Dr. Smith's ECG Blog

JUNE 29, 2018

Angiogram The patient did go for an angiogram and there was no occlusion present, and no definite culprit, although there was diffuse CAD and one possible culprit: "There is a medium-large caliber OM3 with 40-50% stenosis in the mid-segment and lumen irregularity that could suggest dissection or plaque rupture, but TIMI III flow throughout."

CAD 52

CAD Coronary OR 52

Dr. Smith's ECG Blog

MAY 28, 2024

Multivessel CAD 2. The calculated post stress ejection fraction is 44%. Inferolateral/anterolateral/inferior akinesis noted. EKG reveals marked ST segment depression at rest and following stress. Cardiology consult impression 1. Ischemic cardiomyopathy, EF 45 --> 20% 3.

Coronary 52

Coronary CAD ACS STEMI 52

EMS 12-Lead

AUGUST 18, 2024

He denied any known history of CAD, but did report ASCVD risk factors to include HTN, HLD, and DM. Readers of the Smith ECG Blog will probably recognize this a very subtle inferior OMI. The VT vs SVT with Aberrancy debate is beyond the scope of this particular blog post. Here is the ECG after 200J. Examples provided below.

CAD 147

CAD ACS EMT EMT 147

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Edited by Smith He also sent me this great case.

CAD 132

CAD STEMI Coronary ACS 132

Dr. Smith's ECG Blog

MAY 29, 2024

Patient 2 A man in his 50s with history of CAD and prior PCI, diabetes, presented with acute constant chest pain for the past few hours. Triage ECG: It was interpreted as lateral STEMI, and he was sent to the cath lab, where the angiogram showed unchanged CAD from known prior, with no acute culprit. He was discharged home.

CAD 122

CAD OR STEMI 122

Dr. Smith's ECG Blog

APRIL 9, 2024

By Magnus Nossen This ECG is from a young man with no risk factors for CAD, he presented with chest pain. Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. Keep an eye on the blog as an OMI QUIZ soon will be published where you test yourself vs the Queen!

Coronary 113

Coronary CAD ACS OR 113

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 118

CAD STEMI ACS ALS 118

Dr. Smith's ECG Blog

JANUARY 1, 2018

No known risk factors for ACS/CAD. A medic sent this case A 33 yom who presented to an urgent care facility with a complaint of chest pain for several days. His chest pain started after he began taking a testosterone supplement.

CAD 40

CAD ACS Paramedic OR 40

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 109

CAD ED OR Coronary 109

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 128

STEMI Coronary ALS CAD 128

ESO

SEPTEMBER 5, 2024

With API , participating CAD and RMS vendors will be able to automatically send data back and forth to NERIS. For any CAD and RMS vendors who are interested, you can share information and ask questions during the USFA development tea m’s regular NERIS office hours.

CAD 59

CAD PSAP Mobile Integrated Health Community Paramedicine 59

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 125

ED Coronary CAD STEMI 125

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 134

OR STEMI CAD Coronary 134

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

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.

CAD 52

CAD Coronary ACS STEMI 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 64

STEMI Coronary CAD ED 64

Dr. Smith's ECG Blog

JANUARY 16, 2025

Transferred to our ED and taken to cath lab Cath- mild nonobstructive CAD, mild mid LAD bridge Echo- EF 65-70%, normal wall motion, no diastolic dysfunction. "Feels like a fake to me, but would be an awful miss so I would be very careful 4. STE from lead I all the way around to lead III would be pretty unusual for OMI, I guess."

CAD 52

CAD ACS STEMI ED 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.

STEMI 52

STEMI 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

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

SEPTEMBER 4, 2023

Multivessel coronary artery disease --severe 3v CAD --subtotal occlusion mLAD with TIMI-1 flow --D1 subtotal occlusion --RCA 80% mid stenosis --Lcx OM2 ostial stenosis 70% Ischemic cardiomyopathy, LVEF 30% Acute decompensated heart failure Hypoxic respiratory failure, now resolved Here is an MRI image of the LV aneurysm.

CAD 52

CAD Coronary OR 52

Dr. Smith's ECG Blog

APRIL 24, 2015

He had a history of CAD with CABG. A middle-aged male had a V Fib arrest. He had not complained of any premonitory symptoms (which is very common). Here was his initial ED ECG: There is atrial fibrillation with a rapid ventricular response. There is profound ST depression especially in I, II, V2-V6.

Defibrillator 52

Defibrillator ACS CAD 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

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 89

ACS Coronary ALS CAD 89

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

JANUARY 19, 2025

Inferior STEMI s/p DES with significant residual LM/left sided obstructive CAD : TnI 11,344 on admission, suggesting significant infarct prior to presentation. Subsequently, determined that the patient was too unstable for transfer in the current state. Hence, decision made to ECMO cannulation prior to transfer.

MICU 52

MICU ICU CAD STEMI 52

ESO

JULY 3, 2024

On May 6, 2024, version 1 of NERIS core data schema was released, including: Fire Department (Entity) Specification CAD/Dispatch schema Incident schema Since the upgrade was announced, ESO’s Fire Incidents team has been preparing and planning to ensure your team will be ready for the transition to NERIS.

Mobile Integrated Health 52

Mobile Integrated Health MIH Critical Care Community Paramedicine 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

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

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 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. In Figure-1 I have excerpted from the above blog post, the Pearls of Wisdom from Drs.

ACS 52

ACS STEMI Coronary 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

JUNE 20, 2020

A 75 yo with h/o CAD, CABG, and HFrEF presented after a syncopal episode. There was no prodrome and no associated symptoms such as SOB or CP. The medics recorded an ECG: There is STE in V1-V3 and aVL, with reciprocal ST depression in II, III, aVF. The medics were worried about STEMI, as it meets STEMI criteria. What do you think?

STEMI 52

STEMI CAD OR Coronary 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

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 ED 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 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