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

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

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

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 November 10, 2020 post — for PTA. There are new Q-waves in aVL, V5-6.

OR 58

OR Critical Care ALS STEMI 58

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

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). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Herzog et al. Khan et al. Circulation 2007 2.

STEMI 86

STEMI ACS OR ALS 86

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

APRIL 22, 2024

EKG from triage: Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in comparison to an EKG in 2020 this is new. Patient still not having chest pain however this is more concerning for OMI/STEMI. Lemkes JS, et al. Aspirin given.

Coronary 117

Coronary STEMI ED OR 117

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. 3–8 Shi et al. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 Sandoval Y, Smith SW, Sexter A, et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 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." Canto et al. 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."

STEMI 52

STEMI ACS OR Coronary 52

EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. The distribution of findings is consistent with the LAD, of which is now open with improved TIMI flow. The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. link] [1] Mirand, D. 2] Aslanger, E.,

Coronary 130

Coronary ALS OR ACS 130

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 February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ). The August 28, 2020 post ( LA-LL reversal ). The November 19, 2020 post ( LA-LL reversal ). What do you think?

ALS 91

ALS STEMI Coronary OR 91

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

While this ECG is negative for “posterior STEMI”, the resolution of anterior ST depression (accompanied by the troponin elevation) confirms posterior OMI with spontaneous reperfusion. The second opportunity to make the diagnosis and expedite angiography was missed because the ECG never met STEMI criteria and continued to be labeled ‘normal.’

STEMI 40

STEMI ALS Emergency Department OR 40

Dr. Smith's ECG Blog

JULY 14, 2023

So we activated the Cath Lab Angiogram: Impression and Recommendations: Culprit for the patient's anterior ST segment myocardial infarction and out of hospital V-fib cardiac arrest is a thrombotic occlusion of the mid LAD The first troponin returned barely elevated at 36 ng/L (URL = 35) In our study of initial troponin in STEMI, 26.8%

E-9-1-1 89

E-9-1-1 Defibrillator CPR STEMI 89

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

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

STEMI 52

STEMI Coronary ACS 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. Is this OMI?

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

JUNE 1, 2022

This " imbalance of precordial T waves" is not seen very often — and in the “right” clinical setting, has been associated with recent OMI from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM ).

STEMI 52

STEMI Coronary OR ALS 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. Learn the signs of reperfusion: as Dr. Backus BE, Six AJ, Kelder JC, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS 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

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 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. 24 yo woman with chest pain: Is this STEMI? This is not "diffuse", this is simply anterior, lateral, and likely apical.

Coronary 52

Coronary STEMI Heart Attack 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. See My Comment at the bottom of the page in the May 19, 2020 post in Dr. Smith's Blog ). That was also my initial concern.

Coronary 97

Coronary EMR STEMI Emergency Department 97

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). Hayakawa A, Tsukahara K, Miyagawa S, et al. Academic Emergency Medicine 27(S1): S220; May 2020. Am J Emerg Med.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia mimics STEMI and OMI in many distributions, but probably the most common is the Brugada morphology in V1-V2 which mimics anterior OMI for those who cannot recognize the Brugada pattern. The February 11, 2020 post ( LA-RA reversal ).

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

Code STEMI was activated. A man in his 80s with chest pain What, besides large anterior STEMI, is so ominous about this ECG? Widimsky PW, Roh á c F, St á sek J, et al. link] == MY Comment by K EN G RAUER, MD ( 11/11/2020 ): == As per Dr. Meyers — today's case involves an important ECG pattern in need of prompt recognition.

STEMI 52

STEMI OR ALS EMS 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Here is the repeat ECG at 52 minutes after arrival to triage: Obvious posterolateral STEMI Angiographic findings: 1. Reference: • Writing Committee, Kontos MC, de Lemos JA, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. Meyers HP, Smith SW.

OR 52

OR STEMI ED Critical Care 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). CREDIT to Drs.

STEMI 52

STEMI ACS OR ED 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

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

DECEMBER 12, 2022

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. POINT #2: The initial tracing in today's case does not show acute changes.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Lupu L, et al. Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Smith comment: Cardiology should know, by its own guidelines, that ischemic ST depression that is refractory to medical therapy, is an indication for emergent cath lab, with angiography at < 2 hours. mg/dL, K 3.5

ACS 52

ACS Coronary ICU STEMI 52

Dr. Smith's ECG Blog

MAY 19, 2022

The Cardiorespiratory Implications of Ultra-marathon Bjørkavoll‐Bergseth et al. Paana et al. Anterior STEMI? Potential Adverse Cardiovascular Effects From Excessive Endurance Exercise Exercise Is Medicine? A similar profile was found for cTnT: baseline, <3.0 (<3.0–3.8) ng/L; 3 hours, 38.3 ng/L ( P <0.001). 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

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI.

STEMI 52

STEMI OR Coronary ED 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

This is a case written by Dan Lee (One of our fantastic Hennepin Residents, class of 2020 ) edits by Smith A 60 something-year-old man with a history of ESRD, LVH and prior CABG presented after an episode of hypotension during his hemodialysis, run followed by a syncopal episode which caused his run to be terminated early. Herzog et al.

CAD 52

CAD OR ED ALS 52

Dr. Smith's ECG Blog

JULY 19, 2024

It was read by the treating physician and the overreading cardiologist as "Paced, no STEMI." Lupu et al. As the troponin T was 1521 ng/L (peak troponin T over 1000 ng/L is typical of STEMI) and still rising, no further troponins were measured. How does the Queen of Hearts do? Clinical Cardiology.

Coronary 103

Coronary STEMI OR ALS 103