Ken Grauer, MD

MARCH 7, 2023

This blog post reviews the basics for predicting the " C ulprit" A rtery — as well as the importance of the term, " O MI" ( = O cclusion-based MI ) as an improvement from the outdated STEMI paradigm. ECG Blog #271 — Reviews determination of the ST segment baseline ( with discussion of the entity of diffuse Subendocardial Ischemia).

Blog 78

Blog Chest Pain STEMI Ischemia 78

Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. 2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia STEMI 52

Ken Grauer, MD

MARCH 18, 2023

To EMPHASIZE: Despite there not being "enough" ST elevation to satisfy millimeter-based criteria for an acute "STEMI" in ECG #1 — this initial ECG is absolutely diagnostic of OMI. ECG Blog #184 and ECG Blog #167 — illustrate the "magical" mirror-image opposite relationship with acute ischemia between lead III and lead aVL.

Blog 78

Blog Chest Pain STEMI Ischemia 78

Dr. Smith's ECG Blog

APRIL 22, 2022

The HEART and EDACS scores are helpful to risk stratify patients with chest pain, but they hinge on accurate ECG interpretation: a low score doesn’t apply if the ECG shows STEMI(+)OMI, and shouldn’t be used for STEMI(-)OMI or OMI reperfusion either 2. Case Rep Emerg Med 2014 7. Patel J, Alattar F, Koneru J, et al.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Dr. Smith's ECG Blog

JULY 1, 2019

Although as a general rule, there should be no ST elevation in RBBB in the absence of ischemia, there sometimes is ST elevation that looks like this. There is also much STE in V3-V6, especially V4-V6, that must be considered to be STEMI. The challenge is magnified when trying to assess BBB tracings for acute ischemia.

Chest Pain 52

Chest Pain Ischemia STEMI Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

Does this mean that the ST depression in V3 represents "anterior" subendocardial ischemia, and not posterior OMI? This is most consistent with ischemia/infarction in the distribution of the left circumflex coronary artery. non-occlusive ischemia) 2. Thus, they have much less voltage. They have ZERO ST Elevation.

Chest Pain 52

Chest Pain Blog Ischemia STEMI 52

Dr. Smith's ECG Blog

MARCH 11, 2019

The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." Here is the patient's troponin I profile: These were interpreted as due to demand ischemia, or type II MI. Here is data from a study we published in 2014 for type II NonSTEMI: Sandoval Y.

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Thelin et al.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI 52

STEMI Chest Pain Ischemia Myocardial Infarction 52

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. KEY Point: A number of conditions other than Brugada Syndrome may temporarily produce a Brugada-1 ECG pattern ( World J Cardiol 6(3):81-86, 2014 ).

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

Chest Pain 104

Chest Pain STEMI Aortic Ultrasound 104

Dr. Smith's ECG Blog

MARCH 9, 2025

It is not clear by her note what she meant by this (whether or not she recognized this EKG as diagnostic of transmural ischemia, and if so, of what territory) but emergent reperfusion therapy was not pursued. Subendocardial ischemia does not localize. At 1022, a troponin I (ref range <0.034 ng/mL) resulted at 4.437 ng/mL.

Ischemia 87

Ischemia Blog STEMI Coronary Angiogram 87

Ken Grauer, MD

MARCH 8, 2025

PEARL # 3: Knowing there is an acute inferior STEMI I looked next to see if there is also acute posterior involvement ( which so often accompanies inferior MI ). But larger-than-expected Q waves in each of the inferior leads ( especially in lead III ) are probably the result of this patients ongoing acute inferior STEMI.

Blog 103

Blog STEMI Download Chest Pain 103

Dr. Smith's ECG Blog

MARCH 8, 2025

It is possible there is microvascular dysfunction producing residual transmural ischemia. But this is most common when there is prolonged ischemia, and this patient had the fastest reperfusion imaginable! There was indication of parasympathetic overdrive ( the acute inferior STEMI with profound bradycardia and junctional escape ).

Cardiomyopathy 74

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 74