2019, Electrocardiogram and STEMI - Cardiovascular Update

Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI

STEMI Article Chest Pain Blog

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

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] have published a number of warnings about the previous reassuring studies.[4,5]

Chest Pain

Chest Pain STEMI Electrocardiogram Ischemia

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

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? Am J Med 2019, 132(5):622-630.

Ischemia

Ischemia STEMI Stenosis Chest Pain

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

Chest Pain

Chest Pain STEMI Blog Stents

A 50-something with chest pain. what to do? And get the PM Cardio app for your own use here!

Dr. Smith's ECG Blog

MARCH 31, 2023

This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria. This was sent to me by a friend. What About the Initial ECG?

Chest Pain

Chest Pain STEMI Blog Academic

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

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

STEMI Chest Pain Ischemia Myocardial Infarction

Hypertrophic Cardiomyopathy

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. New insights into the use of the 12-lead electrocardiogram for diagnosing acute myocardial infarction in the emergency department.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

Dark Side of the Moon

EMS 12-Lead

APRIL 8, 2022

BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI. The EMS crews were correct moving forward with STEMI activation. 1] Driver, B.

Myocardial Infarction

Myocardial Infarction Coronary Angiogram STEMI Ischemia

Physical Examination as a Helpful Aid in Decision-Making in Challenging ECGs

Dr. Smith's ECG Blog

JANUARY 1, 2024

An initial electrocardiogram (ECG) is provided below. As per Dr. Aslanger — a number of medical providers were initial confused by what initially appears as marked ST elevation with reciprocal ST depression, indicative of an acute STEMI. The patient was promptly admitted to the hospital for further evaluation. What do you think?

Tachycardia

Tachycardia Blog Ischemia Heart Failure

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

Dr. Smith's ECG Blog

JANUARY 17, 2024

The limb leads have been removed because there was no ST elevation in those leads, the QRS complexes have been obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation. But STEMI criteria ignore all this and look at ST segments in isolation.

Chest Pain

Chest Pain STEMI Myocardial Infarction Blog

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. We wrote this Editorial in the Journal of Electrocardiology in 2019. These include about 60 occlusion MI (OMI) with clear ST segment elevation (none of which would be called “Normal” by the computer) and about 165 Non-STEMI.

Chest Pain

Chest Pain STEMI Article Myocardial Infarction

An ECG with only «marginal» change

Dr. Smith's ECG Blog

DECEMBER 15, 2023

Below is the post -PCI electrocardiogram. 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 ). In the cath lab the patient was found to have a 100% occlusion of a small 1st marginal branch of the LCx.

Chest Pain

Chest Pain Blog Ischemia Risk Factors

A man in his 70s with chest pain during a bike ride

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

You will note that it is essentially an unremarkable electrocardiogram except for some PACS. At baseline, the patient has some expected, normal STE in lead V2, further demonstrating that the STD morphology in the presentation ECG above is "true" and diagnostic. This raised our concerns that the findings on his initial one were real.

Chest Pain

Chest Pain Pulmonary ACE Inhibitor Pacemaker

Hyperthermia and ST Elevation

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. Induced Brugada-type electrocardiogram, a sign for imminent malignant arrhythmias. Bicarb 20, Lactate 4.2,

Heart Rhythm

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. This figure comes from the Diamond T study (all type 1 MI were NSTEMI, not STEMI): Notice that the 6 hour value (far right) is very low for type 2 MI. Angiogram: LM 30% ostial.

Myocardial Infarction

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI

A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? Diphenhydramine toxicity? Tricyclic?

Dr. Smith's ECG Blog

DECEMBER 5, 2019

How well does the computer interpretation perform? -- in this case, the computer diagnosed STEMI but the patient had Fever with Brugada _ _ Fever and Brugada-- Important articles The literature below shows that fever-induced Brugada is indeed a high risk for an arrhythmic event. Annals of Noninvasive Electrocardiology 2019.

Sudden Cardiac Death

Sudden Cardiac Death Heart Rhythm Article Tachycardia

Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

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

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

A 50-something with chest pain. what to do? And get the PM Cardio app for your own use here!

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

Hypertrophic Cardiomyopathy

Dark Side of the Moon

Physical Examination as a Helpful Aid in Decision-Making in Challenging ECGs

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

An ECG with only «marginal» change

A man in his 70s with chest pain during a bike ride

Hyperthermia and ST Elevation

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? Diphenhydramine toxicity? Tricyclic?

Stay Connected