Dr. Smith's ECG Blog

JUNE 27, 2024

COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab. Lemkes JS, Janssens GN, van der Hoeven NW, et al. These physicians did not want a patient with an OMI that was not a STEMI to be randomized to no angiogram.

Defibrillator 91

Defibrillator STEMI Coronary ALS 91

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. This is diagnostic of LAD occlusion but is equivocal for STEMI criteria and was missed (and both labeled ‘normal’ by final cardiology interpretation).

STEMI 118

STEMI Emergency Department Coronary OR 118

EMS 12-Lead

APRIL 8, 2022

BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI. The EMS crews were correct moving forward with STEMI activation. 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 130

The Skeptics' Guide to EM

FEBRUARY 2, 2019

Date: January 28th, 2019 Reference: Chu DK et al. Date: January 28th, 2019 Reference: Chu DK et al. In the 2015 AVOID study there was some suggestion of increased MI size in the group of STEMI patients that received oxygen at 8 L/min compared to a room air control group. Reference: Chu DK et al.

Life Support 130

Life Support ALS STEMI Emergency Department 130

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

It is diagnostic of OMI, but this is SUBACUTE OMI I sent this ECG to my "EKG Nerdz" friends, without any clinical info at all and they answered "OMI" The Queen said: "STEMI-Equivalent with High Confidence:" Notice she sees findings in both normal beats and PVCs. The September 22, 2019 post — intermittent ST-T wave artifact.

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57

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Lindahl et al. From Gue at al. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. This has resulted in an under-representation of STEMI MINOCA patients in the literature. References: 1.

Coronary 102

Coronary E-9-1-1 STEMI ACS 102

Dr. Smith's ECG Blog

MARCH 4, 2024

Unknown algorithm The Queen gets it right Case 4 How unreliable are computer algorithms in the Diagnosis of STEMI? The patient's prehospital ECG showed that there was massive STEMI and these are hyperacute T-waves "on the way down" as they normalize. Pain was resolving. Diagnosed as Normal by the computer. Troponin negative.

STEMI 110

STEMI OR ED ALS 110

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 52

STEMI Coronary ALS ACS 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. Harhash AA, Huang JJ, Reddy S, et al. aVR ST segment elevation: acute STEMI or not?

Coronary 52

Coronary ACS STEMI ALS 52

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. Smith comment : V5 and V6 are excessively discordant!!!! Here are two examples of HATW’s in the setting of confirmed LVH. Tower-Rader, A.

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. In such cases — radiofrequency ablation of ectopic beats triggering malignant ventricular arrhythmias was needed for control of arrhythmic storm because the antiarrhythmic medications tried were ineffective ( Marrouche et al — JACC 5;43(9): 1715-20, 2004 ).

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

MARCH 9, 2023

Barely any STE, and thus not meeting STEMI criteria. Annals of Emergency Medicine Cardiology was called to evaluate the patient immediately for emergent cath, but they stated that the ECG did not meet STEMI criteria and elected to wait for further information before proceeding with cath. He was given 6mg IV morphine for ongoing pain.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

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. Then, three minutes later… Crews activated STEMI as she deteriorated into PEA arrest. A finger-stick glucose resulted 551 mg/dL, and the following ECG was recorded. 2] Birnbaum, Y., Physiology.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

STEMI 90

STEMI Coronary Paramedic OR 90

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). link] [1] Zachary et al. Western Journal of Emergency Medicine, 18 (4), 752-760. [2] 2] Costanzo, L. Physiology.

ACS 130

ACS Paramedic Coronary ALS 130

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

FEBRUARY 10, 2023

Inferior ST Depression does NOT mean there is inferior subendocardial ischemia; it is generally reciprocal to high lateral (aVL) subepicardial ischemia (OMI/STEMI) == MY Comment by K EN G RAUER, MD ( 2/10/2023 ): == There are certain patterns in ECG interpretation that experienced providers are able to immediately recognize. See text ).

STEMI 52

STEMI ALS Coronary OR 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

From My Comment in the November 15, 2023 post in Dr. Smith's ECG Blog: Clinical Points about MINOCA: Given the literature citing a 5-15% estimated incidence of MINOCA in patients initially diagosed as having a STEMI or "NSTEMI" — it is important to be aware of the more common entities associated with this entity ( See Figure-2 ).

E-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Lindahl et al. From Gue at al. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery.

