ACS, Blog and STEMI - Paramedicine Now

What does a final diagnosis of STEMI vs. NSTEMI depend upon?

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

STEMI OR ED EMS

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

REBEL EM

MARCH 2, 2023

Based on recent studies, current guidelines recommend that O2 should not be given to non-hypoxemic patients with STEMI or NSTEMI [2,3]. REBEL Cast Ep114 – High Flow O2, Suspected ACS, and Mortality? 4159 patients (10% of total population) had STEMI 30d Mortality: High O2 protocol: 8.8% Low O2 protocol: 3.1%

ACS

ACS Coronary STEMI Ambulance

Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin.

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

STEMI EMS ACS ED

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. For more on MINOCA — See My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog ). He does have a recently diagnosed PE, and has not been taking his anticoagulation due to cost. He was started on nitro gtt.

Coronary

Coronary ACS OR EMR

Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?

Dr. Smith's ECG Blog

MARCH 14, 2024

These have all been small studies, studying very few patients with ACS, and often used final cardiology interpretation rather than patient outcome. Smith : This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG.

STEMI

STEMI ACS Coronary Emergency Department

Chest pain with anterior ST depression: look what happens if you use posterior leads.

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

If there were diffuse ischemic STD, with precordial STDmaxV5-6 and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from ACS or supply-demand mismatch. So when the first troponin returned at 2,200 ng/L (normal <26 in males and <16 in females) the patient was referred to cardiology as a non-STEMI.

STEMI

STEMI ACS Coronary OR

A man with chest pain off and on for two days, and "No STEMI" at triage.

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Do you think we discussed this patient's 2-3 hour delay to reperfusion in our quarterly "STEMI meeting"?

STEMI

STEMI ACS Coronary Defibrillator

Resuscitated from ventricular fibrillation. Should the cath lab be activated?

Dr. Smith's ECG Blog

JULY 25, 2024

Then assume there is ACS. Cardiac arrest #3: ST depression, Is it STEMI? As we have often emphasized on Dr. Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! The ST depression usually resolves, or is clearly resolving (getting much better).

Defibrillator

Defibrillator Coronary Epinephrine ACS

What happened after the Cath lab was activated for a chest pain patient with this ECG?

Dr. Smith's ECG Blog

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI").

STEMI

STEMI ACS ED

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

Dr. Smith's ECG Blog

MAY 31, 2023

Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. It is a mass delusion.

STEMI

STEMI Coronary ACS OR

Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

STEMI

STEMI Coronary ALS CAD

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC).

E-9-1-1

E-9-1-1 ACS Coronary STEMI

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? The ST depressions in I and aVL have resolved.

CAD

CAD STEMI Coronary ACS

70-year-old with acute chest pain, STEMI negative: just an old infarct?

Dr. Smith's ECG Blog

APRIL 4, 2023

This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI? As cardiology documented, “possible STEMI.

STEMI

STEMI Coronary OR ACS

75 year old dialysis patient with nausea, vomiting and lightheadedness

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. This is not unusual. Take home 1.

STEMI

STEMI ACS OR ALS

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

Dr. Smith's ECG Blog

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! 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. Deutch et al.

STEMI

STEMI Coronary ACS ED

An elderly male with acute altered mental status and huge ST Elevation

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. Version 2 = 0.0272.

STEMI

STEMI Coronary Emergency Department OR

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

Coronary

Coronary E-9-1-1 STEMI ACS

Is there OMI on this ECG?

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient has active chest pain, so if these are abnormally large T-waves This link shows 13 blog posts of Posterior Reperfusion T-waves. Comment : ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). Therefore, we activate the Cath Lab.

ACS

ACS STEMI OR

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Day 12 ECG: FINAL DIAGNOSIS: "NSTEMI" Despite the fact that his day 4 ECG easily meets STEMI criteria, the patient is diagnosed as NSTEMI. No TIMI flow was listed in the report. Am Heart J.

E-9-1-1

E-9-1-1 ACS STEMI Coronary

ECG Cases 8 Cardiovascular Emergencies During The COVID-19 Pandemic

Emergency Medicine Cases

APRIL 14, 2020

In this ECG Cases blog we look at 6 patients who presented with cardiorespiratory symptoms, possibly from COVID and illustrate the dangers of anchoring, being hypervigilant for cardiovascular complications, and why testing for COVID in patients being admitted for ACS is important.

ACS

ACS STEMI

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. His response: “subendocardial ischemia. Anything more on history? POCUS will be helpful.”

Coronary

Coronary ACS STEMI ALS

Healthy 45-year-old with chest pain: early repolarization, pericarditis or injury?

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. For more on this topic — See discussion in the October 24, 2019 and July 31, 2018 posts in Dr. Smith's ECG Blog ).

OR

OR STEMI ACS Coronary

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI

STEMI ED ACS Coronary

Interventionalist at the Receiving Hospital: "No STEMI, no cath. I do not accept the transfer."

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? This is the response he got: Interventionist: "No STEMI, no cath. After stabilizing the patient and recording more ECGs, he tried again: Interventionalist: "It isn't a STEMI." It is a STEMI equivalent. We don't know how many though.

STEMI

STEMI Defibrillator ED ACS

Two ECGs texted to me in the same hour. What would you recommend?

Dr. Smith's ECG Blog

JUNE 15, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. High sensitivity troponin I was 23 ng/L.

STEMI

STEMI Coronary ACS OR

Serial ECGs for chest pain: at what point would you activate the cath lab?

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

STEMI Paramedic Coronary EMS

50 Shades of T

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI).

