Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. Coronary arteries cannot be assessed because the scan was not gated, but proximal segments of the coronary arteries seem to be open with some contrast. Again nothing diagnostic.

STEMI 52

STEMI EMR Coronary OR 52

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. Am Heart J.

STEMI 81

STEMI Coronary ACS OR 81

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion.

OR 106

OR STEMI Coronary ED 106

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." Transient STEMI is at high risk of re-occlusion.

Coronary 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later? This caused a type 2 anterior STEMI. The April 8, 2022 post by Drs.

STEMI 80

STEMI Coronary Defibrillator OR 80

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents. J Am Coll Cardiol.

STEMI 72

STEMI Coronary Emergency Department ICU 72

Dr. Smith's ECG Blog

OCTOBER 22, 2024

"Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Peak troponin: 128,000 ng/L.

Coronary 66

Coronary STEMI OR ALS 66

Dr. Smith's ECG Blog

APRIL 22, 2024

Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty.

Coronary 116

Coronary STEMI ED OR 116

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 93

STEMI Coronary ACS OR 93

Dr. Smith's ECG Blog

OCTOBER 17, 2024

The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Coronaries were normal, as was serial troponin. Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

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

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. When EMS found her, she was dyspneic and diaphoretic.

E-9-1-1 109

E-9-1-1 Coronary STEMI ALS 109

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." For the same reason, you should not delay coronary angiography because pain resolves with morphine. The case continues. Mukherjee, D.,

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 117

STEMI Emergency Department Coronary OR 117

Dr. Smith's ECG Blog

JANUARY 8, 2024

She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. She went to angio and had normal coronaries. Medics recorded the above ECG and called a STEMI alert. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. Her troponin I returned at 900 ng/L.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., Here is the bottom line of the article: It is widely believed that hyperacute T-waves are a transitional state preceding ST Elevation 1–4 Thus, it is tempting to postulate that early cases of OMI will eventually evolve to STEMI; yet, our data contradicts that notion. This one is easy for the Queen.

OR 107

OR STEMI ICU Coronary 107

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. aVR ST segment elevation: acute STEMI or not? Incidence of an acute coronary occlusion.

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

JUNE 19, 2024

The ED provider ordered a coronary CT scan to assess the patient for CAD. His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”. The patient started receiving medications for “STEMI” (including heparin!!!)

STEMI 60

STEMI Coronary CAD ED 60

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. Figure-1: The initial ECG in today’s case.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

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

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

STEMI 103

STEMI Coronary OR ALS 103

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 52

STEMI Coronary ED ACS 52

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. Sequence of events in angina at rest: Primary reduction in coronary flow. 2022 Nov, 80 (20) 1925–1960. Normalization of abnormal T waves in ischemia. Arch Intern Med.

Emergency Department 52

Emergency Department STEMI 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

NOVEMBER 29, 2023

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." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

OR 116

OR STEMI EMS ED 116

Dr. Smith's ECG Blog

OCTOBER 10, 2024

Unfortunately you can see that the conventional Zoll algorithm sees nothing even to suggest AMI, let alone STEMI. For review on how I apply the Mirror Test I devised — See My Comment in the September 21, 2022 post in Dr. Smith's ECG Blog ). = Really unusual to me that QOH V1 only has low confidence, but at least its correct.

STEMI 97

STEMI EMS Coronary OR 97

Dr. Smith's ECG Blog

MAY 30, 2023

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. What is the atrial activity? Is it sinus arrest with junctional escape?

E-9-1-1 82

E-9-1-1 STEMI Coronary OR 82

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). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain.

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. In other words, the inferior "ST elevation" is due to the abnormal rhythm, and does not signify OMI or STEMI in any way. The angiogram showed completely normal coronary arteries.

STEMI 119

STEMI ED OR Coronary 119

Dr. Smith's ECG Blog

JUNE 1, 2022

Moreover, the research which appears to confirm this idea was indeed in relation to the circumflex, but they did not study Occlusion ; rather, they studied asymptomatic coronary disease. I showed conclusively that this is a common finding in normal ECGs, though it is more common in LAD Occlusion than in norml variant STE.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

APRIL 25, 2023

Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease.

Coronary 52

Coronary STEMI ALS OR 52

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.

STEMI 52

STEMI ACS Coronary OR 52

Dr. Smith's ECG Blog

APRIL 17, 2023

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)? Physician interpretation: "No STEMI." Physician: "No STEMI." Cardiologist interpretation: "Technically does not meet STEMI criteria but concerning for ischemia."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. All coronary arteries were patent without atherosclerotic change. . == Below is the ECG of Patient #2 — as interpreted by the QOH. The ECG is diagnostic of occlusion myocardial infarction (OMI).

Coronary 85

Coronary OR STEMI EMS 85

Dr. Smith's ECG Blog

JULY 24, 2024

2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”. Many ( if not most ) NSTEMIs are actually OMIs ( = acute coronary O cclusion MI s ).

E-9-1-1 52

E-9-1-1 Coronary STEMI OR 52