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. The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible.

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Chest Pain STEMI Bradycardia Ischemia 114

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] The patient was found to be hypertensive and treated accordingly.

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Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

JUNE 11, 2021

Case submitted and written by Dr. 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. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes.

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Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

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. It was stented. Comment: most T-wave inversion is nonspecific, but not these ones!

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Chest Pain Myocardial Infarction Thrombosis STEMI 52

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. Peak troponin was 12 ng/mL.

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Chest Pain Myocardial Infarction Blog Stents 131

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. Two stents were placed with resultant TIMI 3 flow.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. The patient’s angiogram should have been expedited, but the EKG change was not recognized as recurrence of transmural ischemia.

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Chest Pain Blog Hospital Tachycardia 120

EMS 12-Lead

MAY 20, 2022

There is ventricular hypertrophy in the absence of abnormal loading conditions, such as aortic stenosis, or hypertension, for example – of which the most common variant is Asymmetric Septal Hypertrophy. There is LBBB-like morphology with persistent patterns of subendocardial ischemia.

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Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). It was thought to be an in stent restenosis and thrombosis from a DES placed in the same region 6 months prior. In there ECG evidence of possible ongoing ischemia? (ie, Herzog et al.

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Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

This is by Magnus Nossen, from Norway The patient is a 70 something male with a hx of hypertension and tobacco use disorder. In other words, the inferior ST segments in the first ECG show more straightening which is more concerning for ischemia. The culprit lesion was opened and stented. He is otherwise healthy.

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Chest Pain Blog Ischemia Risk Factors 60

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?

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Chest Pain STEMI Cardiac Arrest Aneurysm 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

She is somewhat hypertensive, but her vital signs are otherwise normal. Ischemic Hyperacute T waves (Tall, round, symmetric, vs the “pointy” peaked-T’s of HyperK), are often a clue to ischemia. She received PCI with 2 drug-eluting stents in overlying fashion. This was written by Sam Ghali ( @ EM_RESUS ), with a few edits by me.

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Chest Pain Aneurysm STEMI Document 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. So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

DECEMBER 29, 2015

Her vitals signs were remarkable for marked hypertension. All these factors, again, support an ECG diagnosis of LVH The patient was nonetheless taken for emergency angiography, and a 99% mid-LAD lesion was found and stented. It is unclear if ischemia modifies T wave height or morphology in LVH. 3 Is the STE concave or convex?

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STEMI Myocardial Infarction Chest Pain Aneurysm 40

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

The patient stated he had a long history of well-controlled hypertension for which he was compliant with his ACE-inhibitor. These findings are concerning for inferior wall ischemia with possible posterior wall involvement. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Anish Koka

MAY 16, 2023

Women also had more cardiovascular risk factors, including hypertension (66.6% The diagnosis typically requires classic clinical features, with no evidence of obstructive coronary disease, and typical findings of ischemia on functional studies. versus 63.2%; P <0.001), hyperlipidemia (68.9% versus 66.3%; P =0.004), older age (62.4±7.9

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Chest Pain Coronary Artery Disease Cancer Heart Attack 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

NOVEMBER 17, 2024

Written by Willy Frick A 51 year old man with hypertension presented with three hours of acute onset, severe midsternal chest pain associated with two episodes of nausea and vomiting. The operator performed intravascular ultrasound and visualized acute plaque rupture with thrombus formation and placed a stent. ECG 1 What do you think?

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Chest Pain Ischemia Stents Stent 110

Dr. Smith's ECG Blog

JANUARY 23, 2025

Case A 76 year old man with chronic hypertension but no history of coronary disease or myocardial infarction presented to the ED with chest pain at 2343. His triage EKG is shown below: There is left bundle branch block, so the EKG must be evaluated for ischemia by Smith-modified Sgarbossa criteria. ST elevation has now developed in V6.

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Chest Pain Ischemia STEMI Blog 116

Dr. Smith's ECG Blog

OCTOBER 31, 2024

hypertension no other past history presented with 30 minutes of fluctuating non-radiating heaviness in chest, with diaphoresis and nausea. 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. No cardiac past history.

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STEMI Arrhythmia Stents Stent 117

Dr. Smith's ECG Blog

JANUARY 31, 2025

Written by Magnus Nossen The ECG below was obtained from 50-something male with a history of hypertension and tobacco use. At cath there was a 100% proximal LAD occlusion, which was opened and stented. Transient ischemia may lead to "stunning". The ECG below ECG was recorded on the scene. How will you manage this patient?

STEMI 114

STEMI Chest Pain Myocardial Infarction Ischemia 114

Dr. Smith's ECG Blog

JANUARY 5, 2025

Written by Willy Frick A man in his 60s with hypertension and prior stroke presented with three days of crushing chest pain. Unfortunately, although natively conducted beats are the best ones for evaluating ischemia, we only have a few! Moving on to ischemia , the ECG shows reperfused inferoposterolateral infarct.

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Chest Pain Ischemia Angina Echocardiogram 77