ACS

ACS Paramedic Coronary ALS

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

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." 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. Kosuge et al. Witting et al.

E-9-1-1

E-9-1-1 ACS Emergency Department Coronary

46 year old with chest pain develops a wide complex rhythm -- see many examples

Dr. Smith's ECG Blog

AUGUST 9, 2024

This has been discussed many times before on this blog. In-depth discussion is beyond the scope of this blog. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI? The patient continued having chest pain. What is the rhythm? References: Ferrier, G.

STEMI

STEMI Coronary Heart Attack ACS

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

ACS

ACS STEMI OR Critical Care

What will happen if you implement the Queen of Hearts in your Hospital?

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

He has been following the blog for 4 years. The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria. This case was sent by Dr. Jean-christophe Reiters, an interventionalist in Belgium. He has now implemented the Queen of Hearts in his hospital. He wanted to share one of the first cases.

STEMI

STEMI ACS OR

Baseline wander. But what else do you see?

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

ACS Coronary STEMI OR

5 Cardiologists said this is not a STEMI. But was it an OMI?

Dr. Smith's ECG Blog

AUGUST 15, 2019

He had multiple cardiovascular risk factors and the EM physician strongly suspected ACS. Over the next few hours, four other general cardiologists "signed off on the initial ECG without recognizing STEMI." Learning Points: STEMI criteria misses 25-40% of OMI, like this case for example. mm of the "required" 1.0

STEMI

STEMI ACS OR EMS

Watch what happens when you teach others how to find OMI

Dr. Smith's ECG Blog

MARCH 20, 2023

Since then, I started looking for OMI EKG findings and not just STEMI. So, I'm a follower of your blog, and I think I have a interesting case that I attended yesterday." Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED.

STEMI

STEMI ACS CAD ED

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

STEMI

STEMI Coronary ALS ACS

A 40-something with 100 minutes of chest pain

Dr. Smith's ECG Blog

MARCH 27, 2023

I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI. This is now further confirmation of ACS. I was reading ECGs on the system, and saw this one: What do you think? There is no doubt that this is an inferior posterior OMI.

ACS

ACS STEMI OR

Cardiologist declines taking patient to the cath lab. Patient dies.

Dr. Smith's ECG Blog

OCTOBER 11, 2020

The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." Like other cases on this blog who died before cath was done, I cannot prove that this patient had OMI. The whole paradigm is literally called "STEMI" vs. "NSTEMI." Canto et al.

STEMI

STEMI ACS OR Coronary

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery.

Emergency Department

Emergency Department E-9-1-1 Coronary STEMI

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI

STEMI Coronary ACS ED

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. These include: i ) appreciation of how problematic the definition of “acute STEMI” can be; and , ii ) illustration of how dependence on this definition may result in overlooking acute coronary occlusion. Mokhtari et al. JACC 2016;67:1531.

E-9-1-1

E-9-1-1 STEMI ACS Coronary

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

Dr. Smith's ECG Blog

MARCH 19, 2024

The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Most large STEMI have peak troponin I in the 20.0 There are hyperacute T-waves in V5 and V6. Next trop in AM. Peak trop 257.97 ng/mL - 80.0

CAD

CAD STEMI ACS ALS

Compare these two ECGs. Do either, neither, or both show anything important?

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Physician: "No STEMI."

OR

OR STEMI ACS Emergency Department

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)

Dr. Smith's ECG Blog

JUNE 27, 2021

If it is maximal in V1-V4, and the patient's presentation in consistent with ACS (as this certainly is), then it is DIAGNOSTIC of Occlusion with 90% specificity (We have an upcoming article that proves this). Angiogram: "ACS - Non ST Elevation Myocardial Infarction. Because we are hypnotized the STEMI paradigm. "If

STEMI

STEMI ACS Coronary ED

What does a final diagnosis of STEMI vs. NSTEMI depend upon?

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

Trending Sources

Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin.

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?

Chest pain with anterior ST depression: look what happens if you use posterior leads.

A man with chest pain off and on for two days, and "No STEMI" at triage.

Resuscitated from ventricular fibrillation. Should the cath lab be activated?

What happened after the Cath lab was activated for a chest pain patient with this ECG?

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

Is OMI an ECG Diagnosis?

Occlusion myocardial infarction is a clinical diagnosis

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

70-year-old with acute chest pain, STEMI negative: just an old infarct?

75 year old dialysis patient with nausea, vomiting and lightheadedness

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

An elderly male with acute altered mental status and huge ST Elevation

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Is there OMI on this ECG?

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

ECG Cases 8 Cardiovascular Emergencies During The COVID-19 Pandemic

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Healthy 45-year-old with chest pain: early repolarization, pericarditis or injury?

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Interventionalist at the Receiving Hospital: "No STEMI, no cath. I do not accept the transfer."

Two ECGs texted to me in the same hour. What would you recommend?

Serial ECGs for chest pain: at what point would you activate the cath lab?

50 Shades of T

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

46 year old with chest pain develops a wide complex rhythm -- see many examples

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

What will happen if you implement the Queen of Hearts in your Hospital?

Baseline wander. But what else do you see?

5 Cardiologists said this is not a STEMI. But was it an OMI?

Watch what happens when you teach others how to find OMI

7 steps to missing posterior Occlusion MI, and how to avoid them

A 40-something with 100 minutes of chest pain

Cardiologist declines taking patient to the cath lab. Patient dies.

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

Is this a STEMI? No, not by definition! Why not? Why is this Important?

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

Compare these two ECGs. Do either, neither, or both show anything important?

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)

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