2019, Ischemia and Myocardial Infarction

Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. The ECG is diagnostic of occlusion myocardial infarction (OMI).

Chest Pain

Chest Pain Ischemia Pericarditis Tachycardia

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

Abstract 4143007: Pericoronary fat attenuation index as a Novel Tool to predict the morbidity of new-onset atrial fibrillation in patients with myocardial infarction with nonobstructive coronary artery disease

Circulation

NOVEMBER 11, 2024

Background:Myocardial infarction with nonobstructive coronary artery disease (MINOCA) is a special syndrome with clear evidence of myocardial ischemia, but no clear stenosis of coronary artery imaging sign. Circulation, Volume 150, Issue Suppl_1 , Page A4143007-A4143007, November 12, 2024. month follow-up.

Coronary Artery Disease

Coronary Artery Disease Atrial Fibrillation Myocardial Infarction Ischemia

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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

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. associated typical Myocardial Infarction therapies such as statins and ACE inhibitors with significantly decreased 1 year mortality in MINOCA patients, which suggests that they do indeed have a similar pathophysiology to MI patients with obstructive coronary disease. Downstream vasospasm?

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. The absence of STE in V7-V9 is often due to resolution of ischemia, as seen by resolution of ST depression in V7-V9. Int J Cardiol 2019 2. -- Meyers HP, Bracey, Smith et al.

STEMI

STEMI Myocardial Infarction Chest Pain 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

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. Am J Med 2019, 132(5):622-630.

Ischemia

Ischemia STEMI Stenosis Chest Pain

An elderly male with acute altered mental status and huge ST Elevation

Dr. Smith's ECG Blog

OCTOBER 12, 2024

or basilar ischemia. Terminal QRS distortion is present in anterior myocardial infarction but absent in early repolarization. Rather than loss of both a J wave and S wave — there is a "slur" ( J-point equivalent ) in lead V2 of ECG #2 ( See My Comment in the November 14, 2019 post for illustration of T-QRS-D ).

STEMI

STEMI Document Blog Ischemia

Image Analysis Software for Cardiovascular Disease Assessment Gets 510(k) FDA Clearance

DAIC

OCTOBER 1, 2024

The company is also pursuing an indication for non-invasive measurement of fractional flow reserve (FFR CT ), uniquely derived from its PlaqueIQ technology, to measure coronary blockages and the extent of ischemia. 6 (3) (2019). Hafiane, Vulnerable plaque, characteristics, detection, and potential therapies , J. Cardiovasc.

Cardiovascular Disease

Cardiovascular Disease Plaque Quality of Life Myocardial Infarction

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Dr. Smith's ECG Blog

APRIL 22, 2022

ST-elevation myocardial infarction after pharmacologic persantine stress test in a patient with Wellens’ syndrome. JAMA Intern Med 2019 9. Single High-Sensitivity Cardiac Troponin I to Rule Out Acute Myocardial Infarction. Was this objective evidence of inducible ischemia accompanied by chest pain?

Chest Pain

Chest Pain Ischemia Myocardial Infarction Angina

How cardiogenic shock in NSTEMI is different from STEMI?

Dr. S. Venkatesan MD

DECEMBER 29, 2023

This can be simply a equivalent of HT, with no true supply side ischemia with LVF with global ST depression ) Management *More or less similar to STEMI with aggressive opening of culprit lesions with few differences. SCAI 2019 Catheter Cardiovasc Interv.2019;94:29–37 PMID: 35743628; PMCID: PMC9224589. Circ Cardiovasc Qual Outcomes.

Cardiogenic Shock

Cardiogenic Shock STEMI Myocardial Infarction Outcomes

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 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. JACC 2019 Sep 10;74(10):1290-1300. There is also a Q-wave in III. There is also subtle STD in V3-V5.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

Posterior leads can give false reassurance

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. V5-V6) of any amplitude, is specific for Occlusion Myocardial Infarction (vs.

Chest Pain

Chest Pain Blog Ischemia STEMI

How much time are you willing to wait for OMI to become STEMI (if it ever does)?

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

There is no ST depression in V6, II, III, or aVF, and no significant ST elevation in aVR, all confirming that the ST vector is not consistent with diffuse subendocardial ischemia, but rather a focal ST vector pointed at the posterior wall. There is sinus rhythm with normal QRS complex and ST depression in V2-V5, maximal in V3-V4.

STEMI

STEMI Chest Pain Myocardial Infarction Document

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease. An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!! Lindahl et al.

Plaque

Plaque Chest Pain Thrombosis Stenosis

A Patient with Respiratory Failure and a Computer "Normal" ECG

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. ng/mL is seldom a result of demand ischemia (type 2 MI). First was 2.9

Chest Pain

Chest Pain Ischemia Aneurysm Myocardial Infarction

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Dr. Smith's ECG Blog

DECEMBER 16, 2019

Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated. Comparison of the QRS Complex, ST-Segment, and T-Wave Among Patients with Left Bundle Branch Block with and without Acute Myocardial Infarction.

Chest Pain

Chest Pain Myocardial Infarction Stents Stent

Elucid Commences International PRE-VUE CCT Registry Study

DAIC

JULY 18, 2024

Cardiovascular disease is the most common cause of death and disability globally, largely driven by myocardial infarction and ischemic stroke caused by atherosclerosis (plaque build-up in the arteries). 6 (3) (2019). 2017 23, April 2020; Available from: [link]. Cardiovasc.

