Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. An ECG was recorded immediately at triage and, at this hospital, the Queen of Hearts is routinely used to determine cath lab activation.

STEMI 77

STEMI Coronary ED 77

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below is the initial ED ECG. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. Manual of Cardiovascular Medicine (5th ed.). Smith comment : V5 and V6 are excessively discordant!!!!

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

JULY 26, 2023

How would YOU interpret ECG #1 if this was the only tracing you saw — and — the only thing you knew about the patient, was that he/she was being seen in the ED? At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. He presented to the ED for today's visit because of vertigo.

STEMI 52

STEMI ED OR 52

Dr. Smith's ECG Blog

OCTOBER 9, 2018

October 2018. link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. They did not find one STEMI on their triage ECGs (no surprise! They only looked at ED diagnosis, not at any angiogram or even at discharge diagnosis.

STEMI 52

STEMI ED OR Ambulance 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. For more on this topic — See discussion in the October 24, 2019 and July 31, 2018 posts in Dr. Smith's ECG Blog ).

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.

STEMI 52

STEMI Coronary ED ACS 52

EMS 12-Lead

JUNE 20, 2022

A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. Here is the final ECG just prior to ED transfer. The attending crews were concerned for an ACS-equivalent of LAD occlusion and initiated a prehospital STEMI activation to the closest PCI center. 3] Aslanger, E.,

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Eur Heart J 2018. Is it normal STE? Lemkes et al.

STEMI 114

STEMI ACS Critical Care OR 114

EMDocs

OCTOBER 29, 2024

A 43-year-old male with a history of mitral valve regurgitation s/p valvular replacement, hypertension, hyperlipidemia was evaluated in the ED for septic shock secondary to a pyelonephritis with a renal abscess. doi:10.1136/BCR-2018-225879 Dawood S, Hill A, Al Rawi O. He has clinically deteriorated and required intubation. 2019;12(12).

E-9-1-1 87

E-9-1-1 ICU Epinephrine EMS 87

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? aVR ST Segment Elevation: Acute STEMI or Not?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. 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.

E-9-1-1 85

E-9-1-1 STEMI Coronary OR 85

EMS 12-Lead

APRIL 14, 2022

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). Chou's Electrocardiography in Clinical Practice, 6th ed. 2] Costanzo, L. Physiology. 3] Parham, W.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

APRIL 2, 2022

Figure 1-1 My colleague, a faithful student of ECG interpretation, handed me the tracing and said that it warranted STEMI activation because of apparent terminal QRS distortion (TQRSD) in V2. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. Attached is the first ECG.

ALS 130

ALS STEMI Coronary OR 130

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 5, 2022

Submitted and written by Destiny Folk MD , peer reviewed by Meyers, Smith, Grauer, McLaren A man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. On arrival in the ED, he was hypotensive with a systolic blood pressure in the 70s.

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. STEMI was activated and the patient went to Cath on arrival. Chou’s Electrocardiography in Clinical Practice (6th ed). link] [1] Mirand, D. Canadian Journal of Cardiology, 34 ; 132-145. [2]

Coronary 130

Coronary ALS OR ACS 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. Then this was recorded in the ED 10 minutes after the first: Now there is massive STE Many inferior MI are associated with RV MI. BOTTOM — 2nd ECG obtained 10 minutes later in the ED ( See text ). Can you tell from this ECG?

Coronary 52

Coronary STEMI ED ALS 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

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. 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. He denied chest pain or shortness of breath.

E-9-1-1 72

E-9-1-1 CAD OR STEMI 72

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Only 5-18% of ED patients with chest pain have a myocardial infarction of any kind. The patient presented with chest pain. Here is the ECG: What do you think? I frankly did not know what to think. Is it Brugada pattern? But in a very unusual pattern. No angiogram was done.

