumflex (LCx) ST, requiring PCI to his right coronary artery (RCA) chronic total occlusion (CTO). We present a case of reinfarction from ST.

Chest Pain

Chest Pain Coronary Artery Disease Angioplasty Thrombosis

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

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. But the patient's chest pain continues and so you order a 2nd ECG (ECG 2 here). He walked in to triage. I would expect that a stent would be placed.

Chest Pain

Chest Pain STEMI Stent Stents

Abnormal echocardiographic finding mimicking paracardiac cystic lesion

Heart BMJ

AUGUST 14, 2024

Previous medical interventions included a spectrum of procedures, including catheter-directed thrombectomy for popliteal artery aneurysms with thrombosis, vascular bypass grafting for cerebral-anterior communicating artery aneurysms and arch replacement and stent implantation for aortic dissecting aneurysms.

Aneurysm

Aneurysm Chest Pain Myocardial Infarction Thrombosis

Case Report: PROS1 (c.76+2_76+3del) pathogenic mutation causes pulmonary embolism

Frontiers in Cardiovascular Medicine

OCTOBER 10, 2024

The patient had experienced one month of chest pains, coughing and hemoptysis symptoms. Ultrasound showed no thrombosis in the veins of both lower limbs. The patient's father and grandfather have a history of lower limb venous thrombosis. The patient was diagnosed with acute pulmonary embolism and pneumonia.

Embolism

Embolism Pulmonary Chest Pain Thrombosis

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

5 We are aware that the current consensus is that the propensity for plaques to rupture is independent of plaque size; however, in our opinion, the hypothesis that small atherosclerotic plaques are the most likely to rupture, with resulting occlusive thrombosis, is unproven. These are typical findings at sites of plaque rupture.

Ischemia

Ischemia Plaque Stenosis Myocardial Infarction

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

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

Coronary Angiogram Plaque Thrombosis STEMI

Elder Male with Syncope

EMS 12-Lead

APRIL 9, 2024

There was no chest pain. V1 and V2 are probably placed too high on the chest given close morphological similarity to aVR. Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates). The fall was not a mechanical etiology. Type I ischemia.

Ischemia

Ischemia Stenosis Chest Pain Coronary Artery Disease

How important are old ECGs in Non-obvious cases of potential OMI?

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). She has no chest symptoms. What is the diagnosis?

Chest Pain

Chest Pain Blog Thrombosis Hospital

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest. Troponin was ordered. Am J Emerg Med.

Chest Pain

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Plan was for admission for chest pain workup. Jernberg T, et al.

Chest Pain

Chest Pain Thrombosis Myocardial Infarction STEMI

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

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

Plaque Chest Pain Thrombosis Stenosis

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Written by Pendell Meyers and Peter Brooks MD A man in his 30s with no known past medical history was reported to suddenly experience chest pain and shortness of breath at home in front of his family. Chest pain, SOB, Precordial T-wave inversions, and positive troponin. What is the Diagnosis? Now another, with ultrasound.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. His inpatient clinicians did not think that an urgent angiogram was warranted given that he was chest pain free, his EKG appeared nondiagnostic, and serial troponins were not elevating beyond 2 ug/L. Patients on dialysis often do not have chest pain in the setting of acute MI. Why is this?

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Case An elderly patient had acute chest pain and 911 was called. For this analysis, ACO was defined as angiographic evidence of coronary thrombosis with peak cardiac troponin-I (cTn-I) at least 10 ng/mL or cTn-T ≥ 1 ng/ mL. It is important for cardiologists to realize that a paramedic may see something they do not.

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

"The dye don't lie".except when it does. Angiogram Negative, or is it?

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

Written by Willy Frick A 40 year old woman was at home cooking when she developed chest pain. Furthermore, the operator worried about the patient's adherence to dual antiplatelet therapy, in which case she would be at risk for catastrophic stent thrombosis. She took an oxycodone and called EMS. I sent this to Drs.

Plaque

Plaque Stent Stents Chest Pain

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. He described it as "10/10" intensity, radiating across his chest from right to left. This is written by Willy Frick, an amazing cardiology fellow in St.

Plaque

Plaque Angina Blog Stent

Critical Left Main

EMS 12-Lead

JULY 24, 2023

But the symptoms returned with similar pattern – provoked by exertion, and alleviated with rest; except that on each occasion the chest pain was a little more intense, and the needed recovery period was longer in duration. Then, she attempted to reengage the activities at hand, and initially tolerated this well. Severe Hypoxia b.

Angina

Angina Ischemia Coronary Angiogram Stenosis

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia.

