Dr. Smith's ECG Blog

APRIL 11, 2025

Here is the Queen of Hearts interpretation: Here is the cardiologist's impression: "EKG does not show a STEMI." Here is the cath report (TIMI-2 flow in the circumflex -- stented): Learning Point: Just because the cardiologist says it is "not a STEMI" and "wants to teach you about the ECG", it does not mean you should back down.

STEMI 120

STEMI OR 120

Dr. Smith's ECG Blog

JANUARY 18, 2025

Im changed. == MY Comment , by K EN G RAUER, MD ( 1/16 /2025 ): == It's not often that we see a clinical entity for which it seems that the patient "read the textbook" before the ECG was recorded. This ECG has the "South Africa Flag Sign" This image below illustrates the " South Africa Flag Sign " (Image is from this previous post).

STEMI 116

STEMI OR 116

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 82

STEMI E-9-1-1 ACS Coronary 82

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 106

ACS STEMI Coronary OR 106

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 113

STEMI Coronary ALS OR 113

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? I suspect this statement is still true 2 years later, in 2025. 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 ).

Coronary 84

Coronary STEMI EMS ALS 84

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 105

STEMI ED ACS Emergency Department 105

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 64

OR Coronary STEMI ED 64

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 116

STEMI Coronary ED Paramedic 116

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 124

STEMI CAD Coronary ED 124

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 81

ACS STEMI Coronary ALS 81

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 61

OR Coronary STEMI ACS 61

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 86

STEMI Defibrillator ACS OR 86

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 88

Coronary STEMI ED ALS 88

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 118

ALS ED OR ICU 118

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 73

E-9-1-1 Coronary STEMI Emergency Department 73

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 61

STEMI ED Coronary OR 61

Dr. Smith's ECG Blog

APRIL 9, 2025

The paramedics diagnosis was "Possible Anterolateral STEMI." More proof that a huge STEMI may have normal or near normal initial troponin. This is diagnostic of Acute LAD OMI In case you are wondering what the Queen thought, here she is: Notice that she also diagnoses Low Ejection Fraction. She had no further episodes of VF.

Defibrillator 64

Defibrillator STEMI ED OR 64

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

A 12-lead was recorded, showing "STEMI," but is unavailable. Moreover, if you know that catastrophic intracranial hemorrhage can result in an ECG that mimics STEMI, then you know that this patient probably has a severe intracranial hemorrhage. She was BVM ventilated and suctioned. Shortly thereafter, pulses were lost.

STEMI 88

STEMI Paramedic E-9-1-1 Epinephrine 88

Dr. Smith's ECG Blog

APRIL 16, 2025

Here is the Queen of Hearts interpretation, appropriately reading STEMI equivalent, highlighting anterior and lateral leads with explainability, and even detecting reduced LVEF. The Cardiologist stated that the ECG did not show signs of STEMI, but rather NSTEMI, recommended serial ECGs and troponins, and cancelled the activation request.

STEMI 101

STEMI OR ED 101

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 116

Coronary STEMI ED OR 116

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 89

STEMI ALS OR Coronary 89

Dr. Smith's ECG Blog

APRIL 2, 2025

Here is the prehospital ECG, recorded in the presence of pain: Hyperacute anterolateral STEMI The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. So even a massive STEMI, if it reperfused quickly, can result in a relatvely low troponin (in contrast to the next case!)

STEMI 75

STEMI Coronary ED ACS 75

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 137

STEMI Coronary OR 137

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 71

E-9-1-1 OR STEMI ALS 71

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 75

E-9-1-1 OR Defibrillator Coronary 75