ECG Cases 48 – ECG Interpretation in Cardiac Arrest
Emergency Medicine Cases
FEBRUARY 13, 2024
The post ECG Cases 48 – ECG Interpretation in Cardiac Arrest appeared first on Emergency Medicine Cases.
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ECG Cases 2: Early Repolarization or Anterior STEMI?
Emergency Medicine Cases
OCTOBER 22, 2019
In this ECG Cases blog we present ECGs from 7 patients who presented with chest pain and mild anterior ST elevation. Can you identify which were early repolarization and which were anterior STEMI? The post ECG Cases 2: Early Repolarization or Anterior STEMI? appeared first on Emergency Medicine Cases.
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ECG Cases 4: Lateral STEMI or Occlusion MI?
Emergency Medicine Cases
DECEMBER 16, 2019
In this ECG Cases blog we look at seven patients with potentially ischemic symptoms and subtle ECG changes in the lateral leads. The post ECG Cases 4: Lateral STEMI or Occlusion MI? Which had acute coronary occlusion? Introducing the concept of Occlusion MI - a paradigm shift in ECG diagnosis of MI.
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ECG Cases 44 ECG Interpretation in Epigastric pain, Vomiting
Emergency Medicine Cases
AUGUST 8, 2023
In this ECG Cases blog with Dr. Jesse McLaren we interpret 10 ECG cases and explore cardiac, metabolic and GI causes: We consider anginal equivalents, and look for ECG signs of Occlusion MI, including subacute occlusion from delayed presentations.
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ECG Cases 49 – ECG and POCUS for Dyspnea and Chest Pain
Emergency Medicine Cases
APRIL 2, 2024
In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chest pain. They explain complementary diagnostic insights into pericardial effusion and cardiac tamponade, occlusion MI and RV strain.
STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?
REBEL EM
SEPTEMBER 28, 2023
Background: Primary PCI is the recommended reperfusion strategy in patients with STEMI and should be initiated within 2 hours after first medical contact. In non-PCI-capable hospitals this goal is not always achievable due to delays in transfer. In these cases, thrombolysis is recommended to improve morbidity and mortality.
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"Non-STEMI" is a worthless term.
Dr. Smith's ECG Blog
OCTOBER 30, 2023
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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ECG Pointers: STEMI Equivalents from the American College of Cardiology
EMDocs
DECEMBER 11, 2023
Traditionally, emergency providers looked for signs of ST-segment elevation myocardial infarction (STEMI) to indicate the need for intervention. Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG.
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Early repol or anterior OMI?
Dr. Smith's ECG Blog
MAY 13, 2024
This ECG is highly concerning for LAD occlusion despite it not showing a STEMI criteria. You can find the variables used to calculate the value on MD calc here: [link] Utilizing Dr. Smith’s Subtle Anterior STEMI Calculator (4-Variable), the value is greater than 18.2 Chest Pain – Benign Early Repol or OMI?
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Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)
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. This was sent to me by an undergraduate name Hans Helseth, who is an EKG tech, but who is an expert OMI ECG reader. He wrote most of it and I (Smith) edited.
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ECG Cases 46 ECG in Fever and Infectious Disease
Emergency Medicine Cases
OCTOBER 17, 2023
In this ECG Cases blog Dr. Jesse McLaren guides us through 10 cases, driving home the points that sepsis is a common cause of rapid Afib and diffuse ST depression with reciprocal ST elevation in aVR, myo/pericarditis is a diagnosis of exclusion, endocarditis or lyme carditis can cause AV block, PE can cause low grade fever and ECG signs of acute RV (..)
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Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin.
Dr. Smith's ECG Blog
SEPTEMBER 12, 2024
The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.
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ECG Cases 13: LVH and Occlusion MI
Emergency Medicine Cases
SEPTEMBER 15, 2020
LVH produces secondary repolarization abnormalities that can mimic STEMI. In this ECG Cases blog we look at 6 patients who presented with potentially ischemic symptoms and LVH on their ECG.
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Quiz post: 2 similar patients with similar ECGs. Which, if any, or both, are OMI? Will you outperform the Queen of Hearts?
Dr. Smith's ECG Blog
NOVEMBER 29, 2023
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." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.
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This ECG was texted to me: normal variant early repolarization, or LAD Occlusion MI (OMI)?
Dr. Smith's ECG Blog
SEPTEMBER 22, 2023
It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. This ECG was texted to me with no other information. I assumed the presentation was consistent with acute MI. What did I say? Activate the cath lab." The T-waves in V2-V6 are diagnostic. There is also some non-diagnostic STE in inferior leads.
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Quiz post: two patients with chest pain. Do either, both, or neither have OMI?
Dr. Smith's ECG Blog
MAY 29, 2024
Triage ECG: It was interpreted as lateral STEMI, and he was sent to the cath lab, where the angiogram showed unchanged CAD from known prior, with no acute culprit. Written by Pendell Meyers Two patients with acute chest pain. Do either, neither, or both have OMI and need reperfusion? Described as a dull ache, 6/10 in severity.
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60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?
Dr. Smith's ECG Blog
JULY 7, 2024
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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Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall
Dr. Smith's ECG Blog
OCTOBER 1, 2023
She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. Back to the case: Unfortunately, the ECG was not understood by the provider.
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Is OMI an ECG Diagnosis?
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]
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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
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. It is not yet available, but this is your way to get on the list. 2 cases at once!
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Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.
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. For more on MINOCA — See My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog ). He does have a recently diagnosed PE, and has not been taking his anticoagulation due to cost. He was started on nitro gtt.
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How terrible can it be to fail to recognize OMI? To whom is OMI Obvious or Not Obvious?
