Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. years old ± 13.7

STEMI 108

STEMI Coronary Emergency Medical Services OR 108

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 52

ACS Coronary STEMI Ambulance 52

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 52

ACS Coronary STEMI ALS 52

EMS 12-Lead

JUNE 20, 2022

A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. It’s important to stress the presence of a normal QRS (i.e., The pathology is now painfully evident.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

OCTOBER 6, 2024

The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. The door to balloon time was incredibly short and there was a 100% circumflex occlusion that was opened and stented. Then the high sensitivity troponin T returned at 1400 ng/L.

STEMI 77

STEMI Coronary ED 77

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] STEMI was activated and the patient went to Cath on arrival. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

MAY 8, 2023

Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). LAFB, atrial flutter, anterolateral STEMI(+) OMI. Limkakeng AT.

STEMI 52

STEMI Coronary ED ACS 52

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI).

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

Shark Fin has also been called: " Giant R-wave " " Triangular QRS-ST-T waveform " Usually shark fin is in one coronary distribution and represents massive ST elevation that is as high as the peak of the R-wave and therefore fuses the R-wave and ST segment. So this is STEMI, right? Which artery? Could this be myopericarditis?

Coronary 52

Coronary STEMI 52

Dr. Smith's ECG Blog

OCTOBER 10, 2024

Unfortunately you can see that the conventional Zoll algorithm sees nothing even to suggest AMI, let alone STEMI. KEY Point: The best way to confirm acute RV MI — is with use of right -sided leads ( See My Comment in the July 19, 2020 and July 11, 2018 posts). During EMS transport, the pain suddenly resolved.

STEMI 98

STEMI EMS Coronary OR 98

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

OR 116

OR STEMI EMS ED 116

Dr. Smith's ECG Blog

MARCH 31, 2023

This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria. Meyers, Weingart and Smith in their 2018 OMI Manifesto.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. What is the atrial activity? Is it sinus arrest with junctional escape?

E-9-1-1 82

E-9-1-1 STEMI Coronary OR 82

EMS 12-Lead

MAY 8, 2022

The attending crews were concerned for SVT with corresponding ischemic hyperacute T waves (HATW) and subsequently activated STEMI pre-hospital. Cardiology was consulted, who advised to surveil a metabolic process as this did not strike them as acute coronary syndrome. Closer inspection will show that it is Sinus, after all.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Eur Heart J 2018. Is it normal STE? The computer thinks so, and the physician thinks that is quite possible. This is a "Transient OMI".

STEMI 113

STEMI ACS Critical Care OR 113

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. My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. Smith. Two negative troponins do not exclude the possibility of short-lived acute coronary occlusion. JACC 2016;67:1531.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

EMDocs

OCTOBER 29, 2024

doi:10.1136/BCR-2018-225879 Dawood S, Hill A, Al Rawi O. m/s)—problematic and elevated > 50 mm Hg (2.5 2024;166(4):A3026-A3027. doi:10.1016/J.CHEST.2024.06.1821 2024.06.1821 Mampuya WM, Dumont J, Lamontagne F. Norepinephrine-associated left ventricular outflow tract obstruction and systolic anterior movement. BMJ Case Rep. 2019;12(12).

E-9-1-1 86

E-9-1-1 ICU Epinephrine EMS 86

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MAY 19, 2020

Angiography showed normal coronaries. This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI. Troponin I rose to 44.1

Defibrillator 52

Defibrillator CPR Coronary CAD 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. Attached is the first ECG. 5] Walsh, B. 6] Goldberger, A.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. The condition of the coronary artery at the time of angiogram may be different than it was 30 minutes prior during recording of the ECG. She called 911. But which myocardial walls are affected?

Coronary 52

Coronary STEMI ED ALS 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

JANUARY 6, 2024

Here, I do not see OMI (although the ECG is falsely STEMI positive with just over 1 mm STE in V1 and about 2.5 Therefore the impulse must have originated somewhere lower in the atria, perhaps near the coronary sinus. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ). The July 29, 2018 post ( LA-RA reversal ).

ALS 91

ALS STEMI Coronary OR 91

Dr. Smith's ECG Blog

AUGUST 9, 2018

Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 No history, meds, or risk factors. Pattern looked to be BER. mm in V2 and 4.08

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

MAY 13, 2020

There is a subtle but important difference between OMI and subendocardial ischemia: OMI (that is not STEMI) is due to TIMI 0/1 flow and has any combination of subtle STE, hyperacute T-waves, reciprocal ST depression, decreased QRS amplitude, terminal QRS distortion and other findings. Is this OMI? Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. Here is our abstract from SAEM 2018. What happened?" The medic recorded another 12-lead en route 13 minutes later: What do you think?

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

OCTOBER 8, 2018

Steffen writes this case: "A few weeks ago I was able to recognize a STEMI because of what I had seen on your blog." "I However, I was a little unsure on scene whether it was a problem of his coronaries." "But His case provides a perfect example of how sometimes acute coronary occlusion may only be recognized by PVC morphology!

STEMI 52

STEMI Coronary OR 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. What is Spontaneous Coronary Artery Dissection (SCAD)?

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." See far below for data on 24 troponin T in STEMI and NSTEMI, and correlation with infarct size.

STEMI 52

STEMI Coronary ALS OR 52

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 52

STEMI ALS ACS OR 52

Dr. Smith's ECG Blog

JUNE 28, 2018

Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. See these posts for Wellens' mimics: Pseudo-Wellens' Syndrome due to Left Ventricular Hypertrophy (LVH) Anterior STEMI? Am Heart J. Am Heart J.

STEMI 52

STEMI Coronary OR ALS 52

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 70

E-9-1-1 CAD OR STEMI 70

Dr. Smith's ECG Blog

DECEMBER 29, 2018

Here is a repeat ECG 45 minutes later with persistent chest pain: Obviously progressing into a clear STEMI. Meets formal STEMI criteria in V2-V3. Repeat ECGs make difficult decisions easier. -- Comment by K EN G RAUER, MD ( 12/29/2018 ): -- Superb case by Dr. Pendell Meyers, which highlights recognition of subtle acute findings.

OR 52

OR STEMI Coronary ED 52

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

This ECG is diagnostic of an acute coronary occlusion of an artery supplying the inferior and posterior walls. Even at ~4 hours into her acute coronary occlusion there is barely any ST Elevation. 2) Contemporary troponins only start to rise 4-6 hours after the onset of acute coronary occlusion.

Coronary 52

Coronary Critical Care STEMI ED 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Am J Cardiol 2018; 122(8):1303-1309. 4-variable version still to come.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

Eventually with more training the QoH will outperform any human in the detection of acute coronary occlusion. For more on this mirror-image opposite ST-T wave relation in leads III vs aVL — See My Comment in the March 8, 2019 and August 9, 2018 posts in Dr. Smith's ECG Blog ).

ACS 60

ACS STEMI Coronary EMS 60