Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. The patient had no chest symptoms until he had been in the ED for many hours and had been undergoing management of his DKA. The patient was under the care of another ED physician. Another ECG was recorded: What do you think?

ED 108

ED Coronary CAD STEMI 108

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He wrote most of it and I (Smith) edited.

OR 111

OR STEMI Coronary ED 111

Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. J waves can also be induced by Occlusion MI (5), STEMI mimics including takotsubo and myocarditis complicated by ventricular arrhythmias (6, 7), and subarachnoid hemorrhage with VF (8). Take home : Not all STEs are STEMIs or OMIs. What do you think?

STEMI 52

STEMI ALS EMS OR 52

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. The young ED tech immediately suspected LAD OMI.

ED 118

ED STEMI Coronary Paramedic 118

Dr. Smith's ECG Blog

JULY 9, 2024

He arrived to the ED with severe hypotension, heart rate in the 70s, unable to follow commands but moving all extremities requiring restraint and sedation, respiratory rate around 24/min being supported with bag valve mask, with significant hypoxemia. Meyers and Smith in the October 15, 2022 post of Dr. Smith's ECG Blog ).

Defibrillator 107

Defibrillator STEMI CPR EMS 107

Dr. Smith's ECG Blog

OCTOBER 28, 2020

This ECG was texted to me with the implied question "Is this a STEMI?": I responded that it is unlikely to be a STEMI. Septal STEMI often has ST depression in V5, V6, reciprocal to V1. Then combine with clinical presentation and low pretest probability 2 Saddleback STEMIs A Very Subtle LAD Occlusion.T-wave wave in V1??

STEMI 52

STEMI OR ED 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Do either, both, or neither have occlusion MI? Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

MARCH 4, 2024

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. The Queen gets it right First ED ECG: Hyperacute T-waves persist.

STEMI 115

STEMI OR ED ALS 115

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

NOVEMBER 19, 2024

He arrived at the ED just shy of two hours after onset, pain free. Here is the initial ED ECG: Here that first ECG is cleaned up by PM Cardio app: What do you think? The Queen of Hearts Diagnosed "STEMI/STEMI equivalent" on that first ECG (she now uses "STEMI Equivalent" rather than OMI).

OR 64

OR STEMI Coronary CAD 64

Dr. Smith's ECG Blog

JANUARY 20, 2024

Cardiology refused to be the admitting physician because it was "NSTEMI", and forced the ED physician to admit the patient to the hospitalist. Of course, there was terrible boarding and the patient was considered non-emergent (NSTEMI), and so could not leave the ED for some time. YOU TOO CAN HAVE THE PM Cardio AI BOT!!

STEMI 118

STEMI CAD ED ALS 118

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. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

STEMI 107

STEMI Coronary ACS ED 107

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. There is pericardial tamponade.

STEMI 60

STEMI Coronary CAD ED 60

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. The patient re-presented to the ED a few days after his discharge with syncope.

CAD 125

CAD STEMI Coronary ACS 125

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Learning Points: You cannot trust conventional algorithms even to find STEMI(+) OMI, even when they say "normal ECG." We have shown many examples of this on this blog.

STEMI 113

STEMI Coronary Emergency Department OR 113

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 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? He was found in ventricular fibrillation and defibrillated, then brought to a local ED which does not have a cath lab. Here is the initial ED ECG: This is pretty obviously and inferior posterior OMI, right? It is a STEMI equivalent.

STEMI 52

STEMI Defibrillator ED ACS 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. Triage ECG: What do you think?

STEMI 123

STEMI ED OR Coronary 123

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 93

STEMI Coronary Paramedic OR 93

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." What do you think?

OR 120

OR STEMI EMS ED 120

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., Here is the bottom line of the article: It is widely believed that hyperacute T-waves are a transitional state preceding ST Elevation 1–4 Thus, it is tempting to postulate that early cases of OMI will eventually evolve to STEMI; yet, our data contradicts that notion. This one is easy for the Queen.

OR 113

OR STEMI ICU Coronary 113

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? EKG on arrival to the ED is shown below: What do you think? 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). or basilar ischemia.

STEMI 103

STEMI Coronary Emergency Department OR 103

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. It’s unclear if the paramedic ECGs were seen or missed in the ED. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. At this point the emergency physician asked for a stat cardiology consult.

STEMI 78

STEMI Paramedic Coronary EMS 78

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al.

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. On arrival to the ED, this ECG was recorded: What do you think? How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later?

STEMI 84

STEMI Coronary Defibrillator OR 84

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. 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). It is a ssociated with mild dyspnea on exertion. Aspirin given.

Coronary 118

Coronary STEMI ED OR 118

Dr. Smith's ECG Blog

MARCH 31, 2024

The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). Despite the ACC guidelines for posterior STEMI, the cardiologist again refused to take the patient to the cath lab. mm STE in the posterior leads.

STEMI 97

STEMI ACS ED 97

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 115

E-9-1-1 Coronary STEMI ALS 115

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

The biggest problem with STEMI criteria are false negatives – because this costs patient’s myocardium, with greater mortality and morbidity. The essential "immediate" decision to be made in "zero time" in the ED, is whether or not prompt cath and reperfusion is needed. Could this false positive cath lab activation been prevented?

STEMI 93

STEMI Coronary OR ED 93

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab.

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

Dr. Smith's ECG Blog

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. RR18 sat 99% HR 90 BP 90/60, afebrile.

STEMI 91

STEMI ACS OR ALS 91

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. For more on ECG findings in pulmonary disease — Check out My Comment in the May 31, 2024 post in Dr. Smith's ECG Blog ). I thought this was nondiagnostic.

STEMI 77

STEMI Coronary ED 77

Dr. Smith's ECG Blog

OCTOBER 22, 2024

He reported typical chest pain since 4H AM and arrived at our ED at 10h with ongoing chest pain. Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." The first ECG (10h14) showed TWI in inferior leads."

Coronary 66

Coronary STEMI OR ALS 66

Dr. Smith's ECG Blog

JUNE 13, 2024

Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chest pain that started 2-3 hours earlier while sitting on a porch swing. Here is her ED EKG: What do you think? See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6.

Defibrillator 91

Defibrillator STEMI EMT EMT 91

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Having severe pain drives people to the ED for faster treatment! We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7

STEMI 112

STEMI Coronary Emergency Medical Services OR 112

Dr. Smith's ECG Blog

JULY 25, 2024

The patient was brought to the ED and had this ECG recorded: What do you think? Cardiac arrest #3: ST depression, Is it STEMI? As we have often emphasized on Dr. Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! After 1 mg of epinephrine they achieved ROSC.

Defibrillator 115

Defibrillator Coronary Epinephrine ACS 115

Dr. Smith's ECG Blog

JUNE 17, 2016

Jason was very skeptical of STEMI. This also argues against STEMI. Unfortunately, this option might not be available for pre-hospital tracings ( but it can be done once the patient arrives in the ED for their initial hospital tracing ). He complained of 3 days of diarrhea and abdominal pain. What do you think? Jason, I agree.

STEMI 52

STEMI OR Coronary EMS 52