2022, ACS and STEMI - Paramedicine Now

What happened after the Cath lab was activated for a chest pain patient with this ECG?

Dr. Smith's ECG Blog

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI").

STEMI

STEMI ACS ED

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. Review of the 2 ECGs in today's case is insightful ( Figure-1 ): The initial ECG shows sinus rhythm, LAHB and meets Peguero Criteria for LVH ( See My Comment in the August 15, 2022 post of Dr. Smith's ECG Blog for more on LVH criteria ).

Coronary

Coronary ACS OR EMR

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. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. Abstract 556.

STEMI

STEMI Coronary ACS OR

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

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

Two ECGs texted to me in the same hour. What would you recommend?

Dr. Smith's ECG Blog

JUNE 15, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. High sensitivity troponin I was 23 ng/L.

STEMI

STEMI Coronary ACS OR

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

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

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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. His response: “subendocardial ischemia. Anything more on history? POCUS will be helpful.”

Coronary

Coronary ACS STEMI ALS

Case Report: The Not So Normal, Normal EKG

ACEP Now

AUGUST 12, 2024

Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. 2022 Nov, 80 (20) 1925–1960. 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking.

Emergency Department

Emergency Department STEMI ACS ED

Watch what happens when you teach others how to find OMI

Dr. Smith's ECG Blog

MARCH 20, 2023

Since then, I started looking for OMI EKG findings and not just STEMI. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. mm in lead I, thus not STEMI criteria) and was finally understood by the cardiologist.

STEMI

STEMI ACS CAD ED

Compare these two ECGs. Do either, neither, or both show anything important?

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Physician: "No STEMI."

OR

OR STEMI ACS Emergency Department

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. Published 2022 Feb 20.

ACS

ACS Coronary ALS CAD

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

65 year old with syncope and a 'normal' ECG: discharge home?

Dr. Smith's ECG Blog

DECEMBER 6, 2022

Had the cardiologists followed NSTEMI or transient STEMI guidelines, which recommend non-urgent cath, the patient could have redeveloped an OMI and had a worse outcome. But this foresight will not be recorded, because the patient was diagnosed as "transient STEMI", even though no ECG ever met STEMI criteria. Take home 1.

STEMI

STEMI ACS Coronary OR

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). LAFB, atrial flutter, anterolateral STEMI(+) OMI. Limkakeng AT.

STEMI

STEMI Coronary ED ACS

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

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

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

If this is ACS with Aslanger's pattern , the ST depression vector of subendocardial ischemia (due to simultaneous 3 vessel or left main ACS) is directed toward lead II (inferior and lateral). Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

ACS

ACS CPR CAD Heart Attack

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

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. Clin Cardiol 2022; [link] Labs included: hsTnI 156 ng/L, Hb 12 g/dL, WBC 12x10^9/L, Cr. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Lupu L, et al. mg/dL, K 3.5

ACS

ACS Coronary ICU STEMI

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. Comment by K EN G RAUER, MD ( 12/12 /2022 ): = I will summarize in 4 words the important message conveyed by Dr. Meyers in today's post = "Be Aware of Pseudo-Normalization!"

OR

OR ACS STEMI Coronary

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

Dr. Smith's ECG Blog

MAY 10, 2023

Later, she developed chest pain again, and had this ECG recorded: Obvious Anterior OMI that is also a STEMI Coronary angiogram- --Right dominant coronary artery system --The left main artery was normal in appearance and free of obstructive disease. --The Thus, Wellens' syndrome should be thought of as a transient OMI or transient STEMI.

Coronary

Coronary STEMI CAD OR

A man in his 60s with acute chest pain

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS

ACS EMS 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. Chest pain is squeezing or tight in nature.

Overdose

Overdose OR Coronary ACS

Chest pain and anterior ST depression. What’s the cause(s)?

Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. CMAJ 2014.

STEMI

STEMI Coronary OR ACS

Chest pain, and Cardiology didn't take the hint from the ICD

Dr. Smith's ECG Blog

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. Close up of V3 with baseline in red Close up of V4 with baseline in red This ECG alone is highly suspicious for posterior OMI!

ACS

ACS Coronary Defibrillator STEMI

A man in his 70s with chest pain

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

ST depression maximal in V1-V4, in the context of ACS symptoms and unexplained by QRS abnormality or tachydysrhythmia, should be considered posterior OMI until proven otherwise.

Coronary

Coronary Heart Attack ED CPR

75 year old with 24 hours of chest pain, STEMI negative

Dr. Smith's ECG Blog

JUNE 8, 2023

STEMI negative : the EMS automated interpretation read, “STEMI negative. According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Inferior infarct, age undetermined.

STEMI

STEMI Coronary Paramedic ALS

External Validation of Pittsburgh Cardiac Arrest Category (PCAC) Illness Severity Score

REBEL EM

JULY 14, 2022

2022 Mar; 17. 2022 Mar; 17. PMID: 30060961 Koller AC, et al. As above, we take the PCAC score into account when we order our interventions and may prioritize Neuroresuscitation in a PCAC 4 over a cath without a hard indication (STEMI). Paper: Nassal MMJ, et al. Resuscitation. REFERENCES: Nassal MMJ, et al. Resuscitation.

ICU

ICU ALS OR CPR

Paramedicine Now

What happened after the Cath lab was activated for a chest pain patient with this ECG?

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Trending Sources

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

Is OMI an ECG Diagnosis?

75 year old dialysis patient with nausea, vomiting and lightheadedness

Two ECGs texted to me in the same hour. What would you recommend?

Occlusion myocardial infarction is a clinical diagnosis

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

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Case Report: The Not So Normal, Normal EKG

Watch what happens when you teach others how to find OMI

Compare these two ECGs. Do either, neither, or both show anything important?

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

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

65 year old with syncope and a 'normal' ECG: discharge home?

A man in his 70s with acute chest pain and paced rhythm.

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

A 40-something with 100 minutes of chest pain

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

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

A woman in her 50s with acute chest pain

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

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

A man in his 60s with acute chest pain

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

Chest pain and anterior ST depression. What’s the cause(s)?

Chest pain, and Cardiology didn't take the hint from the ICD

A man in his 70s with chest pain

75 year old with 24 hours of chest pain, STEMI negative

External Validation of Pittsburgh Cardiac Arrest Category (PCAC) Illness Severity Score

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