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.

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ECG & Echo Learning

MARCH 8, 2023

Guidelines recommend the use of validated risk models to estimate the risk of acute myocardial infarction , 30-days and 1-year mortality in patients with NSTE-ACS. TIMI Risk Scores for NSTE-ACS (NSTEMI, UA) and STE-ACS ( STEMI ) can be calculated below. TIMI, GRACE and PURSUIT are such risk models. Circulation.

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Dr. Smith's ECG Blog

DECEMBER 29, 2024

The PMCardio Queen of Hearts app asks you, before giving an interpretation of OMI ("STEMI-Equivalent"), whether the patient's clinical presentation is high risk for OMI. Here are 9 cases that involve re-occlusion. If no, then she will tell you that the case is outside of the intended use group.

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Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. Figure-1: The initial ECG in today's case — obtained after ROSC.

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Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% per year incidence of SCD in this cohort [1].

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Dr. Smith's ECG Blog

JANUARY 19, 2020

There is STE in III and aVF which does not meet STEMI criteria due to insufficient STE in lead aVF. The interventionalists insisted that the ECGs did not meet STEMI criteria and cancelled the activation, stating that they would consider urgent cath after further stabilization. This is an obvious inferoposterior OMI. mm STE with 9.5

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Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. 1 mg of Atropine was given and the heart rate increased transiently to 60. What is the atrial activity? How would one tell? What to do?

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Dr. Smith's ECG Blog

MARCH 9, 2023

He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. Barely any STE, and thus not meeting STEMI criteria. Only now that the patient has STEMI criteria is he allowed to go to the cath lab, at around 0530.

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Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Why is this important?

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Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

Then, 1 hour before arrival, it recurred, again lasting 5 minutes. There is STE that does not meet STEMI criteria in V1-V6. For clarity — I’ve put the 2 pieces of the 1st ECG together, and I’ve relabeled the tracings ( Figure-1 ). Figure-1: The first 2 ECGs in this case ( See text ). It lasted 5 minutes then resolved.

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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

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Dr. Smith's ECG Blog

AUGUST 3, 2017

There are two main etiologies of ischemic ST-depression: 1) subendocardial ischemia 2) reciprocal to ST-elevation in an opposite wall Here there are distinct R-waves with marked ST-depression throughout most of the precordium. But if there is none - then you are looking at least at an Isolated Posterior STEMI until proven otherwise.

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Dr. Smith's ECG Blog

JANUARY 30, 2019

The pattern of STE and STD reminded us of Brugada Type 1 morphology. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. 2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. per year incidence of SCD in this cohort [1]. Bicarb 20, Lactate 4.2,

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Dr. Smith's ECG Blog

OCTOBER 15, 2022

As always, LAD OMI need not meet STEMI criteria and usually does NOT! Here are many examples which we have already posted: 5 of LVH mimicking Precordial Swirl 1 case (Case 6) of LVH mimicking precordial swirl, but it is actually LVH + posterior OMI 14 Cases (Cases 7-20) of OMI with Precordial Swirl First, 5 mimics: Case 1.

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Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

For clarity — I’ve put these 2 tracings together in Figure-1. Figure-1: The initial ED ECG ( = E CG # 1) — with comparison to the patient’s baseline ECG done 4 years earlier ( = E CG # 3). The ECG finding that I KNOW is real in ECG #1 is the mirror - image appearance of ST-T waves in leads III and aVL.

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Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. Rather than using terms like “STEMI” and “Wellens”, it’s more helpful to describe the underlying pathology and ECG pattern pattern: Occlusion MI, and reperfusion T wave inversion 4. JAMA Intern Med 2019 9.

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Dr. Smith's ECG Blog

MARCH 1, 2023

A "STEMI alert" was called and soon cancelled. Comment by K EN G RAUER, MD ( 3/1 /2023 ): = Today's case by Dr. Meyers serves as a reminder of the important clinical entity known as diffuse subendocardial ischemia. ST depression will not always be present in 9/12 leads — as is seen in Figure-1.

