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 86

STEMI ACS OR ALS 86

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 52

STEMI ED ACS Coronary 52

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 52

STEMI Coronary ACS ED 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

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 52

STEMI ACS OR Coronary 52

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 101

ACS ED STEMI OR 101

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 52

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

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 52

Coronary ACS EMS ALS 52

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 83

ACS Coronary ALS CAD 83

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 52

ACS STEMI OR 52

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 52

OR ACS STEMI Coronary 52

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 52

E-9-1-1 STEMI Coronary ALS 52

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 52

ACS Coronary ICU STEMI 52

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 130

Coronary ALS OR ACS 130

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-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

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 60

ACS STEMI Coronary EMS 60

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 52

STEMI ACS OR ED 52

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 52

OR ACS STEMI Coronary 52

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 52

Overdose OR Coronary ACS 52

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 52

Critical Care OR ACS STEMI 52

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 52

ACS ED Coronary STEMI 52

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 52

Coronary OR ACS STEMI 52