ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. Mimics of ST elevation myocardial infarction (STEMI). Accessed November 29, 2023.

STEMI 52

STEMI Coronary ACS Critical Care 52

Core EM

NOVEMBER 15, 2023

The Case A 62-year-old male with a history of Hypertension, Hyperlipidemia, Coronary Artery Disease with stents, Pulmonary Embolism on Eliquis, presents with sudden onset, severe, mid-sternal chest pain that started 15 minutes prior to arrival. Serial ECG's should be obtained to assess for evolution to acute STEMI.

Coronary 130

Coronary STEMI ED 130

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. Similarly, if a patient with known CAD presents with refractory ischemic chest pain, the ECG barely matters: the pre-test likelihood of acute coronary occlusion is so high that they need an emergent angiogram.

STEMI 114

STEMI Coronary ALS CAD 114

Dr. Smith's ECG Blog

APRIL 4, 2023

This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI? As cardiology documented, “possible STEMI.

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. Formal echo showed EF 55% with mild inferolateral hypokinesis without any prior for comparison.

STEMI 85

STEMI Coronary OR ED 85

EMDocs

FEBRUARY 24, 2024

Epub 2023 Nov 3. #2: Epub 2023 Oct 4. #3: 3: New AI-Powered OMI Detector Spoon Feed An artificial intelligence (AI) ECG model outperformed standard STEMI criteria in identifying occlusion myocardial infarction (OMI) confirmed by coronary angiography. Source High risk and low prevalence diseases: Infected urolithiasis.

Coronary 77

Coronary STEMI ED OR 77

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI 52

STEMI Coronary EMR ALS 52

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-9-1-1 119

E-9-1-1 ACS Coronary STEMI 119

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. It is a mass delusion.

STEMI 73

STEMI Coronary ACS OR 73

EMDocs

OCTOBER 28, 2023

2023 Sep;164(3):667-669. Epub 2023 Apr 20. #2: 2: STREAM-2 RCT | Half-Dose Tenecteplase for STEMI Spoon Feed The STREAM-2 trial found half-dose tenecteplase was effective in treating STEMI patients ≥60, though with increased risk of intracranial hemorrhage. . #2: 2023 Aug 29;148(9):753-764. Epub 2023 Jul 13. #3:

STEMI 66

STEMI Emergency Department Coronary OR 66

Dr. Smith's ECG Blog

JULY 25, 2024

But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. Cardiac arrest #3: ST depression, Is it STEMI? Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! It also does not uniformly indicate severe coronary disease.

Defibrillator 105

Defibrillator Coronary Epinephrine ACS 105

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

I came to work one day and one of my partners said, "Hey, Steve, we had a STEMI this afternoon!" That is not a STEMI. They had activated the cath lab and the interventionalist did not notice that it was not a STEMI/OMI. I said, "Cool, can I see the ECG?' Of course he said: "Yes, it was a 60 year old diabetic with Chest pain."

STEMI 124

STEMI Coronary 124

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. Fortunately the patient did not reocclude while awaiting the angiogram.

STEMI 96

STEMI Coronary ACS ED 96

Dr. Smith's ECG Blog

AUGUST 6, 2023

link] == MY Comment, by K EN G RAUER, MD ( 8/6 /2023 ): == Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI”. The current STEMI paradigm that continues to be followed by all-too-many clinicians ( including all-too-many cardiologists ) is fallacious.

OR 90

OR STEMI Coronary 90

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. years old ± 13.7

STEMI 102

STEMI Coronary Emergency Medical Services OR 102

Dr. Smith's ECG Blog

OCTOBER 26, 2023

Artificial Intelligence-Augmented ECG Interpretation Using Smartphone Technology @TheEKGGuy [link] == MY Comment , by K EN G RAUER, MD ( 10/26 /2023 ): == Our THANKS to Drs. @RobertHermanMD on Making Waves from Mayo clinic. I’ll offer a word of caution — and a word on the prospects for continued future development.

Coronary 52

Coronary STEMI OR 52

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 116

STEMI Emergency Department Coronary OR 116

REBEL EM

SEPTEMBER 14, 2023

The benefits of this strategy may be outweighed by the risk of the device-related complications (i.e. bleeding, stroke, limb ischemia, and hemolysis). The evidence for this practice has been sparse until now. Zeymer HT et al. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. Control: 53.4% D ECLS: 18.2% Control 8.7% Control 38.0%

Life Support 136

Life Support Coronary CPR ICU 136

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.” Am J Emerg Med 2023 2.

STEMI 72

STEMI Coronary OR ALS 72

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). No ECG was ordered on Day #1.

Coronary 102

Coronary STEMI Emergency Department OR 102

Dr. Smith's ECG Blog

OCTOBER 1, 2023

She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. Back to the case: Unfortunately, the ECG was not understood by the provider.

OR 124

OR STEMI CAD Coronary 124

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 113

STEMI ED OR Coronary 113

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 82

STEMI Coronary Paramedic OR 82

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. 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. So it can miss some OMI.

Defibrillator 126

Defibrillator Coronary STEMI CPR 126

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 113

E-9-1-1 Coronary ACS BLS 113

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. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52

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 97

STEMI Coronary OR ALS 97

Dr. Smith's ECG Blog

APRIL 21, 2023

Now let’s compare this with the existing paradigm to identify multiple preventable delays to reperfusion, which can be improved through the paradigm shift from STEMI to OMI. In the STEMI paradigm, patients with ischemic symptoms and ECGs that don’t meet STEMI criteria get serial ECGs.

STEMI 52

STEMI Coronary EMR EMT 52

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

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 110

OR STEMI EMS ED 110

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. Really unusual to me that QOH V1 only has low confidence, but at least its correct. During EMS transport, the pain suddenly resolved. The most striking finding is the deWinter-like T waves seen in each of the inferior leads.

STEMI 91

STEMI EMS Coronary OR 91

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. To me, that is a meaningless diagnosis. Here is the main learning point: The infarct was due to an occluded artery (Occlusion MI, OMI). In 30% of OMI, there is no significant ST Elevation.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

AUGUST 3, 2023

? OMI Pocket Guide The OMI Pocket Guide ( [link] ) is a user-friendly online resource designed to help healthcare professionals learn how to recognize subtle signs of acute coronary occlusion on the ECG which represent occlusion myocardial infarctions (OMI). The guide organizes OMIs into categories based on each of the steps outlined by Drs.

STEMI 64

STEMI Coronary OR 64

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 80

E-9-1-1 ACS STEMI Coronary 80

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. This ECG was texted to me with no other information. I assumed the presentation was consistent with acute MI. What did I say? Activate the cath lab." The T-waves in V2-V6 are diagnostic. There is also some non-diagnostic STE in inferior leads.

OR 118

OR STEMI Coronary 118

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). My Comment by K EN G RAUER, MD ( 3/31 /2023 ): = Computers are amazing machines. This was sent to me by a friend. It is from a 50-something with chest pain: What do you think?

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

DECEMBER 9, 2023

He has a history of STEMI and heart failure. link] Case continued The conventional algorithm diagnosed STEMI and so did the paramedics. A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA. He was belted and it was low speed.

STEMI 102

STEMI Coronary ED Paramedic 102