Dr. Smith's ECG Blog

MARCH 22, 2024

The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible. Back to the assessment of ischemia: Returning to the ECG, the leads that catch my eye first are -- I, II, V4, V5, V6. For national registry purposes, this will be incorrectly classified as a STEMI.) < 0.049).

Chest Pain 112

Chest Pain STEMI Bradycardia Ischemia 112

Ken Grauer, MD

AUGUST 26, 2023

These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ). ECG Blog #185 — Reviews the P s, Q s, 3 R Approach to Rhythm Interpretation.

Blog 145

Blog Chest Pain STEMI Ischemia 145

Ken Grauer, MD

MAY 20, 2023

The history and associated deep anterior S waves (ie, the reciprocal of tall lateral lead R waves ) will suggest LVH rather than Precordial Swirl ( See ECG Blog #254 and My Comment at the bottom of the page in the February 6, 2020 and June 20, 2020 posts in Dr. Smith's ECG Blog ). ECG Blog #367 — for another example of acute LCx OMI.

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Blog Chest Pain Ischemia STEMI 145

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI 52

STEMI Chest Pain Stents Stent 52

Ken Grauer, MD

AUGUST 8, 2024

ECG Blog #193 — Reviews the basics for predicting the " culprit " artery ( as well as reviewing why the term "STEMI" — should be replaced by "OMI" = O cclusion-based MI ). ECG Blog #400 — Reviews the concept of " dynamic " ST-T wave changes ( and also DSI = Diffuse Subendocardial Ischemia ). ECG Blog #433 — for another subtle OMI case!

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Blog STEMI Ischemia 126

Ken Grauer, MD

JUNE 7, 2024

I thought this finding consistent with the finding of ST depression in lateral leads I; V4,V5,V6 — and possibly indicative of multivessel disease ( ie, Diffuse Subendocardial Ischemia — as discussed in ECG Blog #400 ). ECG Blog #400 — Reviews the concept of " dynamic " ST-T wave changes ( and also Diffuse Subendocardial Ischemia ).

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Blog Chest Pain STEMI Ischemia 137

Dr. Smith's ECG Blog

AUGUST 11, 2024

Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. What do you think?

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Chest Pain STEMI Bradycardia Stents 75

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Smith : the profound persistent STE suggests either persistent occlusion or " no reflow " with persistent downstream ischemia. Academic Emergency Medicine 27(S1): S220; May 2020. Abstract 556.

STEMI 82

STEMI Myocardial Infarction Ischemia Academic 82

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.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

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Blog Chest Pain Ischemia STEMI 99

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

Coronary Angiogram 100

Coronary Angiogram Plaque Thrombosis STEMI 100

Dr. Smith's ECG Blog

OCTOBER 15, 2022

It is due to transmural ischemia not only of the anterior wall and apex, but due to transmural ischemia of the septum, usually due to occlusion proximal to the first septal perforator. As always, LAD OMI need not meet STEMI criteria and usually does NOT! Is this Acute Ischemia? The voltage is high but not huge.

Chest Pain 52

Chest Pain STEMI Blog Ischemia 52

Dr. Smith's ECG Blog

APRIL 24, 2020

When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Subendocardial ischemia results in ST depression, but unfortunately, and rather mysteriously, it does not localize to the ischemic wall.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( The below ECG was recorded.

Arrhythmia 113

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 113

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls.

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Chest Pain STEMI Echocardiogram Stents 106

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The baseline ECG is basically normal with no ischemia. You can see in the lead-specific analysis that she "sees" the STD in V5, V5, and II, with STE in aVR as signs of "Not OMI", because subendocardial ischemia pattern is not the same as OMI. In my opinion, I think it looks more like subendocardial ischemia.

Chest Pain 87

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 87

Ken Grauer, MD

MARCH 15, 2024

This blog post also reviews the basics for predicting the " C ulprit" A rtery — and use 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 161

Blog Arrhythmia STEMI Ischemia 161

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

Chest Pain 82

Chest Pain STEMI Myocardial Infarction Blog 82

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. Concordant STE of 1 mm in just one lead or 2a.

Chest Pain 84

Chest Pain Ischemia Pericarditis Tachycardia 84

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution. So this is STEMI, right? Our chief of cardiology, Gautam Shroff, interprets it differently and thinks this is indeed ischemia. It is often confused with a wide QRS due to conditions such as hyperkalemia. Which artery?

Cardiogenic Shock 52

Cardiogenic Shock STEMI Pericarditis Blog 52

Dr. Smith's ECG Blog

JANUARY 6, 2024

Here, I do not see OMI (although the ECG is falsely STEMI positive with just over 1 mm STE in V1 and about 2.5 In the days before I learned to look for OMI, back when I was counting ST elevation boxes, I used to save ischemia for last.) I interpret tracings systematically in "real time" ( including my assessment for acute ischemia ).

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Blog Ischemia Tachycardia Physiology 91

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

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. For more on the application of this Trace-down; Copy-over technique with Shark Fin ST segment deviations — See My Comment in the May 19, 2020 post in Dr. Smith's ECG Blog.

Cardiac Arrest 85

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 85

Dr. Smith's ECG Blog

JUNE 1, 2022

Here is his ECG: There is no clear evidence of OMI or ischemia. A 40-something male with no previous cardiac disease presented with chest pain. There is a tiny amount of STE in aVL, but it is NOT in the context of a tiny R-wave. There is a tiny amount of STD in lead III, with some non-specific T-wave flattening.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Bradycardia 52

Ken Grauer, MD

MAY 26, 2023

This ST depression appears to be maximal in leads V3-to-V5 — which could reflect acute posterior OMI ( O cclusion-based M yocardial I nfarction ) — most probably with multi -vessel disease ( ie, diffuse subendocardial ischemia suggested by the ST depression with ST elevation in aVR>V1 ). This patient has new CP — and — he is hypotensive.

Blog 78

Blog Ischemia STEMI Cardiac Arrest 78

EMS 12-Lead

AUGUST 14, 2022

[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

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. 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.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

EMS 12-Lead

APRIL 21, 2022

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] STEMI was activated and the patient went to Cath on arrival.

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

MARCH 27, 2023

I knew that, if the patient had presented with chest discomfort, that this ECG is diagnostic of inferior posterior OMI, even though it is not a STEMI. 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 52

Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

AUGUST 1, 2020

The Queen was not able to see this one: Of course we do not know for certain that the inferior findings represent ischemia. The only way to PROVE that ECG findings are due to the alleged OMI/ischemia is to show evolution in that territory. It could have been a false positive ECG, but if it had been, no harm done. It was not.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

Learning Point: Concordant ST segment elevation can arise from profound ischemia triggered by ventricular tachycardia (VT), or it may represent an exaggerated basal ST change accompanying tachycardia. See My Comment at the bottom of the page in the May 19, 2020 post in Dr. Smith's Blog ). A peak troponin level of 70 ng/L was observed.

Tachycardia 97

Tachycardia Blog Ischemia Heart Failure 97

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 a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

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. Am J Emerg Med 2020 3. Shin YS, Ahn S, Kim YJ. Bracey A, Meyers HP, Smith SW.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 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

JANUARY 6, 2023

I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Lupu L, et al. mg/dL, K 3.5 Abstract 556.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Ken Grauer, MD

JULY 22, 2023

KEY Point: In areas of the heart where an acute STEMI produces ST elevation — reperfusion T waves ( that develop after the "culprit" artery reopens ) will appear as T wave inversion. ECG Blog #271 — Reviews determination of the ST segment baseline ( with discussion of the entity of diffuse Subendocardial Ischemia).

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Blog Chest Pain STEMI AFIB 78