2018, Ischemia and Myocardial Infarction

Which patient has the more severe chest pain?

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

See these 2 articles Association between pre-hospital chest pain severity and myocardial injury in ST elevation myocardial infarction: A post-hoc analysis of the AVOID study Author links open overlay panel [link] 1 Background We sought to determine if an association exists between prehospital chest pain severity and markers of myocardial injury.

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. What do you think?

Chest Pain

Chest Pain Pacemaker Ischemia Stents

Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

APRIL 18, 2024

5] Back to the case The patient had serial ECGs over the next hour with no significant change: The first troponin came back at 1,400 ng/L (normal <26 in males and <16 in females), confirming MI – and the patient’s refractory ischemia indicated this was an Occlusion MI. Clin Cardiol 2022 4. Herman, Meyers, Smith et al.

STEMI

STEMI Chest Pain Myocardial Infarction Blog

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What do you think the echocardiogram shows in this case?

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. Nevertheless, the clinical situation made other etiologies unlikely. NTG drip started.

Echocardiogram

Echocardiogram Ischemia Chest Pain Blog

Acute OMI or "Benign" Early Repolarization?

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The pain will resolve and you will think the ischemia is gone when it is only hidden ! Comparative early and late outcomes after primary percutaneous coronary intervention in st-segment elevation and Non–St-segment elevation acute myocardial infarction (from the Cadillac trial). & Griffin, J. link] Lee, T. Weisberg, M.,

Chest Pain

Chest Pain Myocardial Infarction Blog Stents

A 40-something with 100 minutes of chest pain

Dr. Smith's ECG Blog

MARCH 27, 2023

--The STD in V2-V6 might be interpreted as subendocardial ischemia, but with the inferior STE, it is far more likely to represent posterior OMI. In subendocardial ischemia, cath lab is indicated if the pain persists in spite of medical therapy (aspirin, anticoagulant, IV nitro). At 100 minutes, the above ECG was recorded.

Chest Pain

Chest Pain Ischemia Myocardial Infarction Blog

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

His response: “subendocardial ischemia. Smith : It should be noted that, in subendocardial ischemia, in contrast to OMI, absence of wall motion abnormality is common. With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. Anything more on history?

Ischemia

Ischemia STEMI Stenosis Chest Pain

Is there a Right Ventricular MI in addition to Infero-postero-lateral MI?

Dr. Smith's ECG Blog

JULY 11, 2018

Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI. The “bottom line” conclusions of their case report were that transient J waves may on occasion be induced by an acute injury current from impending myocardial infarction.

Chest Pain

Chest Pain STEMI Ischemia Blog

An athletic 30-something woman with acute substernal chest pressure

Dr. Smith's ECG Blog

JULY 31, 2018

This is diagnostic of myocardial infarction. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. It they are static, then they are not due to ischemia. This is better evidence for ischemia than any other data point.

SCAD

SCAD Chest Pain Myocardial Infarction Ischemia

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This is the initial ECG: The QRS is widened with a regular cadence, and there are no discernable P waves.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

A young patient with diminishing pain with a subtle but diagnostic ECG.

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Although not striking, this is clearly a diagnostic ECG for infero"posterior" myocardial infarction due to coronary occlusion (OMI), most likely due to left circumflex (LCx) artery occlusion. mm STE even in the fourth universal definition of myocardial infarction. Considerations on the naming of myocardial infarctions.

Myocardial Infarction

Myocardial Infarction Chest Pain Blog Echocardiogram

The computer calls this a “normal ECG”. We'll just keep making this point.

Dr. Smith's ECG Blog

DECEMBER 19, 2018

This confirms that there were dynamic signs of ischemia on the initial ECG. ng/ml , a three-fold increase from troponin #2, also confirming acute myocardial infarction. The ST depression in aVL is also resolved. It was not normal! A third troponin I returned at 0.27

Chest Pain

Chest Pain Ischemia Myocardial Infarction Angina

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. There is also a Q-wave in III. There is also subtle STD in V3-V5. The initial troponin I was elevated at 0.75

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

Formula Utilization

EMS 12-Lead

JUNE 20, 2022

Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. It’s important to stress the presence of a normal QRS (i.e., With deliberate practice, spot diagnosis of T-to-R ratio will come with time. References 1] Smith, S. Annals of Emergency Medicine, 60 (1), 45-56.

STEMI

STEMI Stents Stent Myocardial Infarction

Large T-waves and a Computer Interpretation of Acute MI

Dr. Smith's ECG Blog

NOVEMBER 24, 2018

Here it is: Computer Interpretation: SINUS RHYTHM INFERIOR MYOCARDIAL INFARCTION, POSSIBLY ACUTE ST ELEVATION, CONSIDER ANTERIOR INJURY [MARKED ST ELEVATION W/O NORMALLY INFLECTED T WAVE IN V2-V5] ACUTE MI What do you think? This ECG was texted to me with no information: I answered: "Show me the whole 12-lead."

