Dr. Smith's ECG Blog

JUNE 23, 2024

He was intubated in the field and sedated upon arrival at the hospital. This was interpreted by the treating clinicians as not showing any evidence of ischemia. Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. Two subsequent troponins were down trending.

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Chest Pain Cardiac Arrest Sudden Cardiac Death Blog 118

Stroke Journal

JANUARY 30, 2025

Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We

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Dr. Smith's ECG Blog

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.

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Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is female in her 80s with a medical hx of previous MI with PCI and stent placement. Are you confident there is no ischemia? Primary VT , and the VT with tachycardia is causing ischemia with chest discomfort (supply-demand mismatch/type 2 MI)? The last echocardiography 12 months ago showed HFmrEF.

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Tachycardia Electrophysiology Atrial Flutter Ischemia 119

DAIC

MAY 14, 2024

The benefits of QFR guidance are supported in a recent study that showed that a QFR-guided strategy of lesion selection for PCI improved two-year clinical outcomes, including reduction in myocardial infraction and ischemia-driven revascularization, when compared with standard angiography guidance alone.2

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Coronary Artery Disease Interventional Cardiology Innovation Physiology 111

Frontiers in Cardiovascular Medicine

FEBRUARY 29, 2024

In this study, we collected case data of patients who underwent cardiac major vascular surgery at our hospital to analyze the effectiveness of reoperation treatment options for type A aortic dissection and to summarize our treatment experience.

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Aortic Quality of Life Stents Stent 49

Dr. Smith's ECG Blog

OCTOBER 28, 2013

STE limited to aVR is due to diffuse subendocardial ischemia, but what of STE in both aVR and V1? The additional ST Elevation in V1 is not usually seen with diffuse subendocardial ischemia, and suggests that something else, like STEMI from LAD occlusion, could be present. Was this: 1) ACS with ischemia and spontaneous reperfusion?

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Cardiac Arrest Ischemia Defibrillator Electrocardiogram 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

He was admitted to the hospital for evaluation of these symptoms — but no ECG was done at that time. The patient’s angiogram should have been expedited, but the EKG change was not recognized as recurrence of transmural ischemia. RAO Caudal View Post PCI This is the RAO Caudal view after thrombectomy and stent placement.

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Chest Pain Blog Hospital Tachycardia 120

Ken Grauer, MD

AUGUST 26, 2023

About 20 minutes later ( on the way to the hospital ) — the patient's CP resolved, and ECG #1 was recorded. That the "culprit" artery spontaneously opened ~20 minutes later while the EMS unit was en route to the hospital ( at which time the patient's CP had resolved — and ECG #1 was obtained ).

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Blog Chest Pain STEMI Ischemia 144

Dr. Smith's ECG Blog

JUNE 11, 2021

Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes. So the RCA was stented.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Stroke: Vascular and Interventional Neurology

NOVEMBER 9, 2023

IntroductionDelirium is an acute cognitive or perceptual disturbance that is associated with prolonged hospital and ICU length of stay, therefore, extending recovery time. This is secondary to delayed postoperative cerebral ischemia and infarction caused by vasospasm.7

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Aneurysm Stroke Strokes Ischemia 40

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. It was opened and stented. Data from stress testing proves that the ST depression of ischemia does not localize.

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Ischemia Chest Pain STEMI Stenosis 40

Dr. Smith's ECG Blog

MARCH 9, 2017

As above, it is unclear from the history whether the patient was experiencing chest pain at the time of this ECG, but these right precordial t-wave findings were appreciated and the patient was treated with medical therapy and admitted to the hospital.

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Chest Pain Angina Ischemia Plaque 52

Dr. Smith's ECG Blog

AUGUST 11, 2024

Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. Cath lab was activated, and found a 95% proximal LAD occlusion which was stented. Figure-1: I've put together the 2 pre-hospital ECGs in today's case — which focus on the initial rhythm. (

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Chest Pain STEMI Bradycardia Stents 100

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. Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls. It was stented.

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Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

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Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital.

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Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

JULY 11, 2018

He did, found the true culprit, and went back in to stent it. Figure-1: Initial ECG, obtained pre-hospital from this 40-ish year old woman with new-onset chest pain ( See text ). Figure-2: TOP — Initial ECG obtained pre-hospital. See P.S. below ) == P.S. : I believe I found another example of ischemia-induced J waves ( See Oct.

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Chest Pain STEMI Ischemia Blog 52

EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. Upon hospital arrival, the patient verbalized slight attenuation of pain. He was rushed to the Cath Lab where an LAD culprit lesion was stented.

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STEMI Stents Stent Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Written by Pendell Meyers, edits by Steve Smith A man in his 60s with history of hypertension and MI 10 years ago, with PCI, presented to an outside hospital complaining of chest pain that started while mowing the lawn. The LAD lesion was acute and required 3 stents to restore flow. Here is his ECG on arrival: What do you think?

