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. It is not yet available, but this is your way to get on the list. 2 cases at once!

STEMI 113

STEMI OR ED ALS 113

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. N Engl J Med [Internet] 2019;Available from: [link] Should all patients with shockable arrest be taken to angiography regardless of STEMI or No STEMI?

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes. Lemke et al 2019 published a multicentre RCT done in the Netherlands looking at patients without ST se.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

AUGUST 15, 2019

Over the next few hours, four other general cardiologists "signed off on the initial ECG without recognizing STEMI." Learning Points: STEMI criteria misses 25-40% of OMI, like this case for example. A millimeter definition of acute STEMI should not be needed to justify the need for prompt cardiac catheterization.

STEMI 52

STEMI ACS OR EMS 52

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. Furthermore, there was no family history of early CAD, MI, or sudden cardiac death. is present.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. He was ventilated with BVM on arrival.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

JUNE 19, 2024

His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”. The patient started receiving medications for “STEMI” (including heparin!!!) Surely, he should be given heparin and taken for an emergent angiogram, right?

STEMI 63

STEMI Coronary CAD ED 63

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. The Lancet 2018. This is Bob’s ninth visit to the SGEM.

Life Support 130

Life Support ALS STEMI Emergency Department 130

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

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. I don't know if her pain was getting better or not.

Coronary 104

Coronary E-9-1-1 STEMI ACS 104

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 89

STEMI Coronary Paramedic OR 89

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The below ECG was recorded.

Defibrillator 117

Defibrillator Coronary ALS STEMI 117

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.

Coronary 52

Coronary ACS STEMI ALS 52

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

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. at the time the ECG was done ).

STEMI 52

STEMI EMS OR Coronary 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. Vitals were within normal limits. hours earlier?

E-9-1-1 52

E-9-1-1 STEMI Coronary 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. As a brief review, HCM is a genetically inherited disorder that produces structural disarray in the myocardial cells. References Naidu, S.

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Of note, there is arguably terminal QRS distortion in V4-V6. I sent this to our group without information and Dr. Smith responded: "Not OMI. Pericarditis maybe."

STEMI 99

STEMI OR Emergency Department 99

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-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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. McCance, K.

STEMI 130

STEMI ED EMS Firefighter 130

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). ACE inhibitors, or potassium-sparing diuretics), are particularly susceptible. ECG's are difficult. McCance, K.

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.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 25, 2023

Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. Smith's ECG Blog how difficult it may sometimes be to distinguish between acute myocarditis vs acute OMI on the basis of ECG findings and the clinical history ( See My Comments in the July 21, 2019 — December 10, 2019 — and January 10, 2020 posts).

Coronary 52

Coronary STEMI ALS 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. What is it?

ALS 52

ALS STEMI Coronary OR 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

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 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 3–8 Shi et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. 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. This physician thought it was an anterior MI and gave thrombolytics. All troponins were negative. Only 1-5% have OMI.

STEMI 52

STEMI Defibrillator OR ALS 52

Dr. Smith's ECG Blog

OCTOBER 17, 2022

If you were thinking that this is not anterior OMI because there is no reciprocal ST depression , it is important to remember that half of anterior STEMI do NOT have any reciprocal ST depression. This ECG has ST Elevation in multiple leads. Is it normal STE? Or is it ischemic STE? What do you think? There are no S-waves in V2 and V3.

E-9-1-1 52

E-9-1-1 OR STEMI 52

Dr. Smith's ECG Blog

JULY 19, 2019

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. But it does not meet STEMI criteria and it was not initially recognized. ng/mL (very elevated).

STEMI 52

STEMI ED ACS OR 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. The patient rapidly regained consciousness, reporting no residual pain. A peak troponin level of 70 ng/L was observed. That was also my initial concern.

Coronary 100

Coronary EMR STEMI Emergency Department 100

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

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

FEBRUARY 4, 2022

We wrote this Editorial in the Journal of Electrocardiology in 2019. These include about 60 occlusion MI (OMI) with clear ST segment elevation (none of which would be called “Normal” by the computer) and about 165 Non-STEMI. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion.

STEMI 52

STEMI Coronary Emergency Department OR 52

Dr. Smith's ECG Blog

APRIL 24, 2020

When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. ST depression maximal in V5 and V6 cannot be reciprocal to subepicardial, transmural ischemia under aVR because, as stated above, there is no ventricular myocardium beneath that lead, no STEMI under aVR. What do you think? It is maximal in V3 and V4.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

This one likely does meet STEMI criteria in II, III, and aVF. Written by Pendell Meyers A woman in her 70s with diabetes, hypertension, and hyperlipidemia suddenly developed nausea, diaphoresis, and brief syncope while eating at a restaurant. She did not report any chest pain or pressure. No baseline was available for comparison.

STEMI 52

STEMI Coronary OR ED 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. NTG drip started. Pain better still. Is this OMI?

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. He reports no personal or familial history of seizures.

STEMI 52

STEMI EMS Coronary ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

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. The standard 12-lead ECG is all that is needed.

STEMI 52

STEMI ED Coronary OR 52