Ischemia

Ischemia STEMI Stenosis Chest Pain

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

Cardiology felt her chest pain to be, most likely, the result of coronary supply-demand mismatch in the context of HCM endothelial remodeling (i.e. Below are two examples of this. Type II MI), however decided to pursue coronary angiogram out of an abundance of caution. References Naidu, S. American College of Cardiology.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

Syncope and ST Elevation on the Prehospital ECG

Dr. Smith's ECG Blog

JUNE 20, 2020

He denied chest pain or dyspnea throughout. Nevertheless, I don't think a thrombosis related type I MI was ruled out here simply because the patient refused further evaluation. No previous study for comparison. Clinical Course: - He had no events on cardiac monitoring overnight. -

STEMI

STEMI Hospital Coronary Angiogram Dysrhythmia

Short-term recurrent coronary artery thrombosis with acute myocardial infarction in a patient with aplastic anemia–paroxysmal nocturnal hemoglobinuria syndrome: a case report

Frontiers in Cardiovascular Medicine

MARCH 14, 2025

Despite standardized coronary intervention and anticoagulant/antiplatelet therapy, the patient reported intermittent chest discomfort with persistently elevated cardiac troponin and d-dimer levels 20 days after initial treatment. Repeat coronary angiography confirmed recurrent thrombosis in the right coronary artery.

Myocardial Infarction

Myocardial Infarction Thrombosis Chest Pain Coronary Artery Disease

Myocardial infarction and pulmonary embolism in pancreatic cancer: a case report of two manifestations of Trousseau's syndrome

Frontiers in Cardiovascular Medicine

MARCH 30, 2025

This study reports a rare case of concurrent AMI and pulmonary thromboembolism in a patient diagnosed with pancreatic cancer.Case presentationA 70-year-old woman presented with acute chest pain and ST-segment elevation myocardial infarction, prompting immediate percutaneous coronary intervention (PCI) with the deployment of a drug-eluting stent.

Myocardial Infarction

Myocardial Infarction Embolism Cancer Pulmonary

Prehospital Cath Lab Activation. What happened when the medics and patient arrived at this Academic ED?

Dr. Smith's ECG Blog

NOVEMBER 14, 2024

This was texted to me by a paramedic while I was out running one day: "54 yo male chest pain started at 1pm. Here it is: Obvious inferior OMI, and now the STE in V1 is huge, with huge hyperacute T-waves of Right ventricular OMI The cath lab was re-activated: Angiogram: 100% occlusion mid-RCA occlusion (in-stent thrombosis).

Academic

Academic Stent Stents Thrombosis

Acute Dyspnea in a Dialysis Patient. K is 6.3 mEq/L. Are ECG findings due to hyperkalemia, or even due to Type 2 MI?

Dr. Smith's ECG Blog

JANUARY 21, 2025

He denied chest pain. This was most likely acute thrombosis of a coronary artery resulting in OMI: The ECG changes were attributed to hyperkalemia. It is correct that he did not have chest pain, but we must remember that fully 1/3 of full blown STEMI do not present with chest pain. The dye don't lie".except

Chest Pain

Chest Pain STEMI Tachycardia Myocardial Infarction

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

Angiography was technically challenging as the patient was receiving CPR, but the cardiologist suspected acute stent thrombosis and initiated cangrelor, although no repeat angiography was able to be obtained. He had no chest pain, dyspnea, or any other anginal equivalent, and his vital signs were normal.

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

ECG Blog #448 — A Young Man with Chest Pain.

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

Severe Chest Pain on ED Arrival, after Wellens' waves Seen on Prehospital ECG

Webinars

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Intravascular Imaging Can Improve Outcomes for Complex Stenting Procedures

Abstract 4137144: Return to Cath Lab: Chest Pain Resolution after Right Coronary Artery Chronic Total Occlusion Intervention

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

Abnormal echocardiographic finding mimicking paracardiac cystic lesion

Case Report: PROS1 (c.76+2_76+3del) pathogenic mutation causes pulmonary embolism

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Elder Male with Syncope

How important are old ECGs in Non-obvious cases of potential OMI?

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

"The dye don't lie".except when it does. Angiogram Negative, or is it?

Concerning EKG with a Non-obstructive angiogram. What happened?

Critical Left Main

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Hypertrophic Cardiomyopathy

Syncope and ST Elevation on the Prehospital ECG

Short-term recurrent coronary artery thrombosis with acute myocardial infarction in a patient with aplastic anemia–paroxysmal nocturnal hemoglobinuria syndrome: a case report

Myocardial infarction and pulmonary embolism in pancreatic cancer: a case report of two manifestations of Trousseau's syndrome

Prehospital Cath Lab Activation. What happened when the medics and patient arrived at this Academic ED?

Acute Dyspnea in a Dialysis Patient. K is 6.3 mEq/L. Are ECG findings due to hyperkalemia, or even due to Type 2 MI?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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