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 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. Sensitivity was 87% for OMI in our validation study (it was 34% for STEMI criteria). So it can miss some OMI.

Defibrillator 129

Defibrillator Coronary STEMI CPR 129

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 81

STEMI ACS OR ALS 81

Dr. Smith's ECG Blog

DECEMBER 3, 2024

He had ongoing pain following the syncopal event but went to bed and awoke in the morning with ongoing pain. This dynamic change is diagnostic of ACS. Cardiology was consulted and agreed that his history was high risk for ACS and a next-day angiogram was merited. He came to the ED at the urging of his wife.

ED 94

ED Coronary ACS STEMI 94

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. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! Is it normal STE? This is a "Transient OMI".

STEMI 112

STEMI ACS Critical Care Coronary 112

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). 3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. As a result — the onset of any acute event that may have occurred is uncertain.

STEMI 95

STEMI OR ACS ALS 95

Dr. Smith's ECG Blog

DECEMBER 26, 2020

Is this inferor STEMI? Atrial Flutter with Inferior STEMI? Inferolateral ST elevation, vomiting, and elevated troponin The treating team did not identify the flutter waves and they became worried about possible "STEMI" (despite the unusual clinical scenario). The EM provider asked if the cardiologist thought it was a "STEMI."

STEMI 52

STEMI ACS Coronary Emergency Department 52

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. First trop was 90 ng/L (normal <16 in females) and peak was 7,400 ng/L.

OR 69

OR STEMI ACS Coronary 69

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 40

E-9-1-1 STEMI ACS Coronary 40

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 52

STEMI ED ACS Coronary 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria. The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI.

STEMI 76

STEMI ACS OR 76

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation. This is not the case.

E-9-1-1 117

E-9-1-1 Coronary ACS BLS 117

ECG & Echo Learning

JANUARY 18, 2023

STEMI , ST-segment elevation acute myocardial infarction ). 1 Initial diagnosis of STEMI ECG Management Recommendation Level of evidence A 12-lead ECG should be interpreted immediately (within 10 minutes) at first medical contact. I C If possible, patients should bypass non-PCI centres to a PCI-capable centre.

STEMI 40

STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. For this test it is VERY low (very good) at 4% at the 99th percentile -- 26 ng/L, but it will not be so good at a level of 9 ng/L. Thus, one considers a test result that varies by 2 or less to be the same result. of the time.

ACS 105

ACS ALS OR STEMI 105

EMS 12-Lead

APRIL 2, 2022

Figure 1-1 My colleague, a faithful student of ECG interpretation, handed me the tracing and said that it warranted STEMI activation because of apparent terminal QRS distortion (TQRSD) in V2. Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion.

ALS 130

ALS STEMI Coronary OR 130

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). In our opinion it should not be given in ACS unless you are committed to the cath lab. Unfortunately — 1.5

ACS 86

ACS Coronary ALS CAD 86

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. Takotsubo is a sudden event, not one with crescendo angina. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

SCAD isn’t rare, especially in women Historically SCAD had been identified in 22% of ACS cases in women. A recent study found that SCAD causes almost 20% of STEMI in young women. Pregnancy is not a common cause of SCAD When ACS occurs in the peripartum period, SCAD is responsible in 43% of cases. A study by Hassan et al.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. 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.

STEMI 40

STEMI ACS Coronary ED 40

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

There’s mild inferior ST elevation in III that doesn’t meet STEMI criteria, but it’s associated with ST depression in aVL and V2 that makes it diagnostic of infero-posterior Occlusion MI (from either RCA or circumflex)– accompanied by inferior Q waves of unknown age. Are there any signs of occlusion or reperfusion?

OR 52

OR STEMI Coronary ACS 52

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI 52

STEMI ALS ACS OR 52

Dr. Smith's ECG Blog

APRIL 14, 2023

The triage ECG was interpreted correctly as "No STEMI." This finally prompted a repeat ECG at 1341: 1350: Obviously STEMI(+) OMI. Obvious ACS history with ongoing pain despite medical management and upgoing troponin is an indication for emergent cath regardless of ECG findings. = The second troponin returned higher at 45 ng/L.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JULY 19, 2019

This morphology can be cause by or associated with cocaine: A Patient with Cocaine Chest Pain and Prehospital Computer interpretation of STEMI This is OMI of the anterior, lateral, and inferior walls until proven otherwise. But it does not meet STEMI criteria and it was not initially recognized. The cath lab was now activated.

STEMI 52

STEMI ED ACS OR 52

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. In other words, after reperfusion therapy for STEMI, the appearance of AIVR is usually a good sign, meaning that the artery is reperfused. Chest pain was resolved upon arrival in the ED. His previous ECG was normal. What is it?

ACS 52

ACS STEMI OR ED 52

Dr. Smith's ECG Blog

OCTOBER 15, 2023

The cardiologists decided to overrule the STEMI criteria and the cath lab activation was NOT cancelled, and she was taken immediately to the cath lab and found to have an acute thrombotic distal LAD occlusion (TIMI 0). At triage she stated her pain is still persistent, but it is mildly improved compared to when she decided to come to the ED.

ACS 99

ACS ED STEMI OR 99

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

Guidelines say that if a patient has ACS but refractory pain, the patient should go emergently to the cath lab. Notice that much of the dark blue is concentrated on the QRS (R-wave); the QRS is totally ignored in the STEMI paradigm!! Fluids and morphine had been given and the patient had spontaneously converted to sinus rhythm.

STEMI 89

STEMI Coronary ACS OR 89

Dr. Smith's ECG Blog

MARCH 20, 2023

Since then, I started looking for OMI EKG findings and not just STEMI. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. mm in lead I, thus not STEMI criteria) and was finally understood by the cardiologist.

STEMI 52

STEMI ACS CAD ED 52

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 52

STEMI Coronary ACS ED 52

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 52

OR STEMI ACS ALS 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Moreover, the Queen is only supposed to be used with a high pretest probability of ACS/OMI. Is it STEMI? We just finished training version 2 with some cases of hypokalemia, so that is in the future. The patient’s VBG resulted as I was speaking with him and confirmed my suspicions, showing a potassium of 1.6 What is going on here?

Overdose 110

Overdose ACS OR ICU 110

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. This case represents the same physiologic event as OMI in terms of the result on the myocardium, therefore with identical ECG features, however there may not be ACS!

STEMI 52

STEMI ACS CAD OR 52

ACEP Now

AUGUST 12, 2024

Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. Sequence of events in angina at rest: Primary reduction in coronary flow. References Noble RJ, Rothbaum DA, Knoebel SB, McHenry PL, Anderson GJ. Arch Intern Med.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS 52

ACS EMS STEMI Coronary 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), In Septal STEMI , transmural ischemia of the septum is recorded by the overlying lead V1 as ST Elevation. Lead III is also on the right and might manifest ST Elevation in Septal STEMI. with ADDED STE in III?

STEMI 40

STEMI ACS OR 40

Dr. Smith's ECG Blog

JULY 11, 2019

These findings are very subtle but suspicious for LAD occlusion, as we have seen in many similar (but less difficult) cases on this blog: A man in his sixties with chest pain at midnight with undetectable troponin How long would you like to wait for your Occlusion MI to show a STEMI? Learning Points: Not all OMI will present as STEMIs.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. The most recent event had occurred just before being triaged. This pattern is recognizable by the ST depressions maximal in lead V4.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Subsequent events: Later, before being taken to her room, the 2nd troponin returned at 1.01 Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. She felt more comfortable being admitted. Again, cath lab was not activated.

Coronary 52

Coronary ACS STEMI OR 52