Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

STEMI 122

STEMI Coronary ALS Emergency Department 122

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

STEMI 88

STEMI OR Coronary Emergency Department 88

EMDocs

SEPTEMBER 14, 2024

2024 Aug;84(2):226-227. 2: Human, Take this Patient to the Cath Lab – AI and STEMI Detection Spoon Feed These researchers developed and trained a deep ensemble artificial intelligence (AI) model to classify ECGs as STEMI versus non-STEMI. 2024 Jul 25:S0196-0644(24)00327-5. 2024 Jul 1;154(1):e2023064364.

Defibrillator 95

Defibrillator STEMI Emergency Department OR 95

Dr. Smith's ECG Blog

JUNE 7, 2024

Obvious infero-postero-lateral STEMI(+)OMI, regardless of context Now let’s put them in order: what was the sequence? With serial ECGs that are ‘STEMI negative’ the physician could have waited for serial troponin levels or referred the patient as “non-STEMI”. 2 Normal ECG #3. What was the outcome and final diagnosis?

STEMI 112

STEMI Coronary OR EMS 112

Dr. Smith's ECG Blog

JULY 9, 2024

Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen. As per My Comment in the above-cited Oct. 15, 2022 post — I like to focus on the ST-T wave appearance in leads V1 and V6 to facilitate recognition of Precordial Swirl.

Defibrillator 116

Defibrillator STEMI CPR EMS 116

ESO

APRIL 19, 2024

From April 2-5, the top fire services and EMS industry thought leaders and data analysts gathered at Wave 2024 to share what trends they’re forecasting for both fields and how they’re enacting change within their own organizations through the power of data-driven insights. It’s four days of thought leadership, networking, and learning.

MIH 105

MIH EMS Paramedic Firefighter 105

Dr. Smith's ECG Blog

JULY 7, 2024

So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 66

STEMI Coronary ALS OR 66

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.

STEMI 109

STEMI Coronary Defibrillator OR 109

EMDocs

MAY 4, 2024

1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. 2024 Mar;31(3):296-300. Originally published at JournalFeed , a site that provides daily or weekly literature updates. Acad Emerg Med. Epub 2023 Sep 17.

STEMI 98

STEMI Emergency Department OR 98

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. or basilar ischemia.

STEMI 115

STEMI Coronary Emergency Department ACS 115

Dr. Smith's ECG Blog

AUGUST 2, 2024

This was a machine read STEMI positive OMI. The meaning of this quote is that at times, something as obvious as the dramatic anterior lead ST elevation that we see in today's tracing is not the result of an acute LAD STEMI. His ECG is shown below. Pretty obvious anterior current of injury. What would you guess is the culprit artery?

STEMI 119

STEMI ALS OR 119

Dr. Smith's ECG Blog

JANUARY 27, 2024

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. West J Emerg Med 2024). Fortunately the patient did not reocclude while awaiting the angiogram.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

AUGUST 16, 2024

Its hard to measure the STE in I exactly with the moving baseline, but there is almost certainly not enough STE to meet STEMI criteria. The ACC recognizes these findings as formal STEMI equivalents (though they do not define how to find them). They are symmetric, fat, convex on both sides, etc.

STEMI 111

STEMI OR 111

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 99

STEMI Paramedic Coronary EMS 99

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. It’s time to learn smarter. Am J Emerg Med. doi: 10.1016/j.ajem.2023.10.049.

Coronary 98

Coronary STEMI ED OR 98

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. A healthy 45-year-old female presented with chest pain, with normal vitals. What do you think? But which one is it?

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

JULY 25, 2024

Cardiac arrest #3: ST depression, Is it STEMI? or is he an ACCESS Trial Candidate? == MY Comment , by K EN G RAUER, MD ( 7/5 /2024 ): == Clinical ECG interpretation is a 2-Step process. The ST depression usually resolves, or is clearly resolving (getting much better). Then assume there is ACS. or is he an ACCESS Trial Candidate?

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

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. I've excerpted the Table shown below in Figure-2 from My Comment in that June 17, 2024 post. 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

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." At this point — a STEMI was diagnosed, and cardiac cath with PCI was performed.

STEMI 113

STEMI Coronary Emergency Department OR 113

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI.

STEMI 109

STEMI Coronary OR ALS 109

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. Do either, both, or neither have occlusion MI? Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

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). As far as I can tell, there is only one randomized trial of immediate vs. delayed intervention for transient STEMI. Labs ordered but not yet drawn.

Coronary 117

Coronary STEMI ED OR 117

Dr. Smith's ECG Blog

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. The patient did well. == MY Comment , by K EN G RAUER, MD ( 8/4 /2024 ): == I thought today's case by Dr. Meyers is an important one for emergency providers for a number of reasons.

STEMI 116

STEMI OR Emergency Department 116

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

MARCH 22, 2024

This is documented as a STEMI in the clinical notes and in the cath report, but certainly does not meet STEMI criteria and is therefore an NSTEMI by definition. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0. Large STEMI are approximately 30-80.

STEMI 114

STEMI OR 114

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

JUNE 19, 2024

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!!!) Surely, he should be given heparin and taken for an emergent angiogram, right?

STEMI 60

STEMI Coronary CAD ED 60

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria. But if the pain is persistent, as reported, then the patient must go to the cath lab even if the ECG suggests reperfusion. This will be corrected in Version 2, coming soon. YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE

STEMI 85

STEMI ACS OR 85

Dr. Smith's ECG Blog

JANUARY 5, 2024

Smith comment: No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matter how normal the ECG. A diagnosis of "reflux" or "GERD" is never supportable without a troponin rule out. Thus, one considers a test result that varies by 2 or less to be the same result. Heitner et al.

ACS 120

ACS ALS OR STEMI 120

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

SEPTEMBER 25, 2024

At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). At 1010, the first troponin I (URL 0.034 ng/mL) returned elevated at 0.4 At 1321, a repeat troponin I returned at 0.62 The T waves have deflated significantly and V2 shows the terminal T wave inversion typical to reperfusion.

Coronary 120

Coronary STEMI Emergency Department OR 120

Dr. Smith's ECG Blog

JULY 14, 2024

Another missed OMI by the False STEMI-NonSTEMI Dichotomy Don't miss them!!! Here's what Version 1 QOH thinks: It is diagnostic of acute LAD OMI, with the precordial swirl pattern. Stopped measuring troponins on the day of presentation around 5,000 ng/L as it was still rising." Use the Queen of Hearts and save myocardium and lives!

STEMI 104

STEMI OR ED 104

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. In any case, the ECG is diagnostic of severe ischemia and probably OMI. Smith Modified Sgarbossa Criteria for LBBB and Ventricular Paced Rhythm : 1. Concordant STE of 1 mm in just one lead or 2a.

Coronary 104

Coronary OR STEMI EMS 104

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean. There was no OMI.

STEMI 70

STEMI ED OR 70

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. He was diagnosed as NSTEMI.

ACS 82

ACS Coronary ALS CAD 82

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 Chest Pain – Benign Early Repol or OMI?

OR 120

OR STEMI Heart Attack Coronary 120

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121