Dr. Smith's ECG Blog

NOVEMBER 19, 2024

No prior similar symptoms or known CAD. As we often emphasize in Dr. Smith's ECG Blog — i n a patient with new CP , the finding of ST depression maximal in leads V2 , V3 and/or V4 = acute posterior OMI until proven otherwise. He took two full strength aspirin prior to EMS arrival. The pain was relieved by one prehospital NTG spray.

OR 105

OR STEMI Coronary CAD 105

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System.

CAD 91

CAD STEMI ACS ALS 91

Dr. Smith's ECG Blog

JANUARY 20, 2024

Scattered other nonobstructive CAD. The STEMI registry will show very high sensitivity of the ECG for STEMI, obscuring the fact the STEMI has low sensitivity for OMI Queen of Hearts sees it easily, like readers of the blog would.

STEMI 117

STEMI CAD ED ALS 117

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 19, 2024

The ED provider ordered a coronary CT scan to assess the patient for CAD. Regular readers of Dr. Smith's ECG Blog are well familiar with what is perhaps my favorite Stephen Smith Adage = "You diagnose acute pericarditis at your peril!" Another blood pressure was checked.

STEMI 60

STEMI Coronary CAD ED 60

Dr. Smith's ECG Blog

FEBRUARY 12, 2024

This is for the version housed on Telegram: [link] You can get the full PM Cardio app here if you live in the UK or EU (or say you do upon registration): [link] Case Continued The cath lab was activated and the patient received 180 mg of ticagrelor, and then was transported to the cath lab.

CAD 87

CAD ED OR Coronary 87

Dr. Smith's ECG Blog

APRIL 18, 2024

Similarly, if a patient with known CAD presents with refractory ischemic chest pain, the ECG barely matters: the pre-test likelihood of acute coronary occlusion is so high that they need an emergent angiogram. 1] European guidelines add "regardless of biomarkers".

STEMI 119

STEMI Coronary ALS CAD 119

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

PEARL #2: = Aslanger's Pattern: Examples of Aslanger's Pattern appear in a number of cases in Dr. Smith's ECG Blog ( This pattern is very nicely described by Dr. Smith in the January 4, 2021 post). Patient stated that he has had glucose over 400 even though he has not missed any doses of insulin.

ED 106

ED Coronary CAD STEMI 106

Dr. Smith's ECG Blog

OCTOBER 24, 2019

However, a smooth tapering of the mid-RCA was seen, highlighted in red below: How do we explain the MI if no sign of CAD was found? This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA. This case occurred 10+ years ago.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MARCH 20, 2023

So, I'm a follower of your blog, and I think I have a interesting case that I attended yesterday." Angiogram soon after (around 4 hrs after presentation) showed multi vessel CAD, with culprit lesion total occlusion of the first obtuse marginal branch (OM1), which was stented. Risk Factors: High Cholesterol. Vitals Signs: Normal."

STEMI 52

STEMI ACS CAD ED 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. This is a re-post of an excellent case from 2021. See it again now, along with our new Queen of Hearts functionality. We've come a long way in 2 years! And the pace only quickens.

OR 126

OR STEMI Coronary CAD 126

Dr. Smith's ECG Blog

JULY 22, 2023

The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. She has not had a heart catheterization or after this event so the presence or absence of CAD is still unknown. mm ( generally ≥2 mm ) in ≥1 right precordial lead, followed by a positive T-wave. —

E-9-1-1 73

E-9-1-1 CAD OR STEMI 73

Dr. Smith's ECG Blog

MARCH 19, 2023

Concerning history, known CAD" Recorded 2 hours after pain onset: What do you think? To realize — Assessment of ECG #1 is complicated by knowing: i ) That today’s patient has a history of documented CAD ; and , ii ) The lack o f a prior tracing for comparison at the time the initial ECG was interpreted.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

MAY 19, 2020

Diagnosis of MINOCA should be made according to the Fourth Universal Definition of MI, in the absence of obstructive coronary artery disease (CAD) (no lesion ≥50%). The authors recommend using optical coherence tomography or intravascular ultrasound imaging in patients with evidence of nonobstructive CAD by angiogram. myocarditis).

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

As in all ischemia interpretations with OMI findings, the findings can be due to type 1 AMI (example: acute coronary plaque rupture and thrombosis) or type 2 AMI (with or without fixed CAD, with severe regional supply/demand mismatch essentially equaling zero blood flow).

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

J Electrocardiol [Internet] 2022;Available from: [link] Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%) V Fib Cardiac arrest Prolonged QTC NSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different) Moderate single-vessel CAD. I could have told you this (and did tell you this) without an MRI.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

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. Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

MAY 10, 2023

CAD-RADS category 1. --No For interested readers, in My Comment in the August 12, 2022 post of Dr. Smith's ECG Blog — I reviewed the original 1982 description of this Syndrome by de Zwaan, Bär & Wellens — and correlated this original description with our understanding of this Syndrome today. A CT Coronary angiogram was ordered.

Coronary 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

A formal echocardiogram was completed the next day and again showed a normal ejection fraction without any focal wall motion abnormalities to suggest CAD. She has not had a heart catheterization or after this event so the presence or absence of CAD is still unknown. The Troponin I was cycled over time and was 0.353 followed by 0.296.

E-9-1-1 52

E-9-1-1 CAD STEMI OR 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

The phenomenon of fragmentation has been discussed and illustrated numerous times on Dr. Smith’s ECG Blog ( I’ll add reference to THIS CASE of mine ).

