ECG & Echo Learning

MARCH 8, 2023

All patients with NSTE-ACS ( NSTEMI or unstable angina) are treated similarly with respect to anti-ischemic and anti-thrombotic drugs. Guidelines recommend the use of validated risk models to estimate the risk of acute myocardial infarction , 30-days and 1-year mortality in patients with NSTE-ACS.

STEMI 40

STEMI E-9-1-1 ACS Coronary 40

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 111

STEMI ACS Coronary OR 111

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 52

STEMI ACS Coronary Defibrillator 52

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 92

STEMI ACS ED 92

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 81

STEMI Coronary ACS OR 81

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 107

STEMI ACS Coronary Emergency Department 107

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 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 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

JULY 25, 2024

Then assume there is ACS. Cardiac arrest #3: ST depression, Is it STEMI? The ST depression usually resolves, or is clearly resolving (getting much better). Just as important is pretest probability: did the patient report chest pain prior to collapse? This may or may not be true, but it should give you pause.

Defibrillator 110

Defibrillator Coronary Epinephrine ACS 110

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-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

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 117

STEMI Coronary ALS CAD 117

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 101

Coronary E-9-1-1 STEMI ACS 101

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 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 101

STEMI Coronary ACS ED 101

EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. The pathology is now painfully evident.

ACS 130

ACS Coronary STEMI CAD 130

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 93

STEMI Coronary ACS OR 93

Dr. Smith's ECG Blog

MAY 20, 2024

The cardiologist recognized that there were EKG changes, but did not take the patient for emergent catheterization because the EKG was “not meeting criteria for STEMI”. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? Assuming that was indeed a culprit, then this was ACS.

CAD 122

CAD STEMI Coronary ACS 122

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 74

STEMI Paramedic Coronary EMS 74

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 52

ACS STEMI OR Critical Care 52

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.”

ACS 52

ACS Coronary STEMI ALS 52

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

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 66

OR STEMI ACS Coronary 66

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 86

STEMI ACS OR ALS 86

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 52

STEMI Defibrillator ED ACS 52

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 52

STEMI ACS OR EMS 52

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 97

STEMI Coronary Emergency Department OR 97

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 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

DECEMBER 22, 2023

Comment : ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). The ESC states that patients with suspected ACS should go to the cath lab in ＜2 hours "regardless of ECG or biomarker evidence of MI!!" Therefore, we activate the Cath Lab.

ACS 103

ACS STEMI OR 103

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-9-1-1 136

E-9-1-1 ACS Emergency Department Coronary 136

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.

EMR 130

EMR Coronary Defibrillator Life Support 130

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 89

CAD STEMI ACS ALS 89

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Similarly, the OMI paradigm respects ACS as a dynamic process in which ECG changes reflect the phase of myocardial injury and risk stratify which patients may benefit from emergent PCI. Is there STEMI? What is the rhythm?

STEMI 84

STEMI Coronary Heart Attack ACS 84

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 52

STEMI ACS Coronary ED 52

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 130

ACS STEMI 130

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 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

ACS would be highly unusual in a young athlete, and given the information on his race bib, one must first suspect that the abnormal ST elevation is due to demand ischemia, not ACS. Thus, this patient had increased ST elevation (current of injury) superimposed on the ST elevation of LVH and simulating STEMI.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

Dr. Smith's ECG Blog

APRIL 2, 2014

He had an immediate ED ECG: There is artifact, but the findings appear to be largely gone now The diagnosis is acute MI, but not STEMI. See this post on the (Five primary patterns of ischemic ST depression, without ST elevation) Because of the dynamic ACS, we activated the cath lab in the middle of the night.

STEMI 52

STEMI ACS Coronary OR 52