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. The two cases were considered: Patient 1 was recognized by the ED provider and the cardiologist as having resolved “STEMI”. It was stented. This was a large OMI.

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Chest Pain STEMI Echocardiogram Stent 116

Dr. Smith's ECG Blog

APRIL 22, 2024

EKG from triage: Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in comparison to an EKG in 2020 this is new. Patient still not having chest pain however this is more concerning for OMI/STEMI. Labs ordered but not yet drawn. Aspirin given.

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Chest Pain Myocardial Infarction Anatomy Angina 118

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." Here is the angiogram after stent placement. Immediate versus delayed invasive intervention for non-stemi patients. Marinkovic, J.,

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Myocardial Infarction Chest Pain STEMI Blood Pressure 123

The British Journal of Cardiology

APRIL 16, 2024

We present the cumulative percutaneous coronary intervention (PCI) data of all comers (stable angina and acute coronary syndromes [ACS]) who presented to Hadi Clinic between January 2018 and December 2020. A total of 567 patients underwent coronary catheterisation for the three-year period between January 2018 and December 2020.

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Outcomes Cardiogenic Shock Angina STEMI 40

Dr. Smith's ECG Blog

MARCH 22, 2024

This is documented as a STEMI in the clinical notes and in the cath report, but certainly does not meet STEMI criteria and is therefore an NSTEMI by definition. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0. Large STEMI are approximately 30-80.

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Chest Pain STEMI Bradycardia Ischemia 114

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Angiogram: Culprit Lesion (s): Thrombotic occlusion of the proximal RCA -- stented. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity? Is it sinus arrest with junctional escape? How would one tell?

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

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%

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STEMI Myocardial Infarction Chest Pain Ischemia 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.

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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. The case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease. Is this OMI?

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Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. As a result, this 45-year old man did not experince any delay in treatment — and a large diagonal branch of the LAD was stented with good outcome. To the uninitiated — this ECG may appear normal.

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Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Unfortunately, we do not have those images for review, but the operators described a ruptured LAD plaque and they stented this area, which ensures the stability of the plaque. The image on the left shows the LAD before intervention, and the red circled portion on the right indicates the stented region. This is not the case.

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Plaque Angina Blog Stent 127

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The reappearance of de Winter's pattern caused by acute stent thrombosis: A case report. Am J Emerg Med. 2014;32:e5–e8. As per Drs.

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Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

While this ECG is negative for “posterior STEMI”, the resolution of anterior ST depression (accompanied by the troponin elevation) confirms posterior OMI with spontaneous reperfusion. The second opportunity to make the diagnosis and expedite angiography was missed because the ECG never met STEMI criteria and continued to be labeled ‘normal.’

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STEMI Myocardial Infarction Chest Pain Angina 40

Dr. Smith's ECG Blog

MARCH 19, 2023

It was opened and stented. The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. Angiogram: Culprit for the patient's inferior ECG changes and non-ST elevation myocardial infarction is a 100% acute thrombotic occlusion of the proximal RCA.

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Chest Pain STEMI Myocardial Infarction Document 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

He was successfully treated with one drug eluting stent. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities. In equivocal cases, point-of-care ultrasound may be the difference between taking the patient to the lab or not. 1] Wereski, R., Chapman, A.

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Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2020

== MY Comment by K EN G RAUER, MD ( 9/17/2020 ): == Todays patient is a previously healthy, 60-something year-old woman who presented with chest pain that began at a reception. However, the cath lab activation was cancelled by the on-call interventionalist who felt the diagnosis of acute STEMI could not be made because of the LBBB.

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Chest Pain STEMI Blog Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The culprit lesion was opened and stented. For those in search of brief review of the Cabrera Format for ECG recording — Please check out My Comment at the bottom of the page in the October 26, 2020 post in Dr. Smith's ECG Blog. The QoH now recognizes the OMI with mid confidence. Below is the post -PCI electrocardiogram.

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Chest Pain Blog Ischemia Risk Factors 60

Dr. Smith's ECG Blog

JANUARY 16, 2020

It was opened and stented with resulting TIMI-3 (normal) flow. The stent to LCX is patent. not left main occlusion == MY Comment by K EN G RAUER, MD ( 1/16/2020 ): == I did not correctly identify the “culprit artery” in this case. Marked acute STEMI changes in no less than 4 lateral leads.

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Aneurysm Heart Disease Stent Stents 40

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 She was having a transient STEMI, briefly. It did not progress to full STEMI with loss of the anterior wall, as in this case. It was stented. She called 911. Learning Points : 1. See this case.

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STEMI Chest Pain Hospital Risk Factors 40

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, This alone could be due to LVH, but V4 could NOT be due to LVH.

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Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 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

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. A single DES stent was placed, and the patient did well post-procedure. Unfortunately, they follow their own guidelines only 6% of the time!! Lupu L, et al. mg/dL, K 3.5 Academic Emergency Medicine 27(S1): S220. Abstract 556.

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Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

AUGUST 28, 2020

This can only be due to STEMI. There is new data showing better outcomes when bystander lesions (non-culprit) are stented. == MY Comment by K EN G RAUER, MD ( 8/28/2020 ): == Dr. Smith highlights a number of important lessons to be learned from today’s case. I said "activate the cath lab." Sotalol prolongs the QT 7.

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Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

This is a case written by Dan Lee (One of our fantastic Hennepin Residents, class of 2020 ) edits by Smith A 60 something-year-old man with a history of ESRD, LVH and prior CABG presented after an episode of hypotension during his hemodialysis, run followed by a syncopal episode which caused his run to be terminated early.

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Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2025

The emergency medicine physician documented, "His initial EKG is riddled with artifact and difficult to interpret but does not look like a STEMI." The ECG remains positive for STEMI by GE. The true AV groove LCx was "jailed" by the stent and appears occluded in the post PCI image. The emergency physician consulted cardiology.

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STEMI Pericarditis Chest Pain Echocardiogram 72

Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. STEMI criteria are only 43% sensitive for OMI.

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Chest Pain STEMI Stent Stents 116

Dr. Smith's ECG Blog

MARCH 1, 2025

He reports this was similar to how he felt when he had his heart attack 4 years prior, now s/p 4 stents. Note: the 2022 ACC Expert consensus Chest pain guidelines state that "posterior STEMI-Equivalent" is a sign of acute coronary occlusion. 2/3 of STEMI have a peak 4th generation troponin I greater than 10.0 NSTEMI-OMI").

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Chest Pain STEMI Stent Stents 121

Dr. Smith's ECG Blog

JANUARY 11, 2025

He had undergone stenting of the LAD several weeks ago (unclear whether elective for stable symptoms, or in response to acute coronary syndrome). Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin. Written by Pendell Meyers An adult man presented with acute chest pain. To quote Drs.

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Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137

Dr. Smith's ECG Blog

MARCH 14, 2025

He has a