Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria. The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI.

STEMI 85

STEMI ACS OR 85

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Discharge ECG showed antero-inferior reperfusion T wave inversion: Had the initial ECG been signed off as “STEMI negative” the patient could have arrested in the waiting room, with a poor cardiac and neurological outcome. First trop was 90 ng/L (normal <16 in females) and peak was 7,400 ng/L.

OR 66

OR STEMI ACS Coronary 66

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. Sometimes it can take 12 or 24 hours to see ECG evidence of reperfusion. == MY Comment , by K EN G RAUER, MD ( 1/4/ 2024 ): == Superb and thorough discussion by Dr. Frick of today's case! of the time.

ACS 120

ACS ALS OR STEMI 120

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. It is already approved in Europe.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Because the most severe LAD OMIs can cause ischemic failure of the RBB and LAF, any patient with ACS symptoms and new RBBB and LAFB with any concordant STE has LAD OMI until proven otherwise. There is no recognition of STEMI equivalency in this setting in the USA guidelines currently. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Similarly, the OMI paradigm respects ACS as a dynamic process in which ECG changes reflect the phase of myocardial injury and risk stratify which patients may benefit from emergent PCI. Is there STEMI? What is the rhythm?

STEMI 107

STEMI Coronary Heart Attack ACS 107

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." Accessed May 28, 2024. 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.

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

REBEL EM

FEBRUARY 3, 2025

Background: ST-segment elevation myocardial infarction (STEMI) is a critical condition requiring rapid diagnosis and intervention. While ECGs play a central role in detecting STEMI, misinterpretations often occur, leading to unnecessary catheterization or missed diagnoses. Paper: Lee SH, Jeon KL, Lee YJ, Ko YG, Choi D, Hong MK, et al.

STEMI 84

STEMI Coronary Emergency Department ALS 84

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. The ECG was transmitted to the Emergency Medicine physician who recognized inferior and posterior OMI findings, and confirmed that the patient has potential ACS symptoms.

STEMI 81

STEMI OR ED EMS 81

Dr. Smith's ECG Blog

DECEMBER 3, 2024

This dynamic change is diagnostic of ACS. Cardiology was consulted and agreed that his history was high risk for ACS and a next-day angiogram was merited. This was also non-diagnostic for OMI, although the dynamic changes are diagnostic of ACS. ECG at time 82 minutes: What do you think?

ED 110

ED Coronary ACS STEMI 110

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? The EMS ECGs: As per Dr. Smith the diagnosis of acute inferior STEMI is obvious from the history of new, severe CP in a patient with the initial EMS ECG that I show below ( TOP tracing in Figure-1 ). He called 911. Medics recorded a BP of 79/52 with pulse of 47.

Coronary 84

Coronary STEMI EMS ALS 84

Dr. Smith's ECG Blog

NOVEMBER 8, 2024

However, due to the nature of the symptoms, the patient was treated for ACS and admitted to the hospital. Smith comment: Approximately 33% of cases that everyone would call STEMI reperfuse spontaneously (TIMI-1, 2, 3 flow) before they undergo emergent angiogram (usually under 90 minute door to balloon time) 20% have TIMI-3 flow.

ACS 101

ACS Coronary STEMI OR 101

Dr. Smith's ECG Blog

JANUARY 21, 2025

Negative trops and negative angiogram does not rule out coronary ischemia or ACS. It is correct that he did not have chest pain, but we must remember that fully 1/3 of full blown STEMI do not present with chest pain. This is extremely elevated for a type 2 MI and totally consistent with STEMI. See these posts: Dynamic OMI ECG.

OR 61

OR Coronary STEMI ACS 61

Dr. Smith's ECG Blog

DECEMBER 31, 2024

But thankfully, when the clinical context is clearly and highly concerning for ongoing ischemia from ACS, this distinction doesn't matter much. Final Diagnosis: "STEMI" (of course, as you can see in the ECGs above, this is not true, by definition this was NSTEMI. In other words, millimeters really don't matter! hours duration.

Coronary 118

Coronary ACS STEMI CAD 118

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

50% of LAD STEMI have Q-waves by one hour. Smith : In limb leads, the ST vector is towards lead II (STE lead II STE lead III, which is more likely with pericarditis than with STEMI). Patients with suspected ACS should be evaluated with echocardiography. This correlates with potentially salvageable myocardium. See Raitt et al.:

STEMI 89

STEMI ALS OR Coronary 89