Filtered By:
Drug: Nitroglycerin
This page shows you your search results in order of date.
Order by Relevance | Date
Total 57 results found since Jan 2013.
Off and on chest pain for 24 hours in a 50s year old man
Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell MeyersA man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath. His pain was initially mild, then became severely worse several hours prior to presentation, but then eased off again and was minimal on arrival. There was no associated diaphoresis, nausea, vomiting, arm pain, jaw pain, syncope, lightheadedness or other acute symptoms.Initial vitals: Temp 36.7 C, BP 161/79, RR...
Source: Dr. Smith's ECG Blog - April 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 60s with acute chest pain
Sent by anonymous, written by Pendell MeyersA man in his 60s presented with acute chest pain with diaphoresis. He had received aspirin and nitroglycerin by EMS, with some improvement. His vitals were within normal limits. Here is his triage ECG:2045:What do you think?The ECG is subtle, but diagnostic of infero-posterior OMI. The QRS is normal, yet in aVL the normal upright small QRS complex is followed by in appropriately large-volume T wave inversion, which is reciprocal to the T waves in lead III, which are probably hyperacute if compared to available baseline. Corroborating this is the subtle ST depression in V2-V3 whic...
Source: Dr. Smith's ECG Blog - February 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, and Cardiology didn ' t take the hint from the ICD
Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and GrauerA 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG:What do you think?Triage physician interpretation: -sinus bradycardia-lateral ST depressionsWhile there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. Additionally, lead V3 has ST depressions, which are always abnormal (recall that lead V3 will haveST elevation under nor...
Source: Dr. Smith's ECG Blog - January 23, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
A woman in her 50s with acute chest pain
Submitted and written by Anonymous, edits by Meyers and SmithA 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache.Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 FTriage ECG:ECG Interpretation:Sinus rhythm with normal QRS. There is slight STE in V1, V2, and aVR, with STD in V3-V6, I, aVL, and II. There are T waves in lead III which are suspicious for hyperacute T waves, with reciprocal negative large T wave inversions in aVL. I do not think this ECG is by itself diagnostico...
Source: Dr. Smith's ECG Blog - January 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 50s with acute chest pain without STEMI criteria. Trop negative. Cath lab cancelled. But how about the ECG and echo?
Case submitted by Matt Tanzi MD, written by Pendell MeyersA man in his early 50s presented with substernal chest pain and that started 1 hour prior to arrival. There was some radiation to the left jaw and diaphoresis. He had ongoing pain on arrival.Initial triage ECG:What do you think?I sent this to Dr. Smith who immediately replied that it is diagnostic of OMI, but difficult to tell whether it is1) anterolateral with de Winter morphology, or instead2) A combination of Aslanger ' s pattern (inferior OMI with single lead STE in III and reciprocal STD in I, aVL, plus widespread STD of subendocardial ischemia) with ...
Source: Dr. Smith's ECG Blog - September 22, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Acute chest pain and a difficult ECG
Conclusion: Whereas I did not feel we could rule out an OMI from the initial tracing shown in Figure-1 — none of the subsequent tracings in today ' s case were suggestive of an acute event. I suspect that IF the initial ECG would have beenimmediately repeated withaccurate chest lead electrode placement — that there maynot have been any need for concern about a possible acute event from the initial ECG.Learning Point: When clinical decision-making hangs in the balance and you strongly suspect an error in lead placement — it is best toimmediately repeat the ECG —&nbs...
Source: Dr. Smith's ECG Blog - June 25, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 60s with chest pain. Cardiologist refuses to take to the lab. Obvious STEMI, even with criteria. Yet final diagnosis " NSTEMI " . This happens far too often.
Submitted by Anonymous MD, edits by MeyersA man in his 60s with past medical history of multiple sclerosis and hypertension was brought in by EMS from home for chest pain thatstarted acutely just prior to arrival. He rated the pain at 9/10, describes as pressure, radiates towards the left arm with associated shortness of breath, diaphoresis and had one episode of emesis. He did not have a prior history of CAD or other cardiac disease. His pain improved to 6/10 after EMS gave him 3 sprays of sublingual nitroglycerin and 324 mg of aspirin. Prehospital ECGs:What do you think?Both ECGs are diagnostic of acute LAD OMI...
Source: Dr. Smith's ECG Blog - April 15, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Understanding this pathognomonic ECG would have greatly benefitted the patient.
Written by Pendell MeyersInterpret this ECG first without context. You don ' t need context yet because this ECG is nearly pathognomonic.After having learned about benign T wave inversion pattern years ago on this blog, and having seen many cases on this blog and in my practice since then, I instantly recognize this as BTWI, a fairly common normal variant. I see maybe one of these ECGs each month in my practice. There is no ischemia, certainly no concern at all for OMI. It meets basically all of the criteria that Dr. Smith has consistently described over the years, after reviewing a large cohort of patients by W...
