Dr. Smith's ECG Blog

JUNE 23, 2024

Stated differently, the differential diagnosis for the presenting syndrome was either ventricular fibrillation due to acute coronary syndrome, or idiopathic ventricular fibrillation and bystander stable CAD. The electrophysiologist is a reader of Dr. Smith's ECG Blog. They consulted EP for evaluation for ICD.

Coronary 108

Coronary CAD CPR Critical Care 108

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. When you register on the app, you need to say you are from a supported country in the EU.

STEMI 115

STEMI CAD ED ALS 115

Dr. Smith's ECG Blog

FEBRUARY 12, 2024

(THE PM CARDIO OMI AI APP) If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.

CAD 84

CAD ED OR Coronary 84

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. This is typical of pericarditis.

STEMI 60

STEMI Coronary CAD ED 60

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. HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA. This was stented with a 2.25

CAD 89

CAD STEMI ACS ALS 89

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 118

STEMI Coronary ALS CAD 118

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

DECEMBER 16, 2018

She had a normal EF, and no significant CAD, and was taking flecainide to suppress the AF. Wide-complex tachycardia: VT or aberrant, or "other?" This case is contributed by Brooks Walsh , an EM physician and ECG expert from Connecticut. The case An older woman presented to the ED with dyspnea, diaphoresis, and chest pressure.

OR 52

OR ED CAD Overdose 52

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 103

ED Coronary CAD STEMI 103

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. Written by Pendell Meyers A man in his 70s with no cardiac history presented with acute weakness, syncope, and fever. He denied chest pain or shortness of breath. PM Cardio digitized version.

E-9-1-1 70

E-9-1-1 CAD OR STEMI 70

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. Angiography Angiography was performed after aspirin and heparin were started.

Coronary 52

Coronary CAD ACS STEMI 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. The K was normal.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

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

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). There is also STD in V2-V4 (but maximal in V5-V6).

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. V1 has 0.5 mm of elevation. ng/mL [IQR: 0.46, 2.35]. Learning Points: 1.

Emergency Department 52

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

Dr. Smith's ECG Blog

MAY 10, 2023

CAD-RADS category 1. --No At this point, with the information above, the patient's overall clinical picture could be consistent with either reperfused OMI, or Non-OMI, since both may have absent pain and inverted T waves. A repeat troponin returned at 0.45 ng/mL, consistent with reperfused OMI, or Non-OMI. A CT Coronary angiogram was ordered.

Coronary 52

Coronary STEMI CAD OR 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. He was diagnosed as NSTEMI.

ACS 83

ACS Coronary ALS CAD 83

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. No further troponins were measured. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack 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. Schick is a PGY3 at the Brown Emergency Medicine Residency in Rhode Island. I remember Allie well from her days in the Research volunteer program at Hennepin. F (rectal). There was a 0.9%

E-9-1-1 52

E-9-1-1 CAD STEMI OR 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. There is clearly a wide complex tachcyardia (although the QRS duration is not far above 120msec). Or it could simply still be classic VT. RVEF 100 ml/m2.

ED 79

ED OR ALS CAD 79

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 ). Not immediately, at least, because this is NOT diagnostic of ACUTE (occlusion) myocardial infarction (Acute OMI). We need to do some more investigation.

ED 52

ED Coronary ACS CAD 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

NOVEMBER 26, 2018

The rhythm differential for narrow, regular, and tachycardic is sinus rhythm, SVT (encompassing AVNRT, AVRT, atrial tach, etc), and atrial flutter (another supraventricular rhythm which is usually considered separately from SVTs). Therefore this patient is either in some form of SVT or atrial flutter. Fatigued-appearing but mentating perfectly.

STEMI 52

STEMI ACS CAD 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 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. The ECG normalized overnight. Maximum troponin was 2.1

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. This was sent by : Jacob Smith, DO Emergency Medicine Resident Ohio Health Doctors Hospital Emergency Residency Christopher Lloyd, DO, FACEP Director of Clinical Education, USACS Midwest Case A 30 year old patient presents to triage with chest pain.

STEMI 52

STEMI CAD Coronary ALS 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

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

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. Why did I say this? There is a down-up T-wave in aVF.

E-9-1-1 52

E-9-1-1 STEMI Coronary CAD 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

AUGUST 9, 2019

Beware crescendo angina in patient with known CAD ST Elevation in aVR Case 7. 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?" Total LM occlusion can present with STE or STD in aVR.

Coronary 52

Coronary STEMI ACS ALS 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

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

JULY 31, 2018

She had zero CAD risk factors. 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 hours of substernal chest pressure. There is 1 mm of STE in lead V2.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

In this study of dialysis patients with severe CAD, 77% had an abnormal resting EKG and the most common abnormality was LVH. Another reason may be that the EKG is more difficult to interpret in patients with dialysis due to baseline abnormalities, including LVH. Herzog et al. What can we learn? Herein lies the “ART” of electrocardiography.

CAD 52

CAD OR ED ALS 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

MARCH 6, 2019

She also had non-acute CAD of the left main (50%) and LCX (75%). Back to the case: The providers recognized persistent ischemia and likely occlusion, and discussed this with cardiology who took the patient immediately for cath. They found an acute, total, thrombotic occlusion of the proximal LAD. They opened it. Initial troponin T was 0.46

STEMI 52

STEMI ALS ACS OR 52