Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? 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). With EMS, patient had a GCS of 3 and was saturating 60% on room air. ng/mL and 0.10

STEMI 101

STEMI Coronary Emergency Department OR 101

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. Pain was resolving. Diagnosed as Normal by the computer. Troponin negative.

STEMI 113

STEMI OR ED ALS 113

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 118

STEMI Emergency Department Coronary OR 118

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

STEMI 73

STEMI Coronary Emergency Department ICU 73

ACEP Now

APRIL 4, 2024

Figure 1: EKG for Dextrocardia showing STEMI. The second EKG was concerning for STEMI in the precordial leads (see figure 1). This delay in recognition can result in the inadvertent underdiagnosis of STEMIs. Dextrocardia with STEMI is a rare clinical presentation that presents with both diagnostic and technical challenges.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

MARCH 19, 2024

The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Most large STEMI have peak troponin I in the 20.0 Next trop in AM. Peak trop 257.97 Smith: This is an enormous myocardial infarction. ng/mL - 80.0

CAD 92

CAD STEMI ACS ALS 92

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. And you can see why: the artery may sponstaneously reperfuse, as it did here well before angiography, and documented with resolution of pain and evolution of the ECG to typical full reperfusion pattern Peak troponin I was 8544 ng/L. What did I say?

OR 126

OR STEMI Coronary 126

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 111

OR STEMI Heart Attack Coronary 111

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

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Repeat ECG: New developing Q waves in V2 and V3, further confirming evolving OMI.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Triage documented a complaint of left shoulder pain. 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." Immediate versus delayed invasive intervention for non-stemi patients.

E-9-1-1 122

E-9-1-1 ACS Coronary STEMI 122

Dr. Smith's ECG Blog

MARCH 22, 2024

This is documented as a STEMI in the clinical notes and in the cath report, but certainly does not meet STEMI criteria and is therefore an NSTEMI by definition. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0. ng/mL (ref. < < 0.049).

STEMI 113

STEMI OR 113

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. We documented that the majority of stenotic lesions had compensatory enlargement and thus exhibited remodeling. He does have a recently diagnosed PE, and has not been taking his anticoagulation due to cost. He was started on nitro gtt.

Coronary 118

Coronary ACS OR EMR 118

NAEMSP

MARCH 5, 2024

Appropriate air medical services utilization and recommendations for integration of air medical services resources into the EMS system of care: a joint position statement and resource document of NAEMSP, ACEP, and AMPA. Air medical transport has been utilized in multiple hospital based programs including trauma, STEMI, and stroke.

Critical Care 52

Critical Care Medical Transportation CPR EMS 52

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented. 2019;154(7):e191152.

Emergency Medical Services 98

Emergency Medical Services EMS OR Overdose 98

REBEL EM

MARCH 2, 2023

Based on recent studies, current guidelines recommend that O2 should not be given to non-hypoxemic patients with STEMI or NSTEMI [2,3]. 4159 patients (10% of total population) had STEMI 30d Mortality: High O2 protocol: 8.8% 4159 patients (10% of total population) had STEMI 30d Mortality: High O2 protocol: 8.8%

ACS 52

ACS Coronary STEMI Ambulance 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)? His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Physician interpretation: "No STEMI."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI? He reported a history of “Wolf-Parkinson-White” and “heart attack” but said neither had been treated. What is the rhythm? Moffat, M.

STEMI 87

STEMI Coronary Heart Attack ACS 87

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

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The following ECG was obtained. ECG 1 What do you think?

ACS 110

ACS ALS OR STEMI 110

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. To me, that is a meaningless diagnosis. Here is the main learning point: The infarct was due to an occluded artery (Occlusion MI, OMI). In 30% of OMI, there is no significant ST Elevation.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JUNE 27, 2021

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!!!) Because we are hypnotized the STEMI paradigm. "If

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life. And, there is no documentation that the tachycardia has resolved. The patient was treated.

STEMI 52

STEMI OR 52

Dr. Smith's ECG Blog

MAY 16, 2023

Here is the Queen of Heart's interpretation: The cath lab had been activated for concern of STEMI. Learning Points: This is one of many examples of false positive STEMI criteria, which is distinguishable by expert humans, and now by AI such as QOH. No prior ECG was available.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). While this may be change that is reciprocal to an Acute/Subacute Inferior STEMI, the problem is that LV aneurysm may also manifest with this reciprocal change. In STEMI, they are generally upright and large in proportion to the QRS. This case is tough.

STEMI 52

STEMI ACS Emergency Department OR 52

Dr. Smith's ECG Blog

JULY 19, 2019

This morphology can be cause by or associated with cocaine: A Patient with Cocaine Chest Pain and Prehospital Computer interpretation of STEMI This is OMI of the anterior, lateral, and inferior walls until proven otherwise. But it does not meet STEMI criteria and it was not initially recognized. ng/mL (very elevated).

STEMI 52

STEMI ED ACS OR 52

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. In both tracings — an exceedingly fast PMVT is documented. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The below ECG was recorded.

Defibrillator 117

Defibrillator Coronary ALS STEMI 117

Dr. Smith's ECG Blog

OCTOBER 6, 2018

He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." See far below for data on 24 troponin T in STEMI and NSTEMI, and correlation with infarct size. This difficulty results in high lateral OMI being the most commonly missed OMIs by the misguided STEMI criteria.

STEMI 52

STEMI Coronary ALS OR 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. Compared to baseline, there is more STE in anterior leads, and significantly increased area under the curve of the T wave in V3 and V4. The second troponin returned higher at 45 ng/L.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

We assume that at some point the patient's pain returned, but it is not documented, so exactly when this happened is uncertain. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities. Clinical concern and gestalt should ultimately guide management.

OR 52

OR ACS STEMI Coronary 52

ACEP Now

JULY 6, 2023

4 Formerly, chest pain patients without an S-T Elevation Acute Myocardial Infarction (STEMI), whose pain was suspected to be cardiac in nature, became inpatients for sequential monitoring of their lactate dehydrogenase and creatine kinase isozyme profiles. This process required at least a full day. In 2023 we must move beyond that title.

ALS 52

ALS Emergency Department STEMI ED 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

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." If this EKG were handed to you to screen from triage without any clinical information, what would you think? Unfortunately, there was a long wait and the patient left before being seen by a provider.

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

Dr. Smith's ECG Blog

JULY 26, 2023

At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. We know today's patient had a documented inferior STEMI in 2010. Without availability of a prior tracing — I would defer my final interpretation until I had a chance to find out the clinical situation.

STEMI 52

STEMI ED OR 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

This is why it is essential that the OMI/NOMI paradigm replace the STEMI/NonSTEMI paradigm. Under Non-STEMI, this patient would not have intervention until at least 20 hours (next day), after the infarct is completed. Learning Points: 1. 25-30% of OMI are not treated in a timely way.

Critical Care 52

Critical Care STEMI ED OR 52

Dr. Smith's ECG Blog

JUNE 8, 2023

STEMI negative : the EMS automated interpretation read, “STEMI negative. According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Inferior infarct, age undetermined.

STEMI 65

STEMI Coronary Paramedic ALS 65

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI. But which myocardial walls are affected?

Coronary 52

Coronary STEMI ED ALS 52