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

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. Fortunately the patient did not reocclude while awaiting the angiogram.

STEMI 105

STEMI Coronary ACS ED 105

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. Lemkes et al. And dynamic ST-T wave changes between ECG #1 and ECG #2 confirm an acute event in progress. Is it normal STE?

STEMI 116

STEMI ACS Critical Care OR 116

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 83

STEMI Emergency Department OR ALS 83

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

STEMI 74

STEMI Coronary OR ALS 74

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). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Herzog et al. Khan et al. Circulation 2007 2.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

MARCH 9, 2023

Barely any STE, and thus not meeting STEMI criteria. Annals of Emergency Medicine Cardiology was called to evaluate the patient immediately for emergent cath, but they stated that the ECG did not meet STEMI criteria and elected to wait for further information before proceeding with cath. He was given 6mg IV morphine for ongoing pain.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 22, 2024

Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). As far as I can tell, there is only one randomized trial of immediate vs. delayed intervention for transient STEMI. Lemkes JS, et al.

Coronary 121

Coronary STEMI ED OR 121

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). As a result — the onset of any acute event that may have occurred is uncertain. Post PCI the patient became gravely hypotensive and "shocky". She stabilized on dobutamine and levosimendan infusions that could be discontinued after 24 hours. 21, 2017 ).

STEMI 100

STEMI OR ACS ALS 100

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. Thelin et al. Mokhtari et al. 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.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

JUNE 1, 2022

While not essential for making the "correct clinical decision" ( which would have been prompt cath performed much sooner than it was ) — I thought serial ECGs did reveal important clues to the ongoing event. Figure-1: I've labeled the 1st, 2nd and 4th tracings in today's case ( See text ).

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

APRIL 17, 2023

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." Cardiologist interpretation: "Technically does not meet STEMI criteria but concerning for ischemia."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. 24 yo woman with chest pain: Is this STEMI? This is not "diffuse", this is simply anterior, lateral, and likely apical.

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

Heitner et al. We also know that initial ECG(s) may be non-diagnostic despite a recent event ( ie, IF an acute occlusion spontaneously opens after only a brief period of time — or if the initial ECG is obtained during the "pseudo-normalization" period ). The PDA plaque was also bulky, but was not described as inflamed or ulcerated.

ACS 110

ACS ALS OR STEMI 110

ACEP Now

OCTOBER 3, 2023

Prognosis from brain injury results not only from the initial or primary injury, but also from secondary injury that occurs after the event, mainly, hypoxic/ischemic brain injury from under resuscitation or cerebral edema from the release of neurotoxic inflammatory mediators. References Lulla A, et al. Prehosp Emerg Care. J Safety Res.

Emergency Medical Services 98

Emergency Medical Services EMS OR Overdose 98

Dr. Smith's ECG Blog

DECEMBER 19, 2023

That's because this patient has clinical, ECG and Troponin evidence that an acute event did in fact occur ( ie, a more than doubling of Troponin in the context of a changing pattern of CP that correlates temporally with "dynamic" ECG changes — therefore strongly suggesting transient acute occlusion regardless of cath findings in today's case ).

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

3–8 Shi et al. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 Sandoval Y, Smith SW, Sexter A, et al. Shi S, Qin M, Shen B, et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

STEMI 52

STEMI Coronary ACS ED 52

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). Hayakawa A, Tsukahara K, Miyagawa S, et al. Am J Emerg Med. 2014;32:e5–e8. J Cardiol Cases. 2022;25(6):404-407. 2022.01.006 6.

ACS 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. See this paper by Smith et al.

STEMI 52

STEMI EMS Coronary ALS 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

STEMI 52

STEMI Paramedic Coronary ALS 52

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

ACEP Now

SEPTEMBER 6, 2024

You may have mastered all the latest changes affecting management of sepsis, STEMI, and opiate-use disorder, but there’s no stopping the relentless revisions to our approach to neurologic emergencies. The authors report an excess bleeding events in the tenecteplase cohort, likely leading to the neutral effect on overall survival.

ALS 64

ALS STEMI Ambulance Critical Care 64

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. Studies such as those by Moise et al 14 and Ellis et al 39 have shown that the relative risk of developing an acute myocardial infarction in the territory supplied by an artery with a 70%. He was started on nitro gtt.

Coronary 80

Coronary ACS OR EMR 80

Dr. Smith's ECG Blog

DECEMBER 27, 2018

I do research on Cardiologs' algorithm: Smith SW et al. 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. A Deep Neural Network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation.

E-9-1-1 52

E-9-1-1 STEMI ALS OR 52

ECG Medical Training

MAY 25, 2017

If it was a shockable rhythm, and the ECG is showing clear-cut STEMI, we want to activate the cardiac cath lab. In my system, we announce CODE-STEMI over the radio and get a time stamp, and we follow up with ECG transmission. References Callaway C, Donnino M, Fink E et al. Got an opinion about post-resuscitation care?

CPR 52

CPR STEMI EMS Ambulance 52

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. In the largest study looking at this topic by Mizusawa et al., She has not had a heart catheterization or after this event so the presence or absence of CAD is still unknown.

E-9-1-1 70

E-9-1-1 CAD OR STEMI 70

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Takotsubo is a sudden event, not one with crescendo angina. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event. Lindahl et al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 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

JUNE 5, 2023

Here it is: Obvious Inferior Posterior STEMI (+) OMI. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) The cath lab was activated prehospital But imagine if the patient had walked in.

STEMI 78

STEMI Coronary Ambulance ED 78

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI. He was discharged home on anticoagulation.

STEMI 52

STEMI OR Coronary ED 52

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. Whether this represents a potential acute cardiac event would depend on the history, comparison with prior tracings and serial tracings.

ALS 130

ALS STEMI Coronary OR 130

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

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. Moumneh T, Sun BC, Baecker A, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

DECEMBER 5, 2019

Bayes de Luna, A et al. This is based on the Sieira et al, 2017, risk calculator , which gives a borderline risk score (2). If there are any syncopal or presyncopal events, she should be evaluated immediately in the ED. --All months, 34 arrhythmic events occurred (event rate: 1.4% ICD was placed in 176.

ALS 52

ALS OR Defibrillator STEMI 52

REBEL EM

FEBRUARY 22, 2024

Paper : Carson JL, et al. References: Carson JL, Brooks MM, Hébert PC, et al. PMID 37952133 Cooper HA, Rao SV, Greenberg MD, et al. PMID 21791325 Carson JL, Brooks MM, Abbott JD, et al. PMID 23708168 Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, et al. N Engl J Med. Circulation. 2012;126(16):2020-2035. Am Heart J.

OR 57

OR ALS STEMI Coronary 57

Dr. Smith's ECG Blog

JULY 19, 2024

It was read by the treating physician and the overreading cardiologist as "Paced, no STEMI." Lupu et al. As the troponin T was 1521 ng/L (peak troponin T over 1000 ng/L is typical of STEMI) and still rising, no further troponins were measured. How does the Queen of Hearts do? Clinical Cardiology.

Coronary 106

Coronary STEMI OR ALS 106