Source: Dr. Smith's ECG Blog - March 22, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Subtle ECG Signs of OMI in LBBB
A 70 yo F with no previous cardiac history, but with a h/o hypertension, hyperlipidemia, and strong family history of ACS, presented with one hour of classic chest pain and appeared uncomfortable.Her systolic BP was 210. The ECG is here:Atypical LBBB (see explanation below)As for Occlusion MI (OMI), what do you think?A bedside echo was normal to that provider ' s eye (no bubble contrast).She had a CT for dissection that was negative.A 2nd ECG was recorded:There is an atypical left bundle branch block (LBBB) -- atypical because the R-wave in V6 is not all upright. But the Smith Modified Sgarbossa criteria w...
Source: Dr. Smith's ECG Blog - January 31, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
Dynamic ST Depression in precordial leads. Does this transient STD signify subendocardial ischemia?
This case was written up by one of our fantastic 3rd year residents, Michael Fischer. Edits by Smith.A mid 60s male with past history of 2 prior STEMI(+) OMIs s/p stenting (most recently ~2 years ago) had onset of substernal chest pain after he came inside from smoking a cigarette. He reported becoming diaphoretic and also having pain in his L hand. After approximately one hour, he called 911. Medics arrived and recorded a prehospital ECG:Sinus rhythm. Deep QS-waves in inferior leads. Tall R-wave in V2, but no definite ST shifts or hyperacute T-waves.He was given aspirin and sublingual nitr...
Source: Dr. Smith's ECG Blog - December 23, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man his 50s with chest pain. What happens when you treat with morphine rather than with reperfusion?
Written by Pendell MeyersA man in his late 50s presented to the ED with 3 days of left chest pain radiating into the jaw and neck. He described it as " heartburn. " The pain radiates into his left arm and causes numbness and tingling from time to time. The history does not state what changed on day 3 that made him finally present to the ED; the history has no details as to whether the pain was off and on, or fluctuating, or whether the pain become persistent soon before arrival (these are key details and would help with many important questions we will have below!). Vitals were normal, and his triage ECG is below, at...
Source: Dr. Smith's ECG Blog - December 17, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Even when the story is obvious, with intractable pain, the STEMI paradigm can cause preventable delays
Written by Pendell MeyersA man in his early 60s presented with acute chest pain rated 10/10 with associated nausea and vomiting with known history of multivessel CAD. He presented at 2300 with onset of symptoms at 2230. He was awoken from sleep by the symptoms, which were identical to prior MI for which he received a stent years ago. On arrival his heart rate was 43 bpm and blood pressure 91/62. Atropine and IV fluid was given.Here was his triage ECG:What do you think? Baseline below for comparison, but try first without it.His baseline ECG was available on file:The presentation ECG shows diagnostic evidence of poste...
Source: Dr. Smith's ECG Blog - December 1, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Any ST depression in V2 and V3 is posterior OMI until proven otherwise, especially if downsloping
A middle aged male presented after onset, approximately 50 minutes prior, of constant crushing 10/10 substernal chest pain, radiating into right arm associated with shortness of breath. He had never felt this way before. There was a history of HTN but he was not taking any medicines.Prehospital ECG was recorded approximately 20 minutes after pain onset and 20 minutes prior to ED arrival:There are somewhat large T-waves in II and aVF and a sagging ST segment in aVL, suggestive of inferior OMI. There is some minimal downsloping ST depression in V2 and V3, which is suggestive of posterior OMI. The ECG isnot di...
Source: Dr. Smith's ECG Blog - November 25, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 52 year old female with chest pain
Written by Pendell Meyers, edits by Steve SmithA 52 year old female with history of hypothyroidism and smoking presented to the ED with an episode of chest pain that began suddenly around 1500 while sitting down at work. She states it felt like a central chest pressure that radiated to her jaw. The pain had been persistently present since since 1500 (seen at 1615 in the ED), but had waxed and waned in severity, with the initial onset of pain being the worst. She had dyspnea and diaphoresis when the pain began. Coworkers called EMS who administered aspirin and NTG, which the patient says did not relieve her pain. During ini...
Source: Dr. Smith's ECG Blog - August 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Acute chest pain, ST Depression in V2 and V3, relief with Nitroglycerine, " normal " coronaries, and apical ballooning. Is it takotsubo?
This was submitted by Michael Fischer, one of our outstanding2nd year EM residents at Hennepin Healthcare.CaseA previously healthy female in her 40s presented 1 hour after abrupt onset 10/10 crushing chest pain that started while brushing her hair that morning. The pain radiated to her bilateral jaw and right shoulder, and did not seem to be exertional or pleuritic in nature. Here is her pre-hospital ECG: What do you think?Smith: V2 and V3 have some minimal ST depression with downsloping. This is highly suggestive of posterior MI.This was read by EMS as non-specific. Aspirin 324mg was given by EMS. Ni...
Source: Dr. Smith's ECG Blog - January 8, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
