Dr. Smith's ECG Blog

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. Here is his most recent previous ECG: This was recorded after intervention for inferior STEMI (with massive ST Elevation, see below), and shows inferior Q-waves with T-wave inversion typical of completed inferior OMI. ng/mL (quite large).

STEMI 124

STEMI ED ALS OR 124

EMDocs

DECEMBER 11, 2023

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.

STEMI 119

STEMI Coronary Emergency Department OR 119

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 Chest Pain – Benign Early Repol or OMI?

OR 121

OR STEMI Heart Attack Coronary 121

Core EM

JULY 23, 2024

EKG Show Details EKG Characteristics Rate 54 Rhythm Sinus Bradycardia Intervals Normal PR, QRS, QT Intervals Axis Normal ST Segments ST Depression in Leads V2-V6 Diagnosis Diagnosis: Posterior STEMI Questions What is the next test that should be obtained in the management of this patient?

STEMI 189

STEMI Coronary Emergency Department OR 189

Dr. Smith's ECG Blog

OCTOBER 15, 2024

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.

OR 117

OR STEMI Coronary ED 117

Emergency Medicine Cases

AUGUST 8, 2023

We consider electrolyte disturbances and look for ECG signs of hyperkalemia or hypokalemia/hypomagnesemia, and we consider the differential of diffuse ST depression with reciprocal ST elevation in aVR, and false positive STEMI.

STEMI 218

STEMI OR EMS 218

Dr. Smith's ECG Blog

NOVEMBER 27, 2024

Doing so literally enables those of us who embrace the OMI Paradigm the ability to recognize within seconds that a patient with new CP ( C hest P ain ) — and — one or more hyperacute T waves — needs prompt cath regardless of potential absence of STEMI criteria.

STEMI 133

STEMI OR 133

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121

Dr. Smith's ECG Blog

MAY 29, 2024

Triage ECG: It was interpreted as lateral STEMI, and he was sent to the cath lab, where the angiogram showed unchanged CAD from known prior, with no acute culprit. Written by Pendell Meyers Two patients with acute chest pain. Do either, neither, or both have OMI and need reperfusion? Described as a dull ache, 6/10 in severity.

CAD 116

CAD OR STEMI 116

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. This ECG was texted to me with no other information. 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.

OR 131

OR STEMI Coronary 131

University of Maryland Department of Emergency Med

JUNE 10, 2023

Is this a STEMI or Pericarditis? a 37 year old patient comes in with chest pain, you obtain the following ECG. Click to view the rest

STEMI 76

STEMI OR 76

Dr. Smith's ECG Blog

JANUARY 3, 2024

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.

STEMI 103

STEMI EMS ED OR 103

Peter Canning

JANUARY 27, 2025

For instance, there was no protocol for stroke or STEMI. At some point along the way we had protocols for spinal motion restriction, alcohol withdrawal, stroke and STEMI, CPAP, and termination of cardiac arrest resuscitation on scene. There were fewer than 50 protocols in the book, along with pages for 24 medications and 8 procedures.

Allergic Reaction 90

Allergic Reaction Naloxone Paramedic STEMI 90

Dr. Smith's ECG Blog

OCTOBER 1, 2023

She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. Back to the case: Unfortunately, the ECG was not understood by the provider.

OR 128

OR STEMI CAD Coronary 128

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

STEMI 90

STEMI OR Coronary Emergency Department 90

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

OR 126

OR STEMI EMS ED 126

Dr. Smith's ECG Blog

AUGUST 6, 2023

link] == MY Comment, by K EN G RAUER, MD ( 8/6 /2023 ): == Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI”. The current STEMI paradigm that continues to be followed by all-too-many clinicians ( including all-too-many cardiologists ) is fallacious.

OR 98

OR STEMI Coronary 98

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., Here is the bottom line of the article: It is widely believed that hyperacute T-waves are a transitional state preceding ST Elevation 1–4 Thus, it is tempting to postulate that early cases of OMI will eventually evolve to STEMI; yet, our data contradicts that notion. This one is easy for the Queen.

OR 123

OR STEMI ICU Coronary 123

Dr. Smith's ECG Blog

MAY 31, 2023

Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. It is a mass delusion.

STEMI 96

STEMI Coronary ACS OR 96

Dr. Smith's ECG Blog

JUNE 7, 2024

Obvious infero-postero-lateral STEMI(+)OMI, regardless of context Now let’s put them in order: what was the sequence? With serial ECGs that are ‘STEMI negative’ the physician could have waited for serial troponin levels or referred the patient as “non-STEMI”. 2 Normal ECG #3. What was the outcome and final diagnosis?