Plaque

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Dark Side of the Moon

EMS 12-Lead

APRIL 8, 2022

When “spot diagnosing” precordial ST-depression I instinctively evaluate aVR for any corresponding ST-elevation to see if an emerging pattern of broad subendocardial ischemia can be appreciated, in which the ST-depression should be otherwise global and demonstrably maximal in Leads II and V5. ST-elevation, etc.) is present. 1] Driver, B.

Myocardial Infarction

Myocardial Infarction Coronary Angiogram STEMI Ischemia

Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. In normal times, the most common use of cTni is in diagnosing, or ruling out, acute myocardial infarction (AMI, a subcategory of acute myocardial injury.

Cardiac Arrest

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock

What are treatment options for this rhythm, when all else fails?

Dr. Smith's ECG Blog

JULY 21, 2024

Troponin T peaked at 38,398 ng/L ( = a very large myocardial infarction, but not massive-- thanks to the pre-PCI spontaneous reperfusion, and rapid internvention!! ). There is no definite evidence of acute ischemia. (ie, Some residual ischemia in the infarct border might still be present.

Arrhythmia

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

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 2019 Sep 10;140(11):e649-e650] [published correction appears in Circulation. Published 2019 Feb 28. 4 In the U.S. 12 Colchicine, 0.5

Cardiovascular Disease

Cardiovascular Disease Heart Attack Heart attacks Coronary Artery Disease

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

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

LAD 80% mid LCx occluded mid (acute infarct lesion) RCA 80% mid. PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. Cardiac Troponin Changes to Distinguish Type 1 and Type 2 Myocardial Infarction and 180-Day Mortality Risk.

Myocardial Infarction

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI

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. I believe this is by far the most common outcome for this patient around the world in 2019. So what will you do for this patient?

STEMI

STEMI Chest Pain Ischemia Myocardial Infarction

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

The Advantages Of A CT Coronary Angiogram

Dr. Paddy Barrett

AUGUST 1, 2023

2 Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. 5 ISCHEMIA Research Group. 5 ISCHEMIA Research Group. Medicine (Baltimore). 2022 Sep 16;101(37):e30583. N Engl J Med. 2018 Sep 6;379(10):924-933. Eur Heart J.

Coronary Angiogram

Coronary Angiogram Plaque Coronary Artery Disease Chest Pain

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

Dr. Smith's ECG Blog

OCTOBER 7, 2019

RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. Smith pointed out that while atropine may may result in slightly more oxygen demand, the increase in cardiac output and in blood pressure would increase overall coronary perfusion and decrease ischemia.

Bradycardia

Bradycardia STEMI Cardiogenic Shock Ischemia

What happens when a patient with LAD OMI does not go immediately to the cath lab?

Dr. Smith's ECG Blog

APRIL 3, 2019

Appearance of Abnormal Q Waves Early in the Course of Acute Myocardial Infarction: Implications for Efficacy of Thrombolytic Therapy.” Pain will resolve with completed infarct or with resolution of ischemia. This looks like infarct completion. ECG recorded at 7 hours All active ischemia is gone. Maynard, G.

STEMI

STEMI Chest Pain Ischemia Aneurysm

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 September 22, 2019 post — intermittent ST-T wave artifact.

Blog

Blog Chest Pain Myocardial Infarction Critical Care

Acute chest pain with LBBB and obvious OMI, worsening on serial ECGs, but repeatedly missed by physicians and Marquette 12SL

Dr. Smith's ECG Blog

JANUARY 23, 2025

Case A 76 year old man with chronic hypertension but no history of coronary disease or myocardial infarction presented to the ED with chest pain at 2343. His triage EKG is shown below: There is left bundle branch block, so the EKG must be evaluated for ischemia by Smith-modified Sgarbossa criteria.

Chest Pain

Chest Pain Ischemia STEMI Blog

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

Three prehospital ECGs in patients with chest pain

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

Abstract 4143007: Pericoronary fat attenuation index as a Novel Tool to predict the morbidity of new-onset atrial fibrillation in patients with myocardial infarction with nonobstructive coronary artery disease

Webinars

What do you think the echocardiogram shows in this case?

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

7 steps to missing posterior Occlusion MI, and how to avoid them

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

An elderly male with acute altered mental status and huge ST Elevation

Image Analysis Software for Cardiovascular Disease Assessment Gets 510(k) FDA Clearance

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

How cardiogenic shock in NSTEMI is different from STEMI?

Hypertrophic Cardiomyopathy

A young peripartum woman with Chest Pain

Posterior leads can give false reassurance

How much time are you willing to wait for OMI to become STEMI (if it ever does)?

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

A Patient with Respiratory Failure and a Computer "Normal" ECG

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Elucid Commences International PRE-VUE CCT Registry Study

Dark Side of the Moon

Extreme shock and cardiac arrest in COVID patient

What are treatment options for this rhythm, when all else fails?

Lowering Atherosclerotic Cardiovascular Disease Events by Treating Residual Inflammatory Risk

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

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

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

The Advantages Of A CT Coronary Angiogram

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

What happens when a patient with LAD OMI does not go immediately to the cath lab?

Chest (or abdominal?) pain and ECG artifact.

Acute chest pain with LBBB and obvious OMI, worsening on serial ECGs, but repeatedly missed by physicians and Marquette 12SL

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

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