Chest Pain

Chest Pain Exercise Myocardial Infarction Blog

Target Acquired

EMS 12-Lead

APRIL 2, 2022

He was found diaphoretic and uncomfortable, and verbalizing a prior history of myocardial infarction and that, furthermore, the acute symptoms were identical to that which had been associated with RCA stent placement 4 years prior. Terminal QRS distortion is present in anterior myocardial infarction but absent in early repolarization.

Myocardial Infarction

Myocardial Infarction Stents Stent STEMI

A female in her 60s who was lucky to get expert ECG interpretation

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

Diagnostic and prognostic value of the QRS-T-angle, an ECG marker quantifying heterogeneity of depolarization and repolarization, in patients with suspected non-ST-elevation myocardial infarc tion. J Electrocardiology January–February, 2018; Volume 51, Issue 1, Pages e5–e6.

Chest Pain

Chest Pain Critical Care Article Pacemaker

A "normal ECG" on a busy night

Dr. Smith's ECG Blog

OCTOBER 6, 2018

If the patient had been "lucky," his symptoms from the prior day might have been due to ischemia prolonged and intense enough to result in small troponin increase. Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel: limitations of ST-segment elevation in standard and extended ECG leads.

Chest Pain

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Electrocardiographic Differentiation of Early Repolarization FromSubtle Anterior ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2018; 122(8):1303-1309. To me, this makes the ECG nearly diagnostic of ischemia, though if it is LAD occlusion, there should be ST depression in III and aVL, so it is a bit confusing.

Chest Pain

Chest Pain STEMI Bradycardia Stenosis

HeartFlow Announces Revolutionary Five-Year Data Demonstrating a 63 Percent Mortality Reduction with FFRCT-Guided Care in PAD Patients

DAIC

MAY 8, 2024

6 This novel study marks a significant milestone in the field, evaluating the effectiveness of FFR CT in detecting ischemia-producing coronary stenosis in patients with severe PAD. Utilization of coronary computed tomography angiography and computed tomography-derived fractional flow reserve in a critical limb-threatening ischemia cohort.”

Coronary Artery Disease

Coronary Artery Disease Chest Pain Ischemia Myocardial Infarction

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished. First , there can simply be diffuse ST depressions (which obligates reciprocal STE in aVR) associated with tachycardia which are not indicative of ischemia.

Ischemia

Ischemia Atrial Flutter Arrhythmia Tachycardia

The Bleeding Heart

EMS 12-Lead

APRIL 21, 2022

His father and brother both died of myocardial infarction at ages 61 and 45, respectively. There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1]

Ischemia

Ischemia Myocardial Infarction Blog Coronary Angiogram

Fractional flow reserve for guiding coronary intervention and functional SYNTAX score

All About Cardiovascular System and Disorders

APRIL 21, 2024

indicates inducible ischemia while an FFR above 0.80 excludes ischemia in 90% of cases. They had lower rates of mortality or myocardial infarction. myocardial infarction rate and 3.2% There is a strong correlation between FFR and inducible myocardial ischemia. Normal FFR is 1.0 An FFR below 0.75

Myocardial Infarction

Myocardial Infarction Stents Stent Coronary Artery Disease

Abstract 4141224: Prognostic Value of Serum Glycated Albumin in Acute Coronary Syndrome Patients Without Standard Modifiable Cardiovascular Risk Factors

Circulation

NOVEMBER 11, 2024

The primary endpoint of this study was major adverse cardiovascular and cerebrovascular events (MACCEs) that included all-cause mortality, non-fatal myocardial infarction, non-fatal ischemic stroke, and ischemia-driven revascularization.Results:The average age of the study participants was 59.55 ± 10.98

Risk Factors

Risk Factors Ischemia Myocardial Infarction Outcomes

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

Diagnosis of Acute Myocardial Infarction in the Presence of Left Bundle Branch Block using the ST Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

Chest Pain

Chest Pain Myocardial Infarction STEMI Pacemaker

Timing of revascularization in patients with transient STEMI: a randomized clinical trial

Dr. Smith's ECG Blog

NOVEMBER 1, 2018

European Heart Journal , ehy651, [link] Published: 26 October 2018 [link] Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial. MRI measure infarct size was the same in both. All patients received aspirin, a P2Y12 inhibitor, and an anticoagulant.

STEMI

STEMI Myocardial Infarction Ischemia Outcomes

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). Acute myocardial infarction in patients with dialysis Patients on dialysis have a well studied history of underdiagnosis and undertreatment for acute myocardial infarction.

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Dr. Smith's ECG Blog

OCTOBER 24, 2018

Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct.

