2014, Coronary and STEMI - Paramedicine Now

Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. 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.

STEMI

STEMI Coronary ALS CAD

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." For the same reason, you should not delay coronary angiography because pain resolves with morphine. The case continues. Kontos, M.

E-9-1-1

E-9-1-1 ACS Coronary STEMI

Two patients with chest pain and RBBB: do either have occlusion MI?

Dr. Smith's ECG Blog

OCTOBER 17, 2024

The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Coronaries were normal, as was serial troponin. Vitals were normal.

STEMI

STEMI Paramedic Coronary ED

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS

ACS Coronary STEMI Ambulance

Acute artery occlusion -- which one?

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. When EMS found her, she was dyspneic and diaphoretic.

E-9-1-1

E-9-1-1 Coronary STEMI ALS

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? Incidence of an acute coronary occlusion.

ACS

ACS Coronary STEMI ALS

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

STEMI

STEMI Coronary ALS ACS

SGEM#192: Sometimes, All You Need is the Air that You Breathe

The Skeptics' Guide to EM

OCTOBER 22, 2017

The ECG shows an inferior ST-Elevated Myocardial Infarction (STEMI). Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow ( Kones et al AM J Med 2011). They give him 180mg of ASA to chew and package him for transportation to the hospital. Class IIb, LOE C-LD)

Emergency Medical Services

Emergency Medical Services Coronary ALS STEMI

A man in his late 30s with acute chest pain and ST elevation

Dr. Smith's ECG Blog

MAY 16, 2023

Here is the Queen of Heart's interpretation: The cath lab had been activated for concern of STEMI. Learning Points: This is one of many examples of false positive STEMI criteria, which is distinguishable by expert humans, and now by AI such as QOH. Emergent CT coronary angio also likely has a role in such cases.

Coronary

Coronary STEMI ED OR

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. These include: i ) appreciation of how problematic the definition of “acute STEMI” can be; and , ii ) illustration of how dependence on this definition may result in overlooking acute coronary occlusion. Thelin et al.

E-9-1-1

E-9-1-1 STEMI ACS Coronary

Chest pain and anterior ST depression. What’s the cause(s)?

Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. CMAJ 2014. The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS.

STEMI

STEMI Coronary OR ACS

Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. At midnight.

Dr. Smith's ECG Blog

DECEMBER 14, 2016

The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI? We could not rule out acute epicardial coronary (large artery) occlusion. It was opened and stented with a door to balloon time of about 120 minutes (this is long for STEMI, but very short for a high risk Non STEMI). The troponin I returned at 4.1

ACS

ACS STEMI Coronary OR

A Tough ECG, But Learn From It!

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. His ECG was repeated at this point: This shows a well developed anterior STEMI. The peak troponin I was over 100.

STEMI

STEMI Coronary ALS CAD

What will you do for this patient transferred to you who is now asymptomatic?

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI

STEMI ALS ACS OR

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve. Look at the aortic outflow tract.

Coronary

Coronary ACS ALS STEMI

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Dr. Smith's ECG Blog

APRIL 22, 2022

The HEART and EDACS scores are helpful to risk stratify patients with chest pain, but they hinge on accurate ECG interpretation: a low score doesn’t apply if the ECG shows STEMI(+)OMI, and shouldn’t be used for STEMI(-)OMI or OMI reperfusion either 2. Case Rep Emerg Med 2014 7. Am J Med 2021 5. Lancet 2015 6.

E-9-1-1

E-9-1-1 STEMI ALS ED

Posterior leads can give false reassurance

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

This is most consistent with ischemia/infarction in the distribution of the left circumflex coronary artery. OMI that are not STEMI can be very subtle and difficult to diagnose even though the findings are very specific. Regional wall motion abnormality-inferior base ( this is the posterior wall ).

STEMI

STEMI ED Coronary OR

A man in his 70s with weakness and syncope

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. So maybe she is better than I am.

E-9-1-1

E-9-1-1 CAD OR STEMI

A man in his 80s with chest pain and ventricular paced rhythm

Dr. Smith's ECG Blog

JULY 19, 2024

It was read by the treating physician and the overreading cardiologist as "Paced, no STEMI." of very high risk NSTEMI patients underwent angiography in less than 2 hours in accordance with the 2014 ACC/AHA guidelines. How does the Queen of Hearts do? In fact, in the one study I'm aware of in which it has been studied, only 6.4%

Coronary

Coronary STEMI OR ALS

Paramedicine Now

Is OMI an ECG Diagnosis?

Occlusion myocardial infarction is a clinical diagnosis

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Two patients with chest pain and RBBB: do either have occlusion MI?

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

Acute artery occlusion -- which one?

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

7 steps to missing posterior Occlusion MI, and how to avoid them

SGEM#192: Sometimes, All You Need is the Air that You Breathe

A man in his late 30s with acute chest pain and ST elevation

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Chest pain and anterior ST depression. What’s the cause(s)?

Persistent Chest Pain, an Elevated Troponin, and a Normal ECG. At midnight.

A Tough ECG, But Learn From It!

What will you do for this patient transferred to you who is now asymptomatic?

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Posterior leads can give false reassurance

A man in his 70s with weakness and syncope

A man in his 80s with chest pain and ventricular paced rhythm

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