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. Lead-by-lead comparison of ECGs #1 and #2 shows definite improvement.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MAY 19, 2020

A followup ECG was recorded 2 days later: No definite evidence of infarction. 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%). In this case, profound shock for 1 hour would result in the same degree of infarction.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

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.

E-9-1-1 92

E-9-1-1 CAD OR STEMI 92

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. In my opinion, I think it looks more like subendocardial ischemia.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

MAY 10, 2023

CAD-RADS category 1. --No The most remarkable finding on ECG #1 — is fairly shallow but-definitely-present T wave inversion in leads V1-thru-V5. Now, with elevated troponins, Wellens' syndrome is likely. A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD

Coronary 52

Coronary STEMI CAD OR 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

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. Lead aVL, for example, has a definite J-wave. Stat echo would also be helpful.

ACS 52

ACS STEMI Coronary CAD 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

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

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. But this is not definite because the angiogram was not done at the same time as the ECG changes suggesting OMI. He was taken to the cath lab.

STEMI 52

STEMI ACS CAD OR 52

My Paramedic Blog

AUGUST 29, 2013

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. Sure doesn’t match the description we were given by dispatch, definitely not a ladies house! Me: “Pretty quiet here.”

Paramedic 52

Paramedic Ambulance CAD EMS 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. So, while the “ Bottom LINE ” is that we do not have a definitive answer — in the interest of academic discussion, I’ll present my rationale for why I believe the initial ECG shows AFlutter ( and not VT ) , in this patient with Flecainide toxicity.

OR 52

OR ED CAD Overdose 52

Dr. Smith's ECG Blog

JUNE 20, 2020

A 75 yo with h/o CAD, CABG, and HFrEF presented after a syncopal episode. The QRS duration is 118 ms , so by definition it is not Left Bundle Branch Block (which must be 120 ms at a minimum and is usually longer) Thus, LVH on the ECG does not always correlate with anatomic LVH. What do you think? There is LVH.

STEMI 52

STEMI CAD OR Coronary 52

Dr. Smith's ECG Blog

JULY 11, 2019

He also had non-acute CAD of the RCA (50%) and LCX (50%). B OTTOM L ine : While ECG #1 does not satisfy the definition of a STEMI — as per Dr. Meyers, it really looks like a cute L AD O MI. Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

As I met the paramedics and cath team in the lab, I was ready to see severe coronary disease (CAD), but the vessels were non-obstructive. 6,7 Surgical repair of AS, by either TAVR or SAVR, is the definitive treatment for this condition. Authors' commentary: Cardiogenic shock in the setting of severe aortic stenosis.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

MARCH 6, 2019

Lead I has a definitively hyperacute T-wave without STE. She also had non-acute CAD of the left main (50%) and LCX (75%). Clearly, if repeat ECG showed more diffuse, increased ST elevation — a definitive diagnosis of a STEMI would more easily be made. This ECG shows persistent Occlusion MI but does not meet STEMI criteria.

STEMI 52

STEMI ALS ACS ICU 52

Dr. Smith's ECG Blog

MARCH 24, 2023

Written by Jesse McLaren, with comments from Smith An 85 year old with a history of CAD presented with 3 hours of chest pain that feels like heartburn but that radiates to the left arm. Below is the ECG. What do you think? There’s sinus bradycardia, first degree AV block, normal axis, delayed R wave progression, and normal voltages.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

DECEMBER 31, 2024

The procedure was described as very complex due to severe multivessel CAD, but ultimately PCI was successfully performed to the ostial LCX. Final Diagnosis: "STEMI" (of course, as you can see in the ECGs above, this is not true, by definition this was NSTEMI. Pre-intervention. In other words, millimeters really don't matter!

Coronary 119

Coronary ACS STEMI CAD 119

Dr. Smith's ECG Blog

JANUARY 24, 2025

Written by Willy Frick A 52 year old man with hypertension, dyslipidemia, and seropositive rheumatoid arthritis (a risk factor for CAD) presented with acute substernal chest pressure with diaphoresis which woke him from sleep just after midnight. He said it felt like "someone ripped [his] heart out."

STEMI 125

STEMI CAD Coronary ED 125

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

No prior similar symptoms or known CAD. Here is the repeat 12 Lead ECG approximately 20 minutes later (still pain free) Now it shows definite reperfusion More inferior T-wave inversion Less STD in V2, V3. He took two full strength aspirin prior to EMS arrival. The pain was relieved by one prehospital NTG spray.

OR 110

OR STEMI Coronary CAD 110

Dr. Smith's ECG Blog

JANUARY 15, 2025

Case A 68 year old man with a medical history of hypertension, hyperlipidemia, and CAD with stent deployment in the RCA presented to the emergency department with chest pain. And so was missed "golden opportunity" to make a definitive diagnosis long before the 11 hours that it ultimately took to get this patient to the cath lab.

Coronary 68

Coronary ED CAD Paramedic 68