Dr. Smith's ECG Blog

MARCH 10, 2025

But like many similar studies, the study was small (one year at one centre with no indication of the incidence of acute coronary occlusion), and it used as the gold standard the final cardiologist interpretation of the ECG - not the patient outcome! Despite serial ECGs being "STEMI negative", the cath lab was activated.

STEMI 89

STEMI OR Coronary Emergency Department 89

EMDocs

FEBRUARY 24, 2024

2024 Jan;75:137-142. 2024 Jan;22(1):140-151. 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 98

Coronary STEMI ED OR 98

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-9-1-1 127

E-9-1-1 Coronary STEMI ALS 127

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. This case is an example of the steps we can all take in daily practice as the paradigm shifts from STEMI to OMI.

STEMI 100

STEMI Paramedic Coronary EMS 100

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. West J Emerg Med 2024). Deutch et al.

STEMI 117

STEMI Coronary ACS ED 117

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 116

OR STEMI Coronary ED 116

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). With EMS, patient had a GCS of 3 and was saturating 60% on room air. ng/mL and 0.10

STEMI 115

STEMI Coronary Emergency Department ACS 115

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 117

Coronary STEMI ED OR 117

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Learning Points: You cannot trust conventional algorithms even to find STEMI(+) OMI, even when they say "normal ECG." It is clearly missed by the conventional algorithm.

STEMI 113

STEMI Coronary Emergency Department OR 113

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 122

OR STEMI ICU Coronary 122

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 120

Coronary STEMI Emergency Department OR 120

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

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. Hammill SC. Edwards WD.

STEMI 109

STEMI Coronary OR ALS 109

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.

STEMI 108

STEMI EMS Coronary OR 108

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE? The computer thinks so, and the physician thinks that is quite possible. However , there is terminal QRS distortion in lead V3.

STEMI 115

STEMI ACS Critical Care Coronary 115

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 104

Coronary OR STEMI EMS 104

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

OCTOBER 6, 2024

The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. For more on ECG findings in pulmonary disease — Check out My Comment in the May 31, 2024 post in Dr. Smith's ECG Blog ). The door to balloon time was incredibly short and there was a 100% circumflex occlusion that was opened and stented.

STEMI 77

STEMI Coronary ED 77

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

JULY 24, 2024

Easy LINK — [link] — My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. 2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”.

E-9-1-1 52

E-9-1-1 Coronary STEMI OR 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). The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. It is already approved in Europe. 2009;95:1701–1706.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

JANUARY 5, 2024

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! We know that even high-sensitivity troponin may not exceed the "normal" range for a period of hours in certain patients with acute coronary occlusion.

ACS 120

ACS ALS OR STEMI 120

Dr. Smith's ECG Blog

JANUARY 17, 2024

The limb leads have been removed because there was no ST elevation in those leads, the QRS complexes have been obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation. Using the current paradigm, can you tell which patient had an acute coronary occlusion?

STEMI 118

STEMI Coronary ALS OR 118

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab. This study failed to do so. 5% vs. 58%!!

Defibrillator 113

Defibrillator STEMI Coronary ALS 113

Dr. Smith's ECG Blog

MAY 13, 2024

This ECG is highly concerning for LAD occlusion despite it not showing a STEMI criteria. You can find the variables used to calculate the value on MD calc here: [link] Utilizing Dr. Smith’s Subtle Anterior STEMI Calculator (4-Variable), the value is greater than 18.2 which is concerning for LAD occlusion.

OR 120

OR STEMI Heart Attack Coronary 120

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Serial ECGs enhance the diagnosis of acute coronary syndrome. Is there STEMI? Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the Crusade Quality Improvement Initiative.

STEMI 107

STEMI Coronary Heart Attack ACS 107

Dr. Smith's ECG Blog

JULY 19, 2024

It was read by the treating physician and the overreading cardiologist as "Paced, no STEMI." Immediate and early percutaneous coronary intervention in very high risk and high risk non-ST segment elevation myocardial infarction patients. How does the Queen of Hearts do? Lupu et al. Clinical Cardiology. Am Heart J [Internet].

Coronary 115

Coronary STEMI OR ALS 115

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

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 131

Defibrillator Coronary ALS STEMI 131

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." Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T Waves - ScienceDirect. Accessed May 28, 2024.

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 30, 2024

Written by Jesse McLaren, with edits from Meyers Four patients presented with chest pain or shortness of breath, and ECGs labeled ‘inferior STEMI’. Less concavity associated with hyperacuity This can help identify false negative STEMI, or STEMI(-)OMI, at risk for delayed reperfusion. More asymmetry 3.

STEMI 118

STEMI OR Coronary 118

Dr. Smith's ECG Blog

OCTOBER 31, 2024

But it does not meet the ridiculous "STEMI criteria" since there is not 1 mm of STE in any lead. Learn to read the ECG for sublte OMI, and get the Queen of Hearts. == MY Comment , by K EN G RAUER, MD ( 11/1 /2024 ): == The beauty of today's case is its simple efficiency. So this is acute OMI. What does the Queen of Hearts say? (Dr.

STEMI 116

STEMI Coronary 116

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 cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. 33% of STEMI are reperfused by the time of angiography. Very frustrating.

STEMI 81

STEMI OR ED EMS 81

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

STEMI 105

STEMI Coronary Critical Care ED 105

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? Myocardial Infarction with Non-Obstructive Coronary Arteries. Etiologies (list not comprehensive): Coronary Spasm. For more on the ECG diagnosis and consequences of acute RV MI Check out My Comment in July 19, 2020 post and the August 2, 2024 post).

Coronary 75

Coronary STEMI EMS ALS 75

Dr. Smith's ECG Blog

JANUARY 31, 2025

This ECG pattern is my favorite example of how the STEMI criteria are fundamentally flawed. We have a series of 20 TIMI-0 LAD Occlusions that do meet STEMI criteria. This typically occurs in the setting of a rapidly reperfused coronary artery following a myocardial infarction. 2024, January 31). 17 have HATW. Wellens, H.

STEMI 113

STEMI Coronary ALS Ambulance 113