STEMI

STEMI Angina Myocardial Infarction Plaque

Lowering Atherosclerotic Cardiovascular Disease Events by Treating Residual Inflammatory Risk

DAIC

JANUARY 23, 2024

3 Patients with ASCVD are at a higher risk for major adverse cardiovascular events (MACE) including heart attack or myocardial infarction (MI), stroke, and cardiovascular (CV) death.4 Published 2018 Feb 6. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. 4 In the U.S. 12 Colchicine, 0.5

Cardiovascular Disease

Cardiovascular Disease Heart Attack Heart attacks Coronary Artery Disease

A Middle-Aged male with Chest Pain and an Unusual ECG

Dr. Smith's ECG Blog

MAY 6, 2019

Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. Ischemia/infarction. It helps a little bit.

Chest Pain

Chest Pain STEMI Ischemia Myocardial Infarction

What will you do for this patient transferred to you who is now asymptomatic?

Dr. Smith's ECG Blog

MARCH 6, 2019

She requires maximal medical management per all current guidelines (including heparin and P2Y12 inhibitor per cardiology), as well as consideration for emergent cath in the case of persistent ischemia. So what will you do for this patient? They found an acute, total, thrombotic occlusion of the proximal LAD. They opened it. Patel et al.,

STEMI

STEMI Chest Pain Ischemia Myocardial Infarction

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Details cannot be shared here, but suffice it to say that inability to recognize acute occlusive myocardial infarction in the presence of ventricular paced rhythm contributed to a poor outcome. Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analys is.

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

The Advantages Of A CT Coronary Angiogram

Dr. Paddy Barrett

AUGUST 1, 2023

2 Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. 2018 Sep 6;379(10):924-933. 5 ISCHEMIA Research Group. 5 ISCHEMIA Research Group. Medicine (Baltimore). 2022 Sep 16;101(37):e30583. N Engl J Med. 3 ESC Scientific Document Group. Eur Heart J. 2020 Jan 14;41(3):407-477. Eur Heart J. N Engl J Med.

Coronary Angiogram

Coronary Angiogram Plaque Coronary Artery Disease Chest Pain

Of Twists and Turns

EMS 12-Lead

APRIL 28, 2022

In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. Unfortunately, today’s case is lacking any such diagnostics, thus I cannot say with certainty that the QT interval is, or is not, culpable in arrhythmogenesis. [1] 6] Goldberger, A.

Tachycardia

Tachycardia AFIB Arrhythmia Coronary Artery Bypass Graft

Chest (or abdominal?) pain and ECG artifact.

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

Compared to TTE from 7/3/24: the anterior regional wall motion abnormality is new and is consistent with ischemia/infarction in the LAD territory == MY Comment , by K EN G RAUER, MD ( 11/20 /2024 ): == There are several insightful aspects of today's case. The January 30, 2018 post — for PTA.

Blog

Blog Chest Pain Myocardial Infarction Critical Care

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

It could also, given a different clinical context be compatible with a subacute myocardial infarction complicated by post infarct regional pericarditis. Due to the atypical and vague symptoms, the myocardial infarct was not initially diagnosed. At presentation he had a history of dyspnea for 6 days.

Chest Pain

Chest Pain Pericarditis Myocardial Infarction Dementia

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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! Acute myocardial infarction: an uncommon complication of takotsubo cardiomyopathy. SanzRuiz, R., Solis, J., &

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

Cardiovascular Update

Which patient has the more severe chest pain?

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

Is OMI an ECG Diagnosis?

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What do you think the echocardiogram shows in this case?

Acute OMI or "Benign" Early Repolarization?

A 40-something with 100 minutes of chest pain

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Is there a Right Ventricular MI in addition to Infero-postero-lateral MI?

An athletic 30-something woman with acute substernal chest pressure

Hypertrophic Cardiomyopathy

A young patient with diminishing pain with a subtle but diagnostic ECG.

The computer calls this a “normal ECG”. We'll just keep making this point.

A young peripartum woman with Chest Pain

Formula Utilization

Large T-waves and a Computer Interpretation of Acute MI

Target Acquired

A female in her 60s who was lucky to get expert ECG interpretation

A "normal ECG" on a busy night

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

HeartFlow Announces Revolutionary Five-Year Data Demonstrating a 63 Percent Mortality Reduction with FFRCT-Guided Care in PAD Patients

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

The Bleeding Heart

Fractional flow reserve for guiding coronary intervention and functional SYNTAX score

Abstract 4141224: Prognostic Value of Serum Glycated Albumin in Acute Coronary Syndrome Patients Without Standard Modifiable Cardiovascular Risk Factors

A man in his 70s with acute chest pain and paced rhythm.

Timing of revascularization in patients with transient STEMI: a randomized clinical trial

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Lowering Atherosclerotic Cardiovascular Disease Events by Treating Residual Inflammatory Risk

A Middle-Aged male with Chest Pain and an Unusual ECG

What will you do for this patient transferred to you who is now asymptomatic?

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

The Advantages Of A CT Coronary Angiogram

Of Twists and Turns

Chest (or abdominal?) pain and ECG artifact.

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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