Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

STEMI 97

STEMI Coronary Defibrillator EMS 97

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? He was found in ventricular fibrillation and defibrillated, then brought to a local ED which does not have a cath lab. Here is the initial ED ECG: This is pretty obviously and inferior posterior OMI, right? It is a STEMI equivalent.

STEMI 52

STEMI Defibrillator ED ACS 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 118

STEMI Emergency Department Coronary OR 118

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. The Queen gets it right First ED ECG: Hyperacute T-waves persist.

STEMI 110

STEMI OR ED ALS 110

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. 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.

Defibrillator 91

Defibrillator STEMI Coronary ALS 91

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. The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 Then, three minutes later… Crews activated STEMI as she deteriorated into PEA arrest.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? EKG on arrival to the ED is shown below: What do you think? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). or basilar ischemia.

STEMI 98

STEMI Coronary Emergency Department OR 98

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. There is pericardial tamponade.

STEMI 60

STEMI Coronary CAD ED 60

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

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. 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. I don't know if her pain was getting better or not. From Gue at al.

Coronary 102

Coronary E-9-1-1 STEMI ACS 102

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 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 patient continued to verbalize cessation of symptoms while in the ED.

STEMI 130

STEMI ALS Coronary CAD 130

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

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).

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

MARCH 8, 2019

This algorithm called it a STEMI. Yet it gave a diagnosis of STEMI. This is, in effect, a transient STEMI 2. See the learning points in that case == Comment by K EN G RAUER, MD ( 3/8/2019 ): == Superb teaching case presented by Dr. Smith regarding this middle-aged man who was transported to the ED after new-onset chest pain.

ED 52

ED STEMI ACS OR 52

Dr. Smith's ECG Blog

APRIL 20, 2019

There is sinus rhythm with minimal STE in V1-V3, not meeting STEMI criteria. Learning Points: Serial ECGs can sometimes turn a difficult decision into a very easy one, but not all OMIs will develop into clear STEMIs quickly, and some OMIs never will manifest STEMI at all.

STEMI 52

STEMI EMS OR Coronary 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? Am J Med 2019, 132(5):622-630.

ACS 52

ACS Coronary STEMI ALS 52

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

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. No prior ECG was available.

Coronary 52

Coronary STEMI ED OR 52

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. Texas Heart Institute Journal, 33 (1), 40-47. [4]

ACS 130

ACS Paramedic Coronary ALS 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. This was sent to me by a friend. What About the Initial ECG?

STEMI 52

STEMI Coronary OR ED 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

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

APRIL 25, 2023

Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. Cath lab activation by the ED and I agree with coronary angiography emergently." My response was: "OMI until proven otherwise" #PMCardio AI Bot (AKA: "The Queen of Hearts"): OMI You can sign up to be on a list to receive the PM Cardio AI App here. It was trained by Drs.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

AUGUST 17, 2019

So there is definitely no STEMI, and the STE is normal. But after reading this blog, you all know that most OMI do NOT meet STEMI criteria. Bedside echo revealed anteroseptal wall motion abnormality at which point I activated a code STEMI. Figure-1: The initial ECG done in the ED ( See text ). mm in men over age 40.

STEMI 52

STEMI Defibrillator ED OR 52

Dr. Smith's ECG Blog

JULY 19, 2019

He still had active pain on arrival to the ED. This morphology can be cause by or associated with cocaine: A Patient with Cocaine Chest Pain and Prehospital Computer interpretation of STEMI This is OMI of the anterior, lateral, and inferior walls until proven otherwise. His initial ECG in the ED ( = E CG # 1 ) is shown in Figure-1.

STEMI 52

STEMI ED ACS OR 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. JAMA Intern Med 2019 9. Yazdi D, Sharim J.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

A 40-something woman with diabetes and peripheral vascular disease who frequently needs the ED for chronic pain called 911 for sudden severe chest pain. Because of this, it was very difficult to record an ED ECG, but eventually it became possible: What do you think? The patient was very agitated and could not hold still.

STEMI 52

STEMI ED Coronary OR 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. 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

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

This 65-year old male patient with severe underlying coronary disease presented to the ED after receiving several ICD shocks. 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.

Coronary 97

Coronary EMR STEMI Emergency Department 97

Dr. Smith's ECG Blog

FEBRUARY 14, 2020

Some patients will not progress (or not as quickly) to obvious STEMI, as in this case. Correlating evolution of this patient’s symptoms in the ED, with corresponding evolution of serial ECGs tells us ( as per Drs. Sometimes serial ECGs minimizes the delay. What will you do for this patient transferred to you who is now asymptomatic?

STEMI 52

STEMI ACS OR ED 52

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

MAY 11, 2019

Computer interpretation: SINUS RHYTHM NON-DIAGNOSTIC ANTEROLATERAL ST ELEVATION BORDERLINE ECG The overreading cardiologist confirmed the computer interpretation (did not diagnose OMI or STEMI). Since the threshold for "STEMI" is 2.0 mm, this ECG actually meets STEMI criteria. Since the threshold for "STEMI" is 2.0

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. A recent study found that SCAD causes almost 20% of STEMI in young women. examined SCAD presenting as STEMI (unlike Hassan et al. JACC 2019 Sep 10;74(10):1290-1300. This is written by Brooks Walsh. A study by Hassan et al. Lobo et al.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

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. From Gue at al. Circulation. 2017;135(16):1490–3.

Emergency Department 52

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

Dr. Smith's ECG Blog

APRIL 24, 2020

Here was his ED ECG, which was identical to the prehospital ECG. When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. A middle aged man had off and on chest pain for 2 weeks, then 2 hours of more severe and constant pain. He did not get prehospital activation. What do you think?

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

JUNE 4, 2019

A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. Here is the ED ECG (no previous ECG was available for comparison). ng/mL (very high, very large MI), so they took her to angiography at 18 hours after ED arrival. Figure-1: The initial ECG in the ED.

STEMI 52

STEMI ED OR 52