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.
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EMS told "Not a STEMI". What do you think?
Dr. Smith's ECG Blog
JANUARY 3, 2024
Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Now it even meets STEMI criteria, and HATWs continue to inflate. So the cath lab was not activated. Ongoing OMI.
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Lecture by Smith: Selected Cases of Occlusion MI (OMI), or not, on the ECG
Dr. Smith's ECG Blog
AUGUST 6, 2023
link] == MY Comment, by K EN G RAUER, MD ( 8/6 /2023 ): == Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI”. The current STEMI paradigm that continues to be followed by all-too-many clinicians ( including all-too-many cardiologists ) is fallacious.
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A man in his 50s with unwitnessed VF arrest, defibrillated to ROSC, and no STEMI criteria on post ROSC ECG. Should he get emergent angiogram?
Dr. Smith's ECG Blog
JULY 9, 2024
Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen. Meyers and Smith in the October 15, 2022 post of Dr. Smith's ECG Blog ). Restoration of sinus rhythm is evident in Figure-1. As per My Comment in the above-cited Oct.
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A man in his 30s with chest pain. How was he managed? What if they had used the Queen of Hearts?
Dr. Smith's ECG Blog
JANUARY 20, 2024
This patient does not show up in the STEMI registry, and the time to reperfusion will likely not be identified as the problem that it was. The STEMI registry will show very high sensitivity of the ECG for STEMI, obscuring the fact the STEMI has low sensitivity for OMI Queen of Hearts sees it easily, like readers of the blog would.
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Chest pain with anterior ST depression: look what happens if you use posterior leads.
Dr. Smith's ECG Blog
FEBRUARY 9, 2024
Posterior leads are unnecessary if anterior leads are diagnostic According to the STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary occlusion, and if there’s no ST elevation on anterior leads you can look for it on posterior leads. Do you need posterior leads? If so, how will they change management?
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Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?
Dr. Smith's ECG Blog
MARCH 14, 2024
This is obviously unreliable data, as Dr. Smith’s Blog has published 51 cases of OMI with ECGs labeled ‘normal’ , 35 of which were identified by the Queen of Hearts – with 10 examples here. Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.
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Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?
Dr. Smith's ECG Blog
MAY 27, 2024
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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What makes a T-wave Hyperacute? And: 30 Examples of Hyperacute T-waves, 10 in each of 3 myocardial territories.
Dr. Smith's ECG Blog
NOVEMBER 27, 2024
Doing so literally enables those of us who embrace the OMI Paradigm the ability to recognize within seconds that a patient with new CP ( C hest P ain ) — and — one or more hyperacute T waves — needs prompt cath regardless of potential absence of STEMI criteria. Figure-1: ECG from the August 26, 2009 post in Dr. Smith's ECG Blog.
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Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?
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.
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Is this Septal STEMI/OMI? Many examples of Septal STEMI/OMI
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??
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What if your system adopted the recommendation that a computer "normal" ECG need not be shown to the doctor?
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.
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An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?
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. Edited by Smith He also sent me this great case. The ST depressions in I and aVL have resolved. Smith: What???!!!
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A man in his 40s with acute chest pain. What do you think?
Dr. Smith's ECG Blog
SEPTEMBER 29, 2023
In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. In other words, the inferior "ST elevation" is due to the abnormal rhythm, and does not signify OMI or STEMI in any way. It is a known OMI mimic that we have shown on the blog many times.
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Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.
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?
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Chest pain with serial ECGs – can you guess the sequence?
Dr. Smith's ECG Blog
JUNE 7, 2024
Obvious infero-postero-lateral STEMI(+)OMI, regardless of context Now let’s put them in order: what was the sequence? With serial ECGs that are ‘STEMI negative’ the physician could have waited for serial troponin levels or referred the patient as “non-STEMI”. 2 Normal ECG #3. What was the outcome and final diagnosis?
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OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article
Dr. Smith's ECG Blog
JULY 31, 2020
Meyers, Weingart and Smith published their OMI Manifesto — in which they extensively document the critically important concept that management of acute MI by separation into a “STEMI” vs “non-STEMI” classification is an irreversibly flawed approach.
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Healthy 45-year-old with chest pain: early repolarization, pericarditis or injury?
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. A healthy 45-year-old female presented with chest pain, with normal vitals. What do you think? But which one is it?
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Occlusion myocardial infarction is a clinical diagnosis
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." She seems a little concerned about some very subtle depression in the high lateral leads, but otherwise sees a pretty benign tracing.
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Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).
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.
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Anterior OMI. What does the angiogram show?
Dr. Smith's ECG Blog
AUGUST 2, 2024
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. The meaning of this quote is that at times, something as obvious as the dramatic anterior lead ST elevation that we see in today's tracing is not the result of an acute LAD STEMI.
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60 yo with chest pain: why the abnormal QRS and abnormal repolarization?
Dr. Smith's ECG Blog
AUGUST 16, 2024
Its hard to measure the STE in I exactly with the moving baseline, but there is almost certainly not enough STE to meet STEMI criteria. The ACC recognizes these findings as formal STEMI equivalents (though they do not define how to find them). They are symmetric, fat, convex on both sides, etc.
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50 year-old in remote rural community with chest pain and ‘normal’ ECG
Dr. Smith's ECG Blog
SEPTEMBER 8, 2023
In the context of remote rural communities, this can help emergency physicians advocate for their patients, and reduce reperfusion delays by days for STEMI(-)OMI == MY Comment , by K EN G RAUER, MD ( 9/8 /2023 ): == Today’s case is distinguished by its occurrence in a remote rural community ( where the nearest cath lab is a plane ride away ).
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