ED 52

ED Coronary ACS CAD 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

No family history of sudden cardiac death, cardiomyopathy, premature CAD, or other cardiac issues. No similar symptoms in the past. No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion.

Coronary 52

Coronary STEMI Heart Attack OR 52

My Paramedic Blog

JULY 8, 2014

I hop into the ambulance, and log onto the CAD (Computer Assisted Dispatch) device. The call pops up onto our CAD. I look at the notes on the CAD it read: Crowning. Partner: “I’d prefer driving if you don’t mind.” Me: “Sure, that’s all good with me.” I wonder what intoxicated person we are going to pick up tonight. Me: “99 Fox.”

CAD 52

CAD Paramedic Ambulance Firefighter 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

They found non-obstructive CAD, with only a 20% stenosis of OM2 and 10% RCA. As we have described multiple times on this blog, false positive "pericarditis" kills by distracting the clinician from actual emergencies including OMI, dissection, PE, and others. A repeat ECG was performed and cardiology was re-consulted: Roughly unchanged.

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 1, 2012

This was a middle aged female with a h/o CAD who presented to the ED by EMS sudden onset of central chest pressure 45 min prior to ED arrival with associated diaphoresis and SOB.  There is LVH and there are ST-T abnormalities (large inferior T-waves and ST elevation, with reciprocal findings in aVL).

STEMI 52

STEMI CAD ED EMS 52

Dr. Smith's ECG Blog

JUNE 2, 2023

Late Gadolinium enhancement: Multifocal scarring of the septum (including RV septum), basal anterior wall and transmural mid inferior region scarring - a non-CAD hyperenhacement pattern. For review of a case of RVOT VT — Please see My Comment at the bottom of the page in the February 14, 2022 post in Dr. Smith's ECG Blog.

ED 82

ED OR ALS CAD 82

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. I saw this 59 year old male 3 weeks ago. Blood pressure was 150/80.

STEMI 52

STEMI CAD OR 52

Dr. Smith's ECG Blog

JUNE 12, 2017

He had a family history of early CAD and occasional drug and tobacco use. It is not yet available, but this is your way to get on the list. link] Here is the history: A 30 yo man presented complaining of severe chest pain. The ECG was alarming to the ED physician who did indeed review it.

STEMI 52

STEMI CAD Coronary ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

These findings are very subtle but suspicious for LAD occlusion, as we have seen in many similar (but less difficult) cases on this blog: A man in his sixties with chest pain at midnight with undetectable troponin How long would you like to wait for your Occlusion MI to show a STEMI? He also had non-acute CAD of the RCA (50%) and LCX (50%).

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

We also asked one of our electrophysiologists who states that patients should not be started on flecainide without first ruling out CAD, to prevent situations like this. The lower heart rate was maintained, as were the ST segment changes above, over the next 10 minutes in the resuscitation room. He was taken to the cath lab.

STEMI 52

STEMI ACS CAD OR 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Here is a case that demonstrates this very well: Isolated "Inferior" ST Segment Depression: Not a Sign of Inferior Ischemia Here is the most viewed post of all time on Dr. Smith's ECG Blog, with nearly 100,000 views: Five Primary Patterns of Ischemic ST depression, without ST elevation. Some are STEMI-equivalents.

E-9-1-1 52

E-9-1-1 STEMI Coronary CAD 52

Dr. Smith's ECG Blog

JANUARY 28, 2018

He has a history of known CAD, diabetes, and dyslipidemia. This post was written by one of our fantastic Hennepin County Medical Center Emergency Medicine interns who is an ECG whiz, Daniel Lee. A man is his late 50’s presents to the ED with 1 hour of post exertional chest pressure associated with diaphoresis and nausea.

Coronary 52

Coronary STEMI CAD ED 52

Dr. Smith's ECG Blog

OCTOBER 26, 2020

The patient was transferred immediately for angiogram which revealed no significant CAD, and no intervention was performed. As I “confessed” in the September 26, 2018 post of Dr. Smith’s ECG Blog — my brain is “programmed” to interpreting 12-lead ECGs and rhythm strips at the 25 mm/second speed that is standard in the United States.

Coronary 52

Coronary Defibrillator ACS CAD 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. Here is his ECG: The resident was alarmed at the "ST elevation in III with reciprocal ST depression in aVL" Are you alarmed? This is a very common misread. It may be difficult to read STEMI in the setting of RBBB. The trick is to find the end of the QRS.

STEMI 52

STEMI CPR CAD Coronary 52

My Paramedic Blog

AUGUST 29, 2013

I want to thank all those who continues to read this blog, and I hope you will find your inspiration to continue pursuing your dreams and what you love. We found the address matching that of a farm, but the message on our CAD (Computer Assisted Dispatch System) said the location was towards the back of the farm and in a trailer.

Paramedic 52

Paramedic Ambulance CAD EMS 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 ACS Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 18, 2013

So I went to look at the chart and here is the history: This patient with no h/o CAD had a couple of episodes of chest pain during the day, then presented with one hour of substernal chest pain that had some reproducibility but also improved from 10/10 to 5/10 with nitroglycerine.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

DECEMBER 16, 2018

She had a normal EF, and no significant CAD, and was taking flecainide to suppress the AF. The case An older woman presented to the ED with dyspnea, diaphoresis, and chest pressure. The patient had a history of paroxysmal atrial fibrillation and several cardioversions.

OR 52

OR ED CAD Overdose 52