Dr. Smith's ECG Blog

FEBRUARY 12, 2025

Even before we have clinical context, this ECG simply does not appear concerning for OMI, notwithstanding the machine's interpretation ** ** ACUTE MI / STEMI ** **. But in the world of STEMI, this is a challenging ECG to most. There were 80 positives by STEMI criteria, 88 by device algorithm, and 77 by AI software.

STEMI 83

STEMI E-9-1-1 ACS Coronary 83

Dr. Smith's ECG Blog

MARCH 14, 2025

He has a history of coronary artery disease and a STEMI two years prior that was treated with primary PCI. At the time of this initial ED ECG, his symptoms were improving ECG #1 on admission to the ED The patient was not seen quickly in the ED as it was a busy shift and the ECG did not meet STEMI criteria. The below ECG was recorded.

ACS 107

ACS STEMI Coronary OR 107

Dr. Smith's ECG Blog

MARCH 19, 2025

STEMI criteria are only 43% sensitive for OMI. Regarding the ECG, this case shows inferior ST elevation with reciprocal depression in aVL that does not quite meet STEMI criteria, ST depression maximal in V2-V3 (>97% specific for posterior MI), and an increasingly anterior R wave progression indicating posterior wall infarction.

STEMI 114

STEMI Coronary ED Paramedic 114

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. However, many patients with de Winter ECG pattern have TIMI 0 at angiography and the ECG pattern does not necessarily progress to STEMI. 17 have HATW. Under Review.

STEMI 114

STEMI Coronary ALS Ambulance 114

Dr. Smith's ECG Blog

JANUARY 28, 2025

His first EKG is shown below, with a lead II rhythm strip: EKG 1, 1645 A provisder who is looking for STEMI would not see much in this EKG. It is possible that the T waves in this EKG are of an intermediate morphology between full-blown STEMI and inferior reperfusion. This is the classic morphology of hyperacute T waves.

STEMI 106

STEMI ED ACS Emergency Department 106

Dr. Smith's ECG Blog

JANUARY 11, 2025

Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin. check out the downsloping STE in this one A man in his 80s with chest pain What, besides large anterior STEMI, is so ominous about this ECG? Written by Pendell Meyers An adult man presented with acute chest pain. He appeared critically ill.

STEMI 138

STEMI Coronary OR 138

Dr. Smith's ECG Blog

MARCH 17, 2025

Limitations of registry data: This patient presented with STEMI (-) OMI and developed STEMI the following day. But the time that elapsed from first STEMI (+) ECG to balloon was 57 minutes, and THIS is what will be recorded for reporting to the National Cardiovascular Data Registry for purposes of quality improvement.

ACS 82

ACS STEMI Coronary ALS 82

Dr. Smith's ECG Blog

FEBRUARY 8, 2025

This was interpreted as "inferior STEMI" and the cath lab was activated. Discharge diagnosis was Non-STEMI. The STEMI/NSTEMI dichotomy can make it difficult to identify the culprit lesion, which can be spontaneously reperfused at the time of the angiogram 3. NSTEMI or reperfused OMI? So which was the culprit?

OR 65

OR Coronary STEMI ED 65

Dr. Smith's ECG Blog

MARCH 8, 2025

In lab, patients are monitored on continuous abbreviated ECG with 5 electrodes. During ballooning, we often see immediate hyperacute T waves. After stent deployment, we often see improvement in the ST-T within seconds or minutes. The patient's ECG at the beginning of the case is shown below. Was her outcome to be expected for ostial RCA OMI?

E-9-1-1 76

E-9-1-1 OR Defibrillator Coronary 76

Dr. Smith's ECG Blog

JANUARY 24, 2025

Learning points: 40% of LAD OMI with TIMI-0 flow do NOT meet STEMI criteria (manuscript under consideration at Eur Ht. 20/53 did not meet STEMI criteria, but all showed OMI diagnosed by both Smith and the Queen of Hearts. Another left ventricle sacrificed at the alter of ST elevation. J Cardiovascular Interventions.--20/53

STEMI 125

STEMI CAD Coronary ED 125

Dr. Smith's ECG Blog

MARCH 9, 2025

At 1210, the case was discussed with a cardiologist at a PCI capable facility, who accepted the patient for transfer, noting the ST depression in anterior leads as consistent with ischemia but not a STEMI. 5 years later ( now in 2025 ) the problem remains. 5 years later ( now in 2025 ) the problem remains.

Coronary 89

Coronary STEMI ED ALS 89

Dr. Smith's ECG Blog

JANUARY 21, 2025

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. Most MINOCA is due to ruptured plaque with thrombus that lyses and does not leave behind a visible culprit.

OR 62

OR Coronary STEMI ACS 62

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Unfortunately, the ECG was interpreted as no significant change from prior , "no STEMI"!! Approximately 5 minutes after ROSC, this ECG was obtained (about 45 minutes after arrival): Obvious anterolateral OMI, and STEMI criteria positive for those who care or need it. He was sent back to the waiting room, where he suffered a VF arrest.

STEMI 87

STEMI Defibrillator ACS OR 87

Dr. Smith's ECG Blog

FEBRUARY 10, 2025

Peaked T waves: Hyperacute (STEMI) vs. Early Repolarizaton vs. Hyperkalemia Recognize subtle findings of hyperK and, if present, treat with Calcium immediately! A good reminder of recommendations for calcium for either K>6 with any ECG changes (when the patient was first seen) or K>6.5 Hyperkalemia requires calcium if >6.5

ALS 119

ALS ED ICU OR 119

Dr. Smith's ECG Blog

MARCH 3, 2025

Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. An EKG from a year prior was available for comparison: The ED physician noted Initial EKG here read by the computer as a STEMI, however, there is a very poor baseline and a lot of artifact. What other pathology is possible?

E-9-1-1 74

E-9-1-1 Coronary STEMI Emergency Department 74

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). This correlates with potentially salvageable myocardium. See Raitt et al.: Let us have a look at the limb lead ST-T changes.

STEMI 90

STEMI ALS OR Coronary 90

Dr. Smith's ECG Blog

FEBRUARY 14, 2025

The ECG meets STEMI criteria objectively. Abdominal Pain in a middle-aged patient True Positive ST elevation in aVL vs. False Positive ST elevation in aVL == MY Comment, by K EN G RAUER, MD ( 2/10/2025 ): == I find cases like today's challenging. Here is his triage ECG: What do you think? Sinus bradycardia, normal QRS.

STEMI 62

STEMI ED Coronary OR 62

Dr. Smith's ECG Blog

JANUARY 13, 2025

How well does the computer interpretation perform? -- in this case, the computer diagnosed STEMI but the patient had Fever with Brugada -- A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? A 50-something male presented to triage with chest pain for one day. There is an rSR' in lead V1 without any spike of the R'-wave.

E-9-1-1 72

E-9-1-1 OR STEMI ALS 72

Dr. Smith's ECG Blog

JANUARY 23, 2025

He has never been poisoned by the STEMI/NSTEMI paradigm because he has never been to medical school. The Queen of Hearts recognizes this as OMI ("STEMI/STEMI Equivalent"). He just graduated from college. He has no medical training, but he has read this blog for years. He is an ECG tech who hopes to go to medical school.

Coronary 117

Coronary STEMI ED OR 117