2020, ACS and STEMI - Paramedicine Now

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

Dr. Smith's ECG Blog

MAY 31, 2023

Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. Academic Emergency Medicine 27(S1): S220; May 2020. Cath attending is aware. It is a mass delusion.

STEMI

STEMI Coronary ACS OR

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Day 12 ECG: FINAL DIAGNOSIS: "NSTEMI" Despite the fact that his day 4 ECG easily meets STEMI criteria, the patient is diagnosed as NSTEMI. Academic Emergency Medicine 27(S1): S220; May 2020.

E-9-1-1

E-9-1-1 ACS STEMI Coronary

Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

STEMI

STEMI Coronary ALS CAD

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC).

E-9-1-1

E-9-1-1 ACS Coronary STEMI

Serial ECGs for chest pain: at what point would you activate the cath lab?

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. This case is an example of the steps we can all take in daily practice as the paradigm shifts from STEMI to OMI.

STEMI

STEMI Paramedic Coronary EMS

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

Coronary

Coronary E-9-1-1 STEMI ACS

75 year old dialysis patient with nausea, vomiting and lightheadedness

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. This is not unusual. Take home 1.

STEMI

STEMI ACS OR ALS

Interventionalist at the Receiving Hospital: "No STEMI, no cath. I do not accept the transfer."

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? This is the response he got: Interventionist: "No STEMI, no cath. After stabilizing the patient and recording more ECGs, he tried again: Interventionalist: "It isn't a STEMI." It is a STEMI equivalent. We don't know how many though.

STEMI

STEMI Defibrillator ED ACS

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI

STEMI ED ACS Coronary

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI

STEMI Coronary ACS ED

7 steps to missing posterior Occlusion MI, and how to avoid them

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

STEMI Coronary ALS ACS

Cardiologist declines taking patient to the cath lab. Patient dies.

Dr. Smith's ECG Blog

OCTOBER 11, 2020

The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain. The whole paradigm is literally called "STEMI" vs. "NSTEMI." Canto et al.

STEMI

STEMI ACS OR Coronary

This ECG was handed over at triage. See how the Queen of Hearts AI does with these explainability images.

Dr. Smith's ECG Blog

OCTOBER 15, 2023

The cardiologists decided to overrule the STEMI criteria and the cath lab activation was NOT cancelled, and she was taken immediately to the cath lab and found to have an acute thrombotic distal LAD occlusion (TIMI 0). At triage she stated her pain is still persistent, but it is mildly improved compared to when she decided to come to the ED.

ACS

ACS ED STEMI OR

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. 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

Emergency Department E-9-1-1 Coronary STEMI

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The ECG was read as "No STEMI" and the patient was treated like an average chest pain patient (despite the fact that a chest pain patient with active pain and active subendocardial ischemia is very high risk). In our opinion it should not be given in ACS unless you are committed to the cath lab.

ACS

ACS Coronary ALS CAD

What do you think the echocardiogram shows in this case?

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease.

Coronary

Coronary ACS EMS STEMI

A 40-something with 100 minutes of chest pain

Dr. Smith's ECG Blog

MARCH 27, 2023

I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI. This is now further confirmation of ACS. I was reading ECGs on the system, and saw this one: What do you think? There is no doubt that this is an inferior posterior OMI.

ACS

ACS STEMI OR

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Dr. Smith's ECG Blog

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities. 1] Wereski, R., Chapman, A.

OR

OR ACS STEMI Coronary

Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. 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.

E-9-1-1

E-9-1-1 STEMI Coronary ALS

A woman in her 50s with acute chest pain

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS. Lupu L, et al.

ACS

ACS Coronary ICU STEMI

The Bleeding Heart

EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. Such aggressive investigation was particularly warranted in this case because of symptoms compatible with ACS, as well as an equally frightening revelation of family history. Conjecture aside, I believe the lesson here, ultimately, is serial ECG’s. 2] Aslanger, E.,

Coronary

Coronary ALS OR ACS

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation. This is not the case.