STEMI 52

STEMI Defibrillator OR ALS 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." We performed a beside US (shown below) which showed lateral wall hypokinesis as read by an US-boarded ED attending in real time. 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

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

OCTOBER 3, 2018

For some reason unknown to me, the interventionalist was in the ED. Here is our abstract from SAEM 2018. Methods : The PERFECT study (#NCT02765477) is a retrospective, 16 center, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms of acute coronary syndrome (ACS).

Coronary 52

Coronary STEMI Paramedic 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. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. Angie Lobo ( @aloboMD ) (For open-access reviews of this literature, see Saw 2016 , Saw 2017 , or Hayes 2018.) A recent study found that SCAD causes almost 20% of STEMI in young women. examined SCAD presenting as STEMI (unlike Hassan et al. Lobo et al.

Coronary 52

Coronary CAD ACS STEMI 52

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

MAY 13, 2020

Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main." Nevertheless, the clinical situation made other etiologies unlikely. Cath lab activated Dual antiplatelet therapy and heparin given. Is this OMI?

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

A middle-aged man presented with 7-8/10 non-radiating chest tightness to the left chest wall, associated with nausea but no diaphoresis, that began while walking approximately 40 minutes prior to arrival at the ED. He was definitely pain free by the time of arrival at his ED room. What do you think?

ED 52

ED STEMI Coronary Emergency Department 52

Dr. Smith's ECG Blog

MAY 19, 2020

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. I believe the latter (type II STEMI) is most likely.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 17, 2018

He had an ECG in clinic which worried the providers because of possible inferior MI, and they sent him to the ED. He was sent to the ED and had this ECG at t = 1 hour: Similar There are several issues which mitigate against acute inferior MI, and these are the Learning Points: 1. Here is that ECG: What do you think?

ED 52

ED STEMI OR ALS 52

Dr. Smith's ECG Blog

JUNE 28, 2018

See these posts for Wellens' mimics: Pseudo-Wellens' Syndrome due to Left Ventricular Hypertrophy (LVH) Anterior STEMI? It even meets STEMI criteria: 2.5 Is it Wellens' Syndrome? This was the first ECG (ECG #1) recorded during pain : This shows ST elevation and hyperacute T-waves in the LAD distribution.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Am J Cardiol 2018; 122(8):1303-1309. Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI.

STEMI 52

STEMI Coronary OR ALS 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. Again, cath lab was not activated. Circ Cardiovasc Interv.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

They recorded a prehospital ECG and diagnosed STEMI and activated the cath lab prehospital. We recorded an ED ECG: The STD, STE, and T-wave inversion are all there, but in this one the voltage is indeed high and diagnostic of LVH. Note a dramatic increase in QRS amplitude in all chest leads on this initial ED tracing!

ACS 52

ACS ED Coronary STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Figure-1: The initial ED ECG ( = E CG # 1) — with comparison to the patient’s baseline ECG done 4 years earlier ( = E CG # 3). A very small QRS complex can only mount a very small amount of STE. This patient had a full RCA occlusion with the smallest visible STE. Baseline and serial ECGs make you much more likely to identify OMI.

E-9-1-1 52

E-9-1-1 Coronary STEMI Emergency Department 52

Dr. Smith's ECG Blog

JUNE 20, 2018

Journal of Electrocardiology 2018. Myocarditis is virtually indistinguishable in the ED from MI. See this case: Pericarditis, or Anterior STEMI? Journal of Emergency Medicine 2006; 31(1):67-77. 40-50% of LAD occlusion have zero reciprocal ST depression. 0 0 1 24 140 MMRF 1 1 163 14.0 That may be the case. Confirmation bias?

Overdose 52

Overdose OR STEMI Coronary 52

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

Submitted and written by Alex Bracey, with edits by Pendell Meyers and Steve Smith: I was walking through the critical care section of the ED when I overheard a discussion about the following ECG. 3) STEMI criteria failed to identify this acute coronary occlusion, like many others. What do you think?

Coronary 52

Coronary Critical Care STEMI ED 52