STEMI 113

STEMI Coronary EMS OR 113

Core EM

FEBRUARY 23, 2024

EKG Show Details EKG Characteristics Rate 54 Rhythm Sinus Bradycardia Intervals Normal PR, QRS, QT Intervals Axis Normal ST Segments ST Depression in Leads V2-V6 Diagnosis Diagnosis: Posterior STEMI Questions What is the next test that should be obtained in the management of this patient?

STEMI 130

STEMI Coronary Emergency Department OR 130

Dr. Smith's ECG Blog

JULY 7, 2024

So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 67

STEMI Coronary ALS OR 67

Dr. Smith's ECG Blog

MAY 27, 2024

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]

STEMI 123

STEMI Coronary ALS Emergency Department 123

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. He does have a recently diagnosed PE, and has not been taking his anticoagulation due to cost. He had a previous ECG on file: Proving the findings are new The cath lab was activated. He was given aspirin and sublingual nitro and the pain resolved.

Coronary 122

Coronary ACS OR EMR 122

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

STEMI 121

STEMI Coronary ALS CAD 121

Emergency Medicine Cases

SEPTEMBER 15, 2020

LVH produces secondary repolarization abnormalities that can mimic STEMI. Signs of occlusion MI in patients with LVH include: new Q waves/loss of R waves, disproportionate and dynamic ST elevation (or ST depression from posterior MI), and hyperacute T waves.

STEMI 130

STEMI Coronary OR EMS 130

Dr. Smith's ECG Blog

JULY 9, 2024

Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen. As per My Comment in the above-cited Oct. 15, 2022 post — I like to focus on the ST-T wave appearance in leads V1 and V6 to facilitate recognition of Precordial Swirl.

Defibrillator 117

Defibrillator STEMI CPR EMS 117

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

The biggest problem with STEMI criteria are false negatives – because this costs patient’s myocardium, with greater mortality and morbidity. For this reason, ECGs need first to be interpreted in isolation, and then applied to the patient. Could this false positive cath lab activation been prevented?

STEMI 110

STEMI Coronary OR ED 110

EMS 12-Lead

AUGUST 14, 2022

link] deWinter first reported his unique characteristics of LAD occlusion in 2008, and since the respective ECG changes do not fit the conventional STEMI paradigm (as he even stated – “instead of signature ST-segment elevation” ….) it has been subsequently deemed a STEMI-equivalent.

MICU 130

MICU STEMI CAD Coronary 130

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. Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis.

STEMI 120

STEMI Coronary Emergency Medical Services OR 120

Dr. Smith's ECG Blog

JANUARY 27, 2024

So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. The patient was admitted as ‘NSTEMI’ which is supposed to represent a non-occlusive MI, but the underlying pathophysiology is analogous to a transient STEMI. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

OCTOBER 28, 2020

This ECG was texted to me with the implied question "Is this a STEMI?": I responded that it is unlikely to be a STEMI. Septal STEMI often has ST depression in V5, V6, reciprocal to V1. Then combine with clinical presentation and low pretest probability 2 Saddleback STEMIs A Very Subtle LAD Occlusion.T-wave wave in V1??

STEMI 52

STEMI OR ED 52

Emergency Medicine Cases

APRIL 2, 2024

In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chest pain. They explain complementary diagnostic insights into pericardial effusion and cardiac tamponade, occlusion MI and RV strain.

Emergency Department 329

Emergency Department OR STEMI EMS 329

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] Written by Jesse McLaren Four patients presented with chest pain. have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 119

STEMI Emergency Department Coronary OR 119

ECG & Echo Learning

JUNE 28, 2023

Posterior (posterolateral) acute myocardial infarction (STEMI) The heart is rotated 30° to the left in the thorax. The answer is rather simple: the probability that the patient has NSTE-ACS/NSTEMI is small and the vast majority has STE-ACS/STEMI. Leads V7–V9 must be placed to reveal the ST-segment elevations.

STEMI 52

STEMI ACS OR 52

Dr. Smith's ECG Blog

MARCH 14, 2024

We also studied 7 years of Code STEMI patients requiring emergent reperfusion, and found that 4% presented with an ECG labeled ‘normal’, often confirmed by the final blinded interpretation. Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.

STEMI 120

STEMI ACS Coronary Emergency Department 120

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. This case is an example of the steps we can all take in daily practice as the paradigm shifts from STEMI to OMI.

STEMI 100

STEMI Paramedic Coronary EMS 100