Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. 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. This study failed to do so. 5% vs. 58%!!

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

Dr. Smith's ECG Blog

MAY 20, 2024

The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand). They too have dense white masses consistent with coronary atherosclerosis. The blue circle shows the LCx.

CAD 127

CAD STEMI Coronary ACS 127

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. Fortunately the patient did not reocclude while awaiting the angiogram.

STEMI 105

STEMI Coronary ACS ED 105

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e STEMI , ST-segment elevation acute myocardial infarction ). I B Ambulance personnel must be trained and equipped to identify STEMI and administer fibrinolysis if necessary.

STEMI 40

STEMI Coronary OR Defibrillator 40

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. There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12).

STEMI 112

STEMI Coronary Emergency Medical Services OR 112

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). A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty.

Coronary 121

Coronary STEMI ED OR 121

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." For the same reason, you should not delay coronary angiography because pain resolves with morphine. The case continues. Mukherjee, D.,

E-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

STEMI 106

STEMI Coronary OR ALS 106

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. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52

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. And dynamic ST-T wave changes between ECG #1 and ECG #2 confirm an acute event in progress. Is it normal STE? This is a "Transient OMI".

STEMI 116

STEMI ACS Critical Care OR 116

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

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-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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 134

Defibrillator Coronary STEMI CPR 134

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). 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

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

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 82

E-9-1-1 ACS STEMI Coronary 82

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. As discussed above in Dr. Smith's excellent discussion — serial ECGs, correlated to severity of patient symptoms soon confirmed the acute event in today's patient. This ECG was texted to me with no other information. What did I say?

OR 127

OR STEMI Coronary 127

Dr. Smith's ECG Blog

MARCH 19, 2023

The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. As per Dr. Smith — as soon as a prior ECG from today’s patient became available — the diagnosis of an acute ( presumably ongoing ) cardiac event was confirmed.

STEMI 52

STEMI Coronary CAD 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

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. Compensatory enlargement was defined as being present when the total coronary arterial cross-sectional area at the stenotic site was greater than that at the proximal nonstenotic site. Furthermore, if this occurs at all, it is a rare event.

Coronary 80

Coronary ACS OR EMR 80

Dr. Smith's ECG Blog

JUNE 1, 2022

Moreover, the research which appears to confirm this idea was indeed in relation to the circumflex, but they did not study Occlusion ; rather, they studied asymptomatic coronary disease. I showed conclusively that this is a common finding in normal ECGs, though it is more common in LAD Occlusion than in norml variant STE.

STEMI 52

STEMI Coronary OR ALS 52

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.

STEMI 86

STEMI ACS OR ALS 86

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. 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

DECEMBER 26, 2020

Is this inferor STEMI? Atrial Flutter with Inferior STEMI? Inferolateral ST elevation, vomiting, and elevated troponin The treating team did not identify the flutter waves and they became worried about possible "STEMI" (despite the unusual clinical scenario). The EM provider asked if the cardiologist thought it was a "STEMI."

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

I showed this to some of my colleagues and they were not able to confidently say that this is an acute coronary occlusion. Thus the AI algorithm is very sure there is a complete coronary occlusion despite there being any significant ST elevation. Back to the case. Initial troponin I returned elevated at 84 ng/L (ref value <34 ng/L).

STEMI 90

STEMI Coronary ACS OR 90

Dr. Smith's ECG Blog

AUGUST 9, 2018

Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 No history, meds, or risk factors. Pattern looked to be BER. mm in V2 and 4.08

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. Meyers note: notice in their documentation many of the classic mistakes of the STEMI generation: "Non ST Elevation MI" as their reasoning for why the patient did not merit emergent reperfusion, while simultaneously calling it "emergently" (after 8 hours!!!) It was not a STEMI) 1.

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

APRIL 14, 2023

The triage ECG was interpreted correctly as "No STEMI." This finally prompted a repeat ECG at 1341: 1350: Obviously STEMI(+) OMI. As per Dr. Meyers — Confirmation of an acute ongoing event was immediately forthcoming as soon as baseline ECGs on this patient were obtained. The second troponin returned higher at 45 ng/L.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 13, 2023

Knowing the patient has a history of coronary disease could be relevant to today's case — as it should add to our suspicion of a new acute event. If this is the case — this size of a Qr wave in lead III, as well as the seemingly wide Q in lead aVF — would seem to suggest prior inferior infarction a t some point in the past.

EMR 117

EMR Coronary OR STEMI 117

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Subsequent events: Later, before being taken to her room, the 2nd troponin returned at 1.01 Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection.

Coronary 52

Coronary ACS STEMI OR 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

AUGUST 30, 2023

One more thing that should be mentioned: since there are only Q waves from V1 to V3, it is possible that there was an old anterior wall MI, or that the current event is subacute, or acute on top of an old Q wave. Regardless, V2 with a hyperacute T wave and abnormal T/S ratio means there must be acute OMI, regardless of prior events.

Coronary 75

Coronary OR STEMI ED 75

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). The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Eur J Emerg Med.

ACS 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

JANUARY 23, 2023

Back to the case: After the patient was roomed, he revealed that he had undergone several episodes of syncope in the last 24 hours with each event resulting in a shock during which his wife reported that he would immediately awaken. The most recent event had occurred just before being triaged.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

And, the drug does provide physiologic benefits for a patient with an acute cardiac event ( ie, it helps to relieve anxiety as well as pain — which may decrease activation of autonomic nervous system activity — often resulting in reduced heart rate, blood pressure, venous return and myocardial oxygen demand — Murphy et al: StatPearls, 2023 ).

ACS 110

ACS ALS OR STEMI 110