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Aneurysm 52

EMS 12-Lead

AUGUST 14, 2022

However, upon entry into the respective hospital campus, the patient experienced restoration of pain and displayed an uncomfortable grimace. One stent was deployed with restorative TIMI-0 flow. The patient’s vital signs remained stable, and he was equally comfortable, even verbalizing that his pain had mostly resolved.

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STEMI Sudden Cardiac Death Thrombosis Thrombolysis 52

Dr. Smith's ECG Blog

JULY 31, 2018

Post by Smith, with short article by Angie Lobo ( [link] ), a third year intermal medicine resident at Abbott Northwestern Hospital Case A 30-something woman with no past history, who is very fit and athletic, presented with 1.5 It was late evening and the patient will be in the hospital overnight with a potentially very unstable LAD lesion.

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SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

Troponin profile The patient underwent angiography and had a 90% thrombotic proximal LAD lesion that was stented. This patient's ischemia was so brief that it did not cause any myocardial stunning. This patient's ischemia was so brief that it did not cause any myocardial stunning.

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Chest Pain Ischemia STEMI Stents 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

He had been seen several weeks ago at an outside hospital for a similar issue and had been discharged home, presumably after unremarkable workup. This proves that the first one was, surprisingly, due to ischemia!! He was successfully treated with one drug eluting stent. Occurred while driving to a doctor’s appointment.

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Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

Ischemic Hyperacute T waves (Tall, round, symmetric, vs the “pointy” peaked-T’s of HyperK), are often a clue to ischemia. Interestingly, in further review of the chart it seems the patient was admitted to the hospital floor 3 weeks prior for an unrelated surgical procedure. The T-waves here are not upright or particularly large.

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Dr. Smith's ECG Blog

FEBRUARY 6, 2023

The ECG was incorrectly interpreted as no signs of ischemia. Admitted to the hospital service for further evaluation and management." Artificial intelligence can be trained to recognize subtle OMI = My Comment by K EN G RAUER, MD ( 2/6 /2023 ): = The initial ECG in today's case was incorrectly interpreted as, "No signs of ischemia".

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Chest Pain Physiology Blog Stents 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. He requested transport to the hospital out of an abundance of caution, and all subsequent serial ECG’s showed no changes from Figure 1-2, shown above. Attached is the first ECG.

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Myocardial Infarction Stents Stent STEMI 52

Dr. Anish Koka

MAY 16, 2023

There may be no better study to symbolize the dysfunction that has invaded cardiology than the VIRGO trial, a study examining the outcomes of young patients (18-55) presenting to the hospital with a heart attack. In the modern era patients who survive a cardiac event to present to the hospital generally do well. This happens.

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Chest Pain Coronary Artery Disease Cancer Heart Attack 52

Dr. Smith's ECG Blog

MARCH 11, 2016

It was treated with and dual "kissing balloons" and drug eluting stents. Here is the post stent ECG: There is greater than 50% resolution of ST elevation (all but diagnostic of successful reperfusion) and Terminal T-wave inversion (also highly suggestive of successful reperfusion). TIMI flow is 0. Door to balloon time was 51 minutes.

Myocardial Infarction 52

Myocardial Infarction Pericarditis STEMI Angina 52

Dr. Smith's ECG Blog

APRIL 8, 2016

This was stented. If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. I have read articles that say that patients without ischemia are at low risk of complications from hypokalemia, But it is not entirely without risk.

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STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. His initial cTnI at the receiving hospital was 27 ng/mL, and no further troponins were measured thereafter. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent.

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Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Case 4 Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04 After many hours, the decided that it was appropriate to do an angiogram and they found a distal LAD occlusion which was opened and stented. This makes it almost certain that the ST elevation on the first one is due to ischemia.

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Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. He was successfully stented. The patient never arrested during his time at the hospital and his prognosis is good. His troponin I peaked at 6.107 ng/mL. He was discharged neurologically intact and did very well.

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Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

distal stent patent. Setting Secondary and tertiary care hospitals in the United Kingdom and United States. Given our concern about possible subtle high-lateral OMI — this raises the question whether the upright T waves in leads V1 and V2 of this 1st ECG might be abnormal and reflect ischemia. The cath lab was activated.

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Myocardial Infarction Chest Pain Cardiogenic Shock STEMI 52

Dr. Smith's ECG Blog

MARCH 25, 2025

There is low voltage in the precordium which always makes reading ischemia harder. In ACS, chest pain is the warning sign of ongoing ischemia. Smith : As Willy says, and as we've said many times before, morphine will resolve pain without resolving ischemia. ECG 1 What do you think? To me, this ECG is not diagnostic.

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Chest Pain Ischemia Plaque Stents 63

Dr. Smith's ECG Blog

OCTOBER 31, 2024

He works in a small hospital in Northern Michigan. The patient was transferred to a hospital with PCI capability. Here is the circumflex after stenting: Wide open The cardiologist called Dr. Lufkin back and said "Great call!!" This case was sent by an old residency friend, Kirk Lufkin. Case A 61 year old female.

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STEMI Arrhythmia Stents Stent 117

Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. He had a 100% RCA occlusion which was stented.

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Chest Pain STEMI Stents Stent 116