Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. In fact, Kosuge et al. Stein et al. This is a paper worth reading : Marchik et al. Kosuge et al.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 117

STEMI Coronary ACS ED 117

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. 2 Proposed hypothesis as described by Hsu et al., Yu ES, Lange JJ, Broor A, et al.

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

JULY 7, 2013

Thus, this is both an anterior and inferior STEMI. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Raitt et al.) [and Armstrong et al.)], the presence of such well developed anterior Q-wave suggests completed transmural STEMI.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. New insights into the use of the 12-lead electrocardiogram for diagnosing acute myocardial infarction in the emergency department.

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

JULY 18, 2014

Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Raitt et al.), Raitt et al.), Armstrong et al.), 3) Oliva et al. (4) Armstrong PW et al.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Bigger et al.

STEMI 107

STEMI Coronary Heart Attack ACS 107

EMS 12-Lead

APRIL 14, 2022

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). link] [1] Zachary et al. Western Journal of Emergency Medicine, 18 (4), 752-760. [2] 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Lindahl et al. From Gue at al.

Emergency Department 52

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

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. It is true this ECG does not meet STEMI criteria (there is 1.0

STEMI 52

STEMI ACS Coronary Epinephrine 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

Quiz : What percent of full blown STEMI have an open artery with normal flow at angiogram? It too is "normal" and you decide that this is not OMI or STEMI and you just decide to get troponins. Jesse McLaren et al. I would expect that a stent would be placed. In the meantime, a lot of myocardium is lost.

STEMI 98

STEMI Emergency Department OR ALS 98

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

STEMI 98

STEMI Coronary Paramedic OR 98

EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. New insights into the use of the 12 Lead Electrocardiogram for diagnosing Acute Myocardial Infarction in the emergency department. The distribution of findings is consistent with the LAD, of which is now open with improved TIMI flow. link] [1] Mirand, D. 4] Meyers, H.

Coronary 130

Coronary ALS OR ACS 130

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 B Designated PCI centres should provide angiography and reperfusion 24/7 without delay.

STEMI 40

STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

JUNE 18, 2013

His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI. It is not a missed STEMI, but it is a missed coronary occlusion. Fesmire et al. Marti D et al.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. The emergency physician was called to see the patient 90 minutes later after the troponin I returned at 1100 ng/L. What do you think? Take home 1.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

OCTOBER 20, 2013

Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. Also note that they allow ST depression c/w posterior MI to be a STEMI equivalent. Kurkciyan et al.

STEMI 52

STEMI Coronary ACS Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. New ST elevation diagnostic of STEMI [equation value = 25.3

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Coronary 52

Coronary STEMI ACS ALS 52

ACEP Now

AUGUST 12, 2024

A 35-year-old male presented to the emergency department complaining of chest pain that started 1.5 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking. Dr. Young is an emergency physician at Saint Francis Hospital and Medical Center, Hartford, Conn.

Emergency Department 52

Emergency Department STEMI ACS ED 52

ACEP Now

JULY 6, 2023

Emergency physicians have earned the right to “re-brand” ourselves as indispensable, money-saving change agents in the health care enterprise. Of course, the bill for any episode of emergency department (ED) care can be substantial, exceeding the billed charges for equivalent care provided in some primary care offices.

ALS 52

ALS Emergency Department STEMI ED 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. As per Dr. Aslanger — a number of medical providers were initial confused by what initially appears as marked ST elevation with reciprocal ST depression, indicative of an acute STEMI.

Coronary 112

Coronary EMR STEMI Emergency Department 112

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. Harhash AA, Huang JJ, Reddy S, et al. aVR ST segment elevation: acute STEMI or not?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. Barely any STE, and thus not meeting STEMI criteria. Only now that the patient has STEMI criteria is he allowed to go to the cath lab, at around 0530.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. 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)? Physician interpretation: "No STEMI." Physician: "No STEMI." He had no symptoms of ACS.

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

APRIL 22, 2022

The HEART and EDACS scores are helpful to risk stratify patients with chest pain, but they hinge on accurate ECG interpretation: a low score doesn’t apply if the ECG shows STEMI(+)OMI, and shouldn’t be used for STEMI(-)OMI or OMI reperfusion either 2. Backus BE, Six AJ, Kelder JC, et al. Am J Emerg Med 2020 3.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. 3–8 Shi et al. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 Sandoval Y, Smith SW, Sexter A, et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

Not seeing any changes on the initial 12 lead ECG, the emergency physician got a 15 lead ECG (below, where V4-6 are actually V4R and V7-8): There’s no posterior ST elevation but the anterior ST depression has resolved between the first and second ECG. Smith : this proves my impression that the inferior T-waves on the first ECG are hyperacute.

STEMI 40

STEMI ALS Emergency Department OR 40

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Khan AR, Golwala H, Tripathi A, et al. The Smith-Modified Sgarbossa Criteria Accurately Diagnose Acute Coronary Occlusion in Emergency Department Patients With Ventricular Paced Rhythm. BOTTOM LINE: Despite cardiac pacing — ECG #2 is diagnostic of a very large acute anterior STEMI. In normal conduction , (i.e.,

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. Annals of Emergency Medicine 2012;60:45-56. These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc A value greater than 22.0

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Here is the repeat ECG at 52 minutes after arrival to triage: Obvious posterolateral STEMI Angiographic findings: 1. Reference: • Writing Committee, Kontos MC, de Lemos JA, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. Meyers HP, Smith SW.

OR 52

OR STEMI ED Critical Care 52

Dr. Smith's ECG Blog

DECEMBER 27, 2018

I do research on Cardiologs' algorithm: Smith SW et al. A Deep Neural Network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation. Peguero JG et al. But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI.

E-9-1-1 40

E-9-1-1 STEMI ALS OR 40

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. Sandoval Y et al. This figure comes from the Diamond T study (all type 1 MI were NSTEMI, not STEMI): Notice that the 6 hour value (far right) is very low for type 2 MI.

STEMI 52

STEMI Emergency Department ED OR 52

Dr. Smith's ECG Blog

JUNE 8, 2023

STEMI negative : the EMS automated interpretation read, “STEMI negative. According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Sinus bradycardia.”

STEMI 86

STEMI Coronary Paramedic ALS 86

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. de Winter et al in N Engl J Med 359:2071-2073, 2008.

STEMI 121

STEMI CAD ED ALS 121

Dr. Smith's ECG Blog

JANUARY 28, 2012

A middle aged patient who was 3 weeks s/p STEMI came from cardiac rehab where he developed some chest pain, dyspnea and weakness on the treadmill. There is no acute STEMI. This is diagnostic of recent, reperfused STEMI. This is diagnostic of recent, reperfused STEMI. Acute STEMI would have upright T-waves.

STEMI 40

STEMI Coronary Critical Care Emergency Department 40