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ECG Pointers: STEMI Equivalents from the American College of Cardiology

EMDocs

Traditionally, emergency providers looked for signs of ST-segment elevation myocardial infarction (STEMI) to indicate the need for intervention. Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG.

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Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Dr. Smith's ECG Blog

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. This was sent to me by an undergraduate name Hans Helseth, who is an EKG tech, but who is an expert OMI ECG reader. He wrote most of it and I (Smith) edited.

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This ECG was texted to me: normal variant early repolarization, or LAD Occlusion MI (OMI)?

Dr. Smith's ECG Blog

This ECG was texted to me with no other information. It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. I assumed the presentation was consistent with acute MI. What did I say? Activate the cath lab." The T-waves in V2-V6 are diagnostic. There is also some non-diagnostic STE in inferior leads.

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EMS told "Not a STEMI". What do you think?

Dr. Smith's ECG Blog

Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Now it even meets STEMI criteria, and HATWs continue to inflate. So the cath lab was not activated. Ongoing OMI.

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Anterior STEMI? Or Benign Early Repolarization?

Dr. Smith's ECG Blog

Jason was very skeptical of STEMI. This also argues against STEMI. But knowing this information ( as described above ) — allows us to rapidly identify the ECG in Figure-1 as one more manifestation of this patient's baseline ECG. He complained of 3 days of diarrhea and abdominal pain. What do you think? Jason, I agree.

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Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Dr. Smith's ECG Blog

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

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A man in his 50s with unwitnessed VF arrest, defibrillated to ROSC, and no STEMI criteria on post ROSC ECG. Should he get emergent angiogram?

Dr. Smith's ECG Blog

Further information is not available. Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen. Only one hs troponin I was measured on arrival: 323 ng/L Initial echo showed10% EF, diffuse severe hypokinesis.