Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. He did, found the true culprit, and went back in to stent it. 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.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

MAY 13, 2020

One would not expect wall motion to recover so quickly after stenting, so this is good evidence that the POCUS echo was indeed accurate. Angiogram: Severe diffuse left main disease, up to 80% at the ostial left main. Post cath ECG: Normal or near normal Peak troponin I was 15 ng/mL. Is this OMI?

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

EMS 12-Lead

JUNE 20, 2022

A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. He was rushed to the Cath Lab where an LAD culprit lesion was stented. Here is the LAD after stent placement. As the conversation progressed, another ECG spontaneously printed. The pathology is now painfully evident.

STEMI 52

STEMI Stents Stent Myocardial Infarction 52

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. A mid-LAD culprit lesion was identified and stented. Smith comment : V5 and V6 are excessively discordant!!!! Pacing Clin Electrophysiol.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

JUNE 28, 2018

See these posts for Wellens' mimics: Pseudo-Wellens' Syndrome due to Left Ventricular Hypertrophy (LVH) Anterior STEMI? It even meets STEMI criteria: 2.5 Is it Wellens' Syndrome? This was the first ECG (ECG #1) recorded during pain : This shows ST elevation and hyperacute T-waves in the LAD distribution.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Am J Cardiol 2018; 122(8):1303-1309. Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. A 99% LAD occlusion was stented. Attached is the first ECG.

Myocardial Infarction 52

Myocardial Infarction Stents Stent STEMI 52

EMS 12-Lead

APRIL 14, 2022

There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI). Troponin I returned 80 ng/mL, and the Cath Lab was then reactivated where a 100% LAD occlusion was found and stented.

ACE Inhibitor 52

ACE Inhibitor Physiology Chest Pain Academic 52

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

The patient was then taken to the cath lab an found to have a proximal RCA 100% thrombotic occlusion which was successfully stented. 3) STEMI criteria failed to identify this acute coronary occlusion, like many others. J Electrocardiology January–February, 2018; Volume 51, Issue 1, Pages e5–e6.

Chest Pain 52

Chest Pain Critical Care Article Pacemaker 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. The lesion was stented. Again, cath lab was not activated.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent. He was taken emergently to the cardiac catheterization lab and found to have multi-vessel coronary artery disease with a near-occlusive culprit lesion in the RCA, possibly reperfused. To our knowledge, the patient did well.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The culprit lesion was opened and stented. For more on this mirror-image opposite ST-T wave relation in leads III vs aVL — See My Comment in the March 8, 2019 and August 9, 2018 posts in Dr. Smith's ECG Blog ). The QoH now recognizes the OMI with mid confidence. Below is the post -PCI electrocardiogram.

Chest Pain 60

Chest Pain Blog Ischemia Risk Factors 60

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Compare to the anatomy after stenting: The lower of the 2 now easily seen branches is the circumflex, now with excellent flow. Here is his angiogram: This shot shows that the left circumflex (LCx) is occluded at the ostium (origin). This is seen just millimeters beyond the tip of the catheter. The patient recovered well.

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40

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. It was stented. My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. Smith. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. There was good flow.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

MAY 8, 2023

Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). LAFB, atrial flutter, anterolateral STEMI(+) OMI. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

EMS 12-Lead

AUGUST 14, 2022

One stent was deployed with restorative TIMI-0 flow. 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.

STEMI 52

STEMI Sudden Cardiac Death Thrombosis Thrombolysis 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

There is a very small amount of STE in some of the anterior, lateral, and inferior leads which do NOT meet STEMI criteria. The case was reviewed by all parties, and it was stated correctly that the ECG does not meet the STEMI criteria. The LAD lesion was acute and required 3 stents to restore flow.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Aneurysm 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. Is that an obvious STEMI underneath that rhythm? Is this inferor STEMI? Atrial Flutter with Inferior STEMI? If I fix the rhythm will the ST changes resolve?

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. Advanced multi-vessel disease was found with stents deployed to the mid-LCx (80% stenosis), D1 (90% stensosis), and the pLAD (95% stenosis). The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above.

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

It was thought to be an in stent restenosis and thrombosis from a DES placed in the same region 6 months prior. He was found to have a 100% occlusion of the proximal anastomotic portion of a prior SVG from the aorta to the OM1 which in turn had a vein graft to the distal RCA. There was initially TIMI 0 flow. THANK YOU Dr. Lee!

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

MAY 23, 2022

Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. Theres inferior STE which meets STEMI criteria, but this is in the context of tall R waves (18mm) and relatively small T waves, and the STD/TWI in aVL is concordant to the negative QRS. This was false positive STEMI with an ECG mimicking OMI.

Chest Pain 52

Chest Pain STEMI Pericarditis Arrhythmia 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2025

Written by Jesse McLaren An 80 year old with a history of CHF, ESRD on dialysis, and multiple prior cardiac stents presented to the emergency department with 3 days of intermittent chest pain and shortness of breath that resolved after nitro, which felt like prior episodes of angina. Discharge diagnosis was Non-STEMI.

Chest Pain 63

Chest Pain Stents Stent STEMI 63

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

It is diagnostic of OMI, but this is SUBACUTE OMI I sent this ECG to my "EKG Nerdz" friends, without any clinical info at all and they answered "OMI" The Queen said: "STEMI-Equivalent with High Confidence:" Notice she sees findings in both normal beats and PVCs. It was opened and stented. The January 30, 2018 post — for PTA.

Blog 62

Blog Chest Pain Myocardial Infarction Critical Care 62

Dr. Smith's ECG Blog

MARCH 8, 2025

After stent deployment, we often see improvement in the ST-T within seconds or minutes. Here is the final angiogram following placement of a stent in the ostial RCA. 2:04 PM, post stent deployment You can see that even after complete restoration of flow, the ECG still looks terrible, V most of all. link] Chatzidou, S.,

Cardiomyopathy 74

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 74