Emergency Department 52

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

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

3–8 Shi et al. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 Sandoval Y, Smith SW, Sexter A, et al. Shi S, Qin M, Shen B, et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 25, 2023

Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. NOTE: For detailed review regarding use of Cardiac MRI in acute chest pain evaluation — See the extensive article by Broncano et al ( RadioGraphics 41:8-31, 2021 ). It was trained by Drs. The young age always makes one suspicious of myocarditis.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

A recent study found that SCAD causes almost 20% of STEMI in young women. A study by Hassan et al. Lobo et al. examined SCAD presenting as STEMI (unlike Hassan et al. Lobo et al. examined SCAD presenting as STEMI (unlike Hassan et al. The SCAD cases in Lobo et al.

Coronary 52

Coronary CAD ACS STEMI 52

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. Backus BE, Six AJ, Kelder JC, et al. Moumneh T, Sun BC, Baecker A, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Excerpted from Vutthikraivit et al: Acta Cardiol Sin 34:267-277, 2018 ). == Distinction is made between 2 types of Brugada ECG patterns: A B rugada - 1 ECG pattern — shows ≥2 mm coved ST elevation with sharp downslope plus T wave inversion in ≥2 anterior leads.

STEMI 52

STEMI Defibrillator OR ALS 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

As per Dr. Aslanger — a number of medical providers were initial confused by what initially appears as marked ST elevation with reciprocal ST depression, indicative of an acute STEMI. That was also my initial concern. No "baseline" ECG is available for comparison.

Coronary 97

Coronary EMR STEMI Emergency Department 97

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? Today’s Post by Dr.

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. See this paper by Smith et al.

STEMI 52

STEMI EMS Coronary ALS 52

Dr. Smith's ECG Blog

FEBRUARY 14, 2020

Some patients will not progress (or not as quickly) to obvious STEMI, as in this case. NOTE: For more on the pattern of de Winter T waves ( including the Figure of various ECG patterns, excerpted from the original 2008 Letter to NEJM by de Winter et al ) — Please SEE My Comment in the May 2, 2019 post).

STEMI 52

STEMI ACS OR ED 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

Meyers, Bracey, Smith, et al. OMI that are not STEMI can be very subtle and difficult to diagnose even though the findings are very specific. With a little bit of practice — it becomes EASY to recognize the "shelf-like" ( flat ) shape of ST depression — that looks like a stemi when this image is inverted. Learning Points.

STEMI 52

STEMI ED Coronary OR 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 The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. What do you think? mm STE in V2). Afterward, I continue to read systematically.

ALS 91

ALS STEMI Coronary OR 91

Dr. Smith's ECG Blog

JUNE 8, 2023

STEMI negative : the EMS automated interpretation read, “STEMI negative. According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Inferior infarct, age undetermined.

STEMI 63

STEMI Coronary Paramedic ALS 63

Dr. Smith's ECG Blog

JANUARY 17, 2024

The limb leads have been removed because there was no ST elevation in those leads, the QRS complexes have been obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation. But STEMI criteria ignore all this and look at ST segments in isolation.

STEMI 99

STEMI Coronary ALS OR 99

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? Learning Points: Not all OMI will present as STEMIs.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

MAY 19, 2022

The Cardiorespiratory Implications of Ultra-marathon Bjørkavoll‐Bergseth et al. Paana et al. International Journal of Cardiology 2019. Anterior STEMI? Indeed, they have a higher incidence of structural problems. Potential Adverse Cardiovascular Effects From Excessive Endurance Exercise Exercise Is Medicine? What is it?

E-9-1-1 52

E-9-1-1 Coronary OR ED 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. In the largest study looking at this topic by Mizusawa et al., Bicarb 20, Lactate 4.2, Ammonia 100.

E-9-1-1 52

E-9-1-1 CAD STEMI OR 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. Sandoval Y et al. This figure comes from the Diamond T study (all type 1 MI were NSTEMI, not STEMI): Notice that the 6 hour value (far right) is very low for type 2 MI.

STEMI 52

STEMI Emergency Department ED OR 52

Dr. Smith's ECG Blog

DECEMBER 5, 2019

Bayes de Luna, A et al. This is based on the Sieira et al, 2017, risk calculator , which gives a borderline risk score (2). Annals of Noninvasive Electrocardiology 2019. An EP study might be helpful in symptomatic patients (Sroubek et al., 8, 2019 ) — ( Jan. 30, 2019 ) — many others. And another finding.

ALS 52

ALS OR Defibrillator STEMI 52