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

OCTOBER 22, 2024

"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 coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Peak troponin: 128,000 ng/L.

Coronary 66

Coronary STEMI OR ALS 66

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

JUNE 15, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. High sensitivity troponin I was 23 ng/L.

STEMI 93

STEMI Coronary ACS OR 93

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.

STEMI 81

STEMI Coronary ACS OR 81

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. How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later? This caused a type 2 anterior STEMI. The April 8, 2022 post by Drs.

STEMI 80

STEMI Coronary Defibrillator OR 80

Dr. Smith's ECG Blog

JULY 25, 2024

But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. Cardiac arrest #3: ST depression, Is it STEMI? Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! It also does not uniformly indicate severe coronary disease.

Defibrillator 110

Defibrillator Coronary Epinephrine ACS 110

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. Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. You can see the deficiency of the definition of MI.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

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." It is clearly missed by the conventional algorithm.

STEMI 111

STEMI Coronary Emergency Department OR 111

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. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. When EMS found her, she was dyspneic and diaphoretic.

E-9-1-1 110

E-9-1-1 Coronary STEMI ALS 110

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. What lowered my confidence in calling ECG #1 a definite OMI — was the finding of somewhat similar-appearing , upright T waves with slight-but-real J-point ST elevation in so many leads ( ie, leads I,II,aVF; V2-thru-V6 ). What did I say?

OR 123

OR STEMI Coronary 123

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

The Queen of Hearts Diagnosed "STEMI/STEMI equivalent" on that first ECG (she now uses "STEMI Equivalent" rather than OMI). The fact that she states "STEMI-Equivalent" here means that she does not think it is reperfused, but she does not know that the patient is pain free now. This is the new version of the Queen.

OR 69

OR STEMI Coronary CAD 69

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.) have perfect coronary flow by the time of angiogram. Clinical history is needed.

STEMI 79

STEMI Coronary Ambulance ED 79

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. So it can miss some OMI.

Defibrillator 131

Defibrillator Coronary STEMI CPR 131

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Serial ECGs enhance the diagnosis of acute coronary syndrome. Is there STEMI? About one hour later his high sensitivity troponin I resulted at 3,000 ng/L (reference 3-54 ng/L). The patient continued having chest pain.

STEMI 85

STEMI Coronary Heart Attack ACS 85

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 90

STEMI Coronary Paramedic OR 90

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

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

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

JANUARY 8, 2024

She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. She went to angio and had normal coronaries. Medics recorded the above ECG and called a STEMI alert. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. Her troponin I returned at 900 ng/L.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

MAY 8, 2023

Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). LAFB, atrial flutter, anterolateral STEMI(+) OMI. Limkakeng AT.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

APRIL 21, 2023

Now let’s compare this with the existing paradigm to identify multiple preventable delays to reperfusion, which can be improved through the paradigm shift from STEMI to OMI. In the STEMI paradigm, patients with ischemic symptoms and ECGs that don’t meet STEMI criteria get serial ECGs.

STEMI 52

STEMI Coronary EMR OR 52

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

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 70

STEMI Coronary OR ALS 70

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 which is concerning for LAD occlusion.

OR 108

OR STEMI Heart Attack Coronary 108

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.

OR 116

OR STEMI EMS ED 116

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). No ECG was ordered on Day #1.

Coronary 108

Coronary STEMI Emergency Department OR 108

Dr. Smith's ECG Blog

MARCH 31, 2023

This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). It is definitely not normal. has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria. This was sent to me by a friend.

STEMI 52

STEMI Coronary OR ED 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. 1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. Attached is the first ECG. Isn’t VT ALWAYS “wide”?

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

Dr. Smith's ECG Blog

MARCH 1, 2023

A "STEMI alert" was called and soon cancelled. This ECG picture should immediately prompt the following diagnostic considerations: Severe Coronary Disease ( due to LMain, proximal LAD, and/or severe 2- or 3-vessel disease ) — which in the right clinical context may indicate ACS ( A cute C oronary S yndrome ).

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). There is no definite evidence of acute ischemia. (ie, The below ECG was recorded. He was taken immediately to the cath lab.

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

AUGUST 6, 2024

It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. All coronary arteries were patent without atherosclerotic change. Only after troponin returned elevated was an Echo was done, revealing a definite wall motion abnormality.

Coronary 85

Coronary OR STEMI EMS 85

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Day 12 ECG: FINAL DIAGNOSIS: "NSTEMI" Despite the fact that his day 4 ECG easily meets STEMI criteria, the patient is diagnosed as NSTEMI. No TIMI flow was listed in the report. Am Heart J.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

DECEMBER 9, 2023

He has a history of STEMI and heart failure. link] Case continued The conventional algorithm diagnosed STEMI and so did the paramedics. A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA. He was belted and it was low speed.

STEMI 107

STEMI Coronary ED OR 107

Dr. Smith's ECG Blog

MAY 19, 2020

Angiography showed normal coronaries. This is a troponin I level that is almost exclusively seen in STEMI. A followup ECG was recorded 2 days later: No definite evidence of infarction. So this is either a case of MINOCA, or a case of Type II STEMI. I believe the latter (type II STEMI) is most likely.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

APRIL 20, 2019

There is sinus rhythm with minimal STE in V1-V3, not meeting STEMI criteria. However, this STE is definitively abnormal in the setting of a normal QRS complex and hyperacute T-wave morphology in V2. The delay between OMI and STEMI sometimes causes unacceptable loss of myocardium or worse.

STEMI 52

STEMI EMS OR Coronary 52