E-9-1-1

E-9-1-1 Coronary ACS BLS

An ECG with only «marginal» change

Dr. Smith's ECG Blog

DECEMBER 15, 2023

Learning Points : Serial ECG are very valuable when it comes to identifying a dynamic process such as ACS. For those in search of brief review of the Cabrera Format for ECG recording — Please check out My Comment at the bottom of the page in the October 26, 2020 post in Dr. Smith's ECG Blog.

ACS

ACS STEMI Coronary EMS

A man in his 50s with "gas pain"

Dr. Smith's ECG Blog

FEBRUARY 14, 2020

This pattern in isolation would signify diffuse supply/demand mismatch without focal complete occlusion, which would be a very large differential of anything causing severe global supply demand mismatch, including ACS and various other processes. Some patients will not progress (or not as quickly) to obvious STEMI, as in this case.

STEMI

STEMI ACS OR ED

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

Dr. Smith's ECG Blog

DECEMBER 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. Failure to do so may result in overlooking subtle ST-T wave changes in a patient "in passage" from a frank STEMI toward reperfusion changes. Serial ECGs are important to perform and incredibly helpful at all stages of expertise.

OR

OR ACS STEMI Coronary

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

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. As per Dr. Smith — the KEY lead is lead V4.

Overdose

Overdose OR Coronary ACS

Chest discomfort, Sinus Tachycardia, Q-waves, ST Elevation, and Intermittent Wide Complex Tachycardia. Activate the Cath Lab?

Dr. Smith's ECG Blog

AUGUST 13, 2020

When there is tachycardia, you should doubt the diagnosis of ACS unless it is: a) massive MI with cardiogenic shock and thus poor LV function and poor stroke volume, b) in a patient with previous poor LV function c) combined with other acute pathology causing tachycardia 3. Learning Points: 1. LV Aneurysm? Would you give Thrombolytics?

Critical Care

Critical Care OR ACS STEMI

Syncope and Prehospital Cath Lab activation -- What do you think?

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

They recorded a prehospital ECG and diagnosed STEMI and activated the cath lab prehospital. Abdominal pain can of course be a symptom of ACS, but it was brief and seemed to have resulted in a vasovagal event. When medics arrived, he denied any chest pain, shortness of breath, or palpitations prior to the syncopal episode.

ACS

ACS ED Coronary STEMI

3 days of shoulder and chest pain, and now cardiogenic shock

Dr. Smith's ECG Blog

AUGUST 28, 2020

This can only be due to STEMI. Cardiogenic shock and ACS is an indication for the cath lab, even if you don't think there is OMI. August 30, 2020 ): Being an “expert” in ECG interpretation is sometimes very humbling. However, cardiogenic shock usually takes some time to develop, so it is probably subacute."

Coronary

Coronary ACS OR STEMI

Paramedicine Now

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

Trending Sources

Is OMI an ECG Diagnosis?

Occlusion myocardial infarction is a clinical diagnosis

Serial ECGs for chest pain: at what point would you activate the cath lab?

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

75 year old dialysis patient with nausea, vomiting and lightheadedness

Interventionalist at the Receiving Hospital: "No STEMI, no cath. I do not accept the transfer."

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

7 steps to missing posterior Occlusion MI, and how to avoid them

Cardiologist declines taking patient to the cath lab. Patient dies.

This ECG was handed over at triage. See how the Queen of Hearts AI does with these explainability images.

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

What do you think the echocardiogram shows in this case?

A 40-something with 100 minutes of chest pain

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Extreme shock and cardiac arrest in COVID patient

A woman in her 50s with acute chest pain

The Bleeding Heart

Concerning EKG with a Non-obstructive angiogram. What happened?

An ECG with only «marginal» change

A man in his 50s with "gas pain"

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

Chest discomfort, Sinus Tachycardia, Q-waves, ST Elevation, and Intermittent Wide Complex Tachycardia. Activate the Cath Lab?

Syncope and Prehospital Cath Lab activation -- What do you think?

3 days of shoulder and chest pain, and now cardiogenic shock

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