Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. It’s unclear if the paramedic ECGs were seen or missed in the ED. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. At this point the emergency physician asked for a stat cardiology consult.

STEMI 74

STEMI Paramedic Coronary EMS 74

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

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." What do you think?

OR 116

OR STEMI EMS ED 116

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

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

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

Dr. Smith's ECG Blog

JUNE 17, 2016

Jason was very skeptical of STEMI. This also argues against STEMI. Look for old ECGs Do serial ECGs Do echocardiography == MY Comment by K EN G RAUER, MD ( 10/1/2020 ): == From time to time — it's helpful to "resurface" prior cases that convey timeless important lessons. He complained of 3 days of diarrhea and abdominal pain.

STEMI 52

STEMI OR Coronary EMS 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. Triage ECG: What do you think?

STEMI 119

STEMI ED OR Coronary 119

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Learning Points: You cannot trust conventional algorithms even to find STEMI(+) OMI, even when they say "normal ECG." The patient was discharged home the next day. No further follow up is available.

STEMI 111

STEMI Coronary Emergency Department OR 111

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. 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. Labs ordered but not yet drawn. Aspirin given.

Coronary 117

Coronary STEMI ED OR 117

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

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. RR18 sat 99% HR 90 BP 90/60, afebrile.

STEMI 86

STEMI ACS OR ALS 86

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 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

Jason was very skeptical of STEMI. This also argues against STEMI. Look for old ECGs Do serial ECGs Do echocardiography June 17, 2016 Anterior STEMI? Unfortunately, this option might not be available for pre-hospital tracings ( but it can be done once the patient arrives in the ED for their initial hospital tracing ).

STEMI 52

STEMI Coronary EMS 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).

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. 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."

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Here is his first ED ECG: What do you see? 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. Apparently he denied chest pain.

STEMI 52

STEMI ACS OR Coronary 52

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Prior episodes had simply resolved after brief symptoms, but the current episode had lasted for 2 hours without improvement, so she presented to the ED. At triage she stated her pain is still persistent, but it is mildly improved compared to when she decided to come to the ED. No diaphoresis or vomiting.

ACS 101

ACS ED STEMI OR 101

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch.

E-9-1-1 82

E-9-1-1 STEMI Coronary OR 82

Dr. Smith's ECG Blog

JANUARY 8, 2024

She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. Medics recorded the above ECG and called a STEMI alert. Her symptoms at the time ECG #1 was obtained were CP and SOB — yet interpretation of this initial tracing prompted a STEMI alert. Her troponin I returned at 900 ng/L.

Coronary 71

Coronary STEMI EMS OR 71

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

APRIL 12, 2023

Prehospital Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI Transformed ECG by PM Cardio: PM Cardio AI Bot interpretation: OMI with High Confidence What do you think? An ECG was recorded: ED ECG 1: The findings are still present but not nearly as profound now. She had acute pulmonary edema on exam.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

His symptoms were reportedly resolved upon arrival to the ED. ED ECGs: 0814 0830 These show continued reperfusion with no evidence of reocclusion. I am going to code this as an acute STEMI as he had transient ST elevation which started to evolve in the emergency department but I think this is most appropriately termed STEMI."

EMS 52

EMS STEMI ED Emergency Department 52

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

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

JANUARY 19, 2020

There is STE in III and aVF which does not meet STEMI criteria due to insufficient STE in lead aVF. On arrival in the ED, she was profoundly hypotensive, nearly obtunded, and bradycardic. The ED team again pointed out the evidence of inferoposterior OMI, this time by the modified Sgarbossa criteria. The cath lab was activated.

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

JULY 14, 2023

A 40-something with persistent Ventricular Fibrillation presented after attempted prehospital resuscitation A 40-something with no previous cardiac history presented to the ED in persistent Ventricular Fibrillation after attempted prehospital resuscitation. So, your next step is to Trace it down, and Copy it over".

E-9-1-1 89

E-9-1-1 Defibrillator CPR STEMI 89

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. 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. JAMA Cardiol [Internet] 2020;Available from: [link] 4.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JUNE 1, 2022

To Emphasize: As isolated findings — I probably would not think much of the T wave in lead V2 of ECG #1 ( which by itself in a less symptomatic patient, could be a normal variant ) — nor would I think much of an upright T wave in lead V1.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

MARCH 19, 2023

The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. That said — we do know that ECG #2 was the last ECG on file prior to this patient’s presentation to the ED on the day of admission. To me, that is a meaningless diagnosis.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

AUGUST 30, 2020

The computer calls it a STEMI. See this case of Type 2 STEMI due to severe hypertension. Here are more Type II STEMI. His BP in the ED was 220/120 mm Hg. And clinically — many ( if not most ) patients with diabetes and longstanding hypertension who present to the ED with a BP = 220/120 mm Hg will have LVH.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

MAY 5, 2022

Submitted and written by Destiny Folk MD , peer reviewed by Meyers, Smith, Grauer, McLaren A man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. On arrival in the ED, he was hypotensive with a systolic blood pressure in the 70s.

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Study idea: We should look at all OMIs who had a chest CT and compare to all patients with Non-OMI pathology who had a contrast chest CT and have radiologists blindly interpret the perfusion of the myocardium The cardiology fellow came down to the ED and said: "What are you worried about? This ST depression?" 2022.08.750 Section 5.2.2,

OR 52

OR STEMI ED Critical Care 52

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. STEMI was activated and the patient went to Cath on arrival. Chou’s Electrocardiography in Clinical Practice (6th ed). Canadian Journal of Cardiology, 34 ; 132-145. [2] 2] Aslanger, E.,

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main." 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. Is this OMI?

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

MAY 19, 2020

This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI. I believe the latter (type II STEMI) is most likely.

Defibrillator 52

Defibrillator CPR Coronary CAD 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. Am J Emerg Med 2020 3. Shin YS, Ahn S, Kim YJ. Bracey A, Meyers HP, Smith SW.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52