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Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Here they are: Learning Points: 1. 7 These 3 studies, as well as 1 smaller meta-analysis, 6 and another small study, 8 make it clear that troponin is associated with increased severity and mortality in COVID when adjusted for multiple other variables. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0

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Dr. Smith's ECG Blog

DECEMBER 13, 2019

On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. normal variant, not pericarditis) A Young Man with Sharp Chest pain (normal variant, not pericarditis) 24 yo woman with chest pain: Is this STEMI? 15-9/6/2017 ). Pericarditis?

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 Note 1: Levels were significantly lower in takotsubo that presented with T-wave inversion. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Learning Points: 1. What do you think? V1 has 0.5

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Dr. Smith's ECG Blog

JULY 30, 2023

It does not meet STEMI criteria. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). Learning Points: We can find OMI on ECG much sooner than STEMI criteria in many cases, and of course many OMIs never meet STEMI criteria at all.

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Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia mimics STEMI and OMI in many distributions, but probably the most common is the Brugada morphology in V1-V2 which mimics anterior OMI for those who cannot recognize the Brugada pattern. Limb lead reversal can be easily recognized.

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Dr. Smith's ECG Blog

JULY 24, 2024

Easy LINK — [link] — My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. 2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”.

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Dr. Smith's ECG Blog

OCTOBER 17, 2022

If you were thinking that this is not anterior OMI because there is no reciprocal ST depression , it is important to remember that half of anterior STEMI do NOT have any reciprocal ST depression. There are some unusual ECG findings in today's tracing ( that I labeled in Figure-1 ). Anterior OMI? Pericarditis?

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Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. But what we truly care about is coronary occlusion, for which STEMI is just a surrogate that is only about 75% sensitive for occlusion. Some are STEMI-equivalents.

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Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio greater than 0.36, then it is STEMI, not LV aneurysm. Is this a transient STEMI? Learning Points: 1.

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Dr. Smith's ECG Blog

JANUARY 10, 2020

I was relieved to see this MRI result: MRI IMPRESSION 1) Mildly decreased LV function with no focal wall motion abnormalities. Learning Points: 1. Cases of acute MI that were initially misdiagnosed as myo- or peri-carditis: 24 yo woman with chest pain: Is this STEMI? BUT — “ Y a g otta b e t here”. Pericarditis?

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Dr. Smith's ECG Blog

MAY 19, 2022

Anterior STEMI? Regarding the History: It sounds from the History as if this patient has at least a significant component of EIA ( E xercise- I nduced A sthma ). Dr. T-wave inversions and dynamic ST elevation Tachycardia, hyperthyroid, and ST elevation. What is it? Activate the Cath Lab?

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Dr. Smith's ECG Blog

JANUARY 16, 2020

Angiogram showed a 99% left main thrombotic occlusion with TIMI-1 flow (this is considered "occlusion" even though there is some flow. not left main occlusion == MY Comment by K EN G RAUER, MD ( 1/16/2020 ): == I did not correctly identify the “culprit artery” in this case. Marked acute STEMI changes in no less than 4 lateral leads.

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Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 If you use something like the HEART score: 1. E EKG: a negative ECG (score = 0) 3. She was having a transient STEMI, briefly. Learning Points : 1. She called 911. A Age: = 0 4. It was stented.

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Dr. Smith's ECG Blog

DECEMBER 27, 2018

S-wave is in V2 = 17 mm S-wave V4 = 9 mm Total = 26 (not greater than 28), so not LVH by the new rule! But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI. For clarity — I’ve reproduced this ECG, to which I’ve made a few additions ( Figure-1 ). Peguero JG et al.

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EMDocs

JANUARY 11, 2024

The neurologic section was divided into (1) brain oxygenation, perfusion, edema, and intracranial pressure (ICP); (2) seizures and the ictal-interictal continuum (IIC); and (3) sedation and analgesia. Authors state early cath may be of benefit in those with no STEMI, but much of the more recent literature suggests this is more controversial.

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EMDocs

OCTOBER 29, 2024

Chu CK, Delia E, Mograder A, Dwyer EM. 2017;45(1):12-20. 2015;7(9):E365-E369. 2018;12(1). m/s)—problematic and elevated > 50 mm Hg (2.5 J Saudi Hear Assoc. 2018;30(4):336. doi:10.1016/J.JSHA.2018.07.001 2018.07.001 Sherrid M V., J Am Coll Cardiol. 1993;22(3):816-825. Anaesth Intensive Care. J Thorac Dis.

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