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 117

STEMI Coronary ALS CAD 117

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. No TIMI flow was listed in the report. Am Heart J.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. The patient was admitted as ‘NSTEMI’ which is supposed to represent a non-occlusive MI, but the underlying pathophysiology is analogous to a transient STEMI. Deutch et al.

STEMI 101

STEMI Coronary ACS ED 101

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 101

Coronary E-9-1-1 STEMI ACS 101

Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. Kosuge et al. Witting et al.

E-9-1-1 136

E-9-1-1 ACS Emergency Department Coronary 136

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

DECEMBER 22, 2023

Comment : ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). The ESC states that patients with suspected ACS should go to the cath lab in ＜2 hours "regardless of ECG or biomarker evidence of MI!!" Therefore, we activate the Cath Lab.

ACS 103

ACS STEMI OR 103

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 52

OR STEMI ACS Emergency Department 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. 2023 May 2;15(5):e38428. 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. Sensitivity was 87% for OMI in our validation study (it was 34% for STEMI criteria). So it can miss some OMI.

Defibrillator 130

Defibrillator Coronary STEMI CPR 130

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 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

APRIL 14, 2023

The triage ECG was interpreted correctly as "No STEMI." This finally prompted a repeat ECG at 1341: 1350: Obviously STEMI(+) OMI. Obvious ACS history with ongoing pain despite medical management and upgoing troponin is an indication for emergent cath regardless of ECG findings. = The second troponin returned higher at 45 ng/L.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

MARCH 1, 2023

This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. A "STEMI alert" was called and soon cancelled. You must understand that this pattern does not differentiate ACS from other causes of supply/demand mismatch.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 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 82

ACS Coronary ALS CAD 82

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

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

There’s mild inferior ST elevation in III that doesn’t meet STEMI criteria, but it’s associated with ST depression in aVL and V2 that makes it diagnostic of infero-posterior Occlusion MI (from either RCA or circumflex)– accompanied by inferior Q waves of unknown age. Are there any signs of occlusion or reperfusion?

OR 52

OR STEMI Coronary ACS 52

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.

E-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

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

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. For this test it is VERY low (very good) at 4% at the 99th percentile -- 26 ng/L, but it will not be so good at a level of 9 ng/L. Thus, one considers a test result that varies by 2 or less to be the same result. of the time.

ACS 106

ACS ALS OR STEMI 106

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

Guidelines say that if a patient has ACS but refractory pain, the patient should go emergently to the cath lab. Notice that much of the dark blue is concentrated on the QRS (R-wave); the QRS is totally ignored in the STEMI paradigm!! Fluids and morphine had been given and the patient had spontaneously converted to sinus rhythm.

STEMI 85

STEMI Coronary ACS OR 85

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). 3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. Post PCI the patient became gravely hypotensive and "shocky". The LV EF was 57% at formal echo.

STEMI 95

STEMI OR ACS ALS 95

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

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). link] == MY Comment , by K EN G RAUER, MD ( 10/16 /2023 ): == Today’s case by Dr. Meyers is subtle.

ACS 101

ACS ED STEMI OR 101

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 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Moreover, the Queen is only supposed to be used with a high pretest probability of ACS/OMI. Is it STEMI? Another diagnostic ECG of a potentially deadly condition == MY Comment , by K EN G RAUER, MD ( 10/19 /2023 ): == Today's excellent case discussion by Drs. Magnesium later resulted at 0.8 mg/dL, and ionized calcium was 0.73

Overdose 112

Overdose OR ACS ICU 112

Dr. Smith's ECG Blog

JULY 30, 2023

It does not meet STEMI criteria. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). Learning Points: We can find OMI on ECG much sooner than STEMI criteria in many cases, and of course many OMIs never meet STEMI criteria at all. Easy for anyone.

E-9-1-1 52

E-9-1-1 STEMI OR ED 52

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 52

ACS EMS STEMI Coronary 52

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. My Comment by K EN G RAUER, MD ( 1/23 /2023 ): = The importance of today's case by Drs. mm in any posterior lead to be considered positive).

ACS 52

ACS Coronary Defibrillator STEMI 52

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. The ST-T changes in the limb leads on the repeat ECG (#3) results in a correct diagnosis of OMI. This patient’s OMI was identified early due to expert ECG interpretation.

ACS 60

ACS STEMI Coronary EMS 60

EMDocs

JANUARY 11, 2024

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association (AHA) and Neurocritical Care Society (NCS) released their 2023 Scientific Statement on the critical care management of post ROSC patients. 2023 Dec 1. Evaluate for mechanical support in those with refractory hypotension (ECMO).

Critical Care 74

Critical Care E-9-1-1 OR ICU 74

Dr. Smith's ECG Blog

AUGUST 10, 2023

This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. The initial ECG suggested either subacute or reperfused inferoposterior occlusion and clearly does not meet traditional STEMI criteria. So now there was ACS + electrical instability, another indication for emergent angiogram.

STEMI 90

STEMI ACS Emergency Department ED 90

Dr. Smith's ECG Blog

NOVEMBER 1, 2023

I assumed it was from a patient with symptoms compatible with ACS/OMI. If you are convinced by all the data, including the troponin, that the patient's pain is due to ACS, and he has persistent pain, then he should go to the cath lab. This ECG was texted to me by a colleague. What do you think? Stay tuned.

ACS 118

ACS ALS OR STEMI 118