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STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?

REBEL EM

Background: Primary PCI is the recommended reperfusion strategy in patients with STEMI and should be initiated within 2 hours after first medical contact. Paper: Van de Werf, F et al. In non-PCI-capable hospitals this goal is not always achievable due to delays in transfer. Primary PCI: 95.7% Primary PCI: 95.7% Primary PCI: 78.4%

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"Non-STEMI" is a worthless term.

Dr. Smith's ECG Blog

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. Here is his most recent previous ECG: This was recorded after intervention for inferior STEMI (with massive ST Elevation, see below), and shows inferior Q-waves with T-wave inversion typical of completed inferior OMI. ng/mL (quite large).

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Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

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]

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Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Dr. Smith's ECG Blog

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

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60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?

Dr. Smith's ECG Blog

So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

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When the conventional algorithm diagnoses the ECG as COMPLETELY NORMAL, but there is in fact OMI, what does the Queen of Hearts PM Cardio AI app say? (with 10 case examples)

Dr. Smith's ECG Blog

Unknown algorithm The Queen gets it right Case 4 How unreliable are computer algorithms in the Diagnosis of STEMI? The patient's prehospital ECG showed that there was massive STEMI and these are hyperacute T-waves "on the way down" as they normalize. Pain was resolving. Diagnosed as Normal by the computer. Troponin negative.

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Anterior OMI. What does the angiogram show?

Dr. Smith's ECG Blog

This was a machine read STEMI positive OMI. Readers of this blog can easily appreciate the hyperacute T waves in the precordium, clearest in V1-V4. 118.007305) from Heitner et al. , Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain. His ECG is shown below.

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