Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event. See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

Coronary 104

Coronary E-9-1-1 STEMI ACS 104

Dr. Smith's ECG Blog

AUGUST 10, 2023

This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. The initial ECG suggested either subacute or reperfused inferoposterior occlusion and clearly does not meet traditional STEMI criteria. Discharge diagnosis was ‘STEMI’, even though no ECG ever met STEMI criteria.

STEMI 90

STEMI ACS Emergency Department ED 90

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Is it normal STE? This is a "Transient OMI".

STEMI 116

STEMI ACS Critical Care OR 116

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. 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.

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. 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). It is a ssociated with mild dyspnea on exertion. Aspirin given.

Coronary 121

Coronary STEMI ED OR 121

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

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. RR18 sat 99% HR 90 BP 90/60, afebrile.

STEMI 86

STEMI ACS OR ALS 86

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. Setting – large, academic, suburban ED.

E-9-1-1 82

E-9-1-1 ACS STEMI Coronary 82

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

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. 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."

E-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

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

JUNE 1, 2022

While not essential for making the "correct clinical decision" ( which would have been prompt cath performed much sooner than it was ) — I thought serial ECGs did reveal important clues to the ongoing event. Figure-1: I've labeled the 1st, 2nd and 4th tracings in today's case ( See text ).

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? Is this inferor STEMI? Atrial Flutter with Inferior STEMI? The EM provider asked if the cardiologist thought it was a "STEMI." No obvious adverse events were attributed to the thrombolytics.

STEMI 52

STEMI ACS Coronary Emergency Department 52

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. On arrival in the ED, she was profoundly hypotensive, nearly obtunded, and bradycardic. The ED team again pointed out the evidence of inferoposterior OMI, this time by the modified Sgarbossa criteria. The cath lab was activated.

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

MARCH 20, 2023

Since then, I started looking for OMI EKG findings and not just STEMI. Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. Risk Factors: High Cholesterol.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

JULY 19, 2019

He still had active pain on arrival to the ED. 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. His initial ECG in the ED ( = E CG # 1 ) is shown in Figure-1.

STEMI 52

STEMI ED ACS OR 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

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. Sensitivity was 87% for OMI in our validation study (it was 34% for STEMI criteria). But I'd be less certain about an acute event without more information and prior and/or serial tracings.

Defibrillator 134

Defibrillator Coronary STEMI CPR 134

Dr. Smith's ECG Blog

JULY 26, 2023

How would YOU interpret ECG #1 if this was the only tracing you saw — and — the only thing you knew about the patient, was that he/she was being seen in the ED? Overall — I did not get a "sense" that ECG #1 represented an acute cardiac event. He presented to the ED for today's visit because of vertigo.

STEMI 52

STEMI ED OR 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. They gave him 2 nitroglycerine and transported to the ED. In the ED, the patient was "moaning, writhing in bed, and clutching his chest." A 2nd ED ECG was done at 3 hours after chest pain onset: ST depression maximal in V2-V4 persists, and is actually a bit more profound.

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Prior episodes had simply resolved after brief symptoms, but the current episode had lasted for 2 hours without improvement, so she presented to the ED. At triage she stated her pain is still persistent, but it is mildly improved compared to when she decided to come to the ED. No diaphoresis or vomiting.

ACS 105

ACS ED STEMI OR 105

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. 24 yo woman with chest pain: Is this STEMI? This is not "diffuse", this is simply anterior, lateral, and likely apical.

Coronary 52

Coronary STEMI Heart Attack OR 52

ESO

APRIL 19, 2024

Due to this, it’s important for the industry to develop strategies for better supporting psychiatric patients while avoiding unnecessary ED visits and secondary EMS transports. Improving patient outcomes through data Unsurprisingly, data was a major discussion point at a data-driven conference.

EMS 105

EMS Paramedic Critical Care STEMI 105

Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. Physician interpretation: "No STEMI." Physician: "No STEMI." Full case details and outcomes are below.

OR 52

OR STEMI ACS Emergency Department 52

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

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

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

DECEMBER 19, 2023

That's because this patient has clinical, ECG and Troponin evidence that an acute event did in fact occur ( ie, a more than doubling of Troponin in the context of a changing pattern of CP that correlates temporally with "dynamic" ECG changes — therefore strongly suggesting transient acute occlusion regardless of cath findings in today's case ).

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Diagnosis: Acute non-ST segment elevation MI (Non-STEMI, or NSTEMI) Second troponin returned at around 0200: 15,894 ng/L 0245 (unclear if ongoing pain or not) Inferoposterior (and lateral V5-6) reperfusion findings. Admitted to the hospital service for further evaluation and management." Cardiac cath was not done until 4pm the following day.

ACS 52

ACS EMS STEMI Coronary 52

Dr. Smith's ECG Blog

MARCH 28, 2017

EMS recorded these ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 The patient arrived in the ED. The pain completely resolved after nitroglycerine Moments later, the this ECG was recorded in the ED when she had been pain free for moments only: Computer read: Normal ECG. She called 911.

STEMI 52

STEMI OR ED EMS 52

Dr. Smith's ECG Blog

AUGUST 30, 2020

The computer calls it a STEMI. See this case of Type 2 STEMI due to severe hypertension. Here are more Type II STEMI. His BP in the ED was 220/120 mm Hg. And clinically — many ( if not most ) patients with diabetes and longstanding hypertension who present to the ED with a BP = 220/120 mm Hg will have LVH.

STEMI 52

STEMI Coronary ED OR 52

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 The patient arrived in the ED. The pain completely resolved after nitroglycerine Moments later, the this ECG was recorded in the ED when she had been pain free for moments only: Computer read: Normal ECG.

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

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 4, 2019

A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. Here is the ED ECG (no previous ECG was available for comparison). ng/mL (very high, very large MI), so they took her to angiography at 18 hours after ED arrival. Figure-1: The initial ECG in the ED.

STEMI 52

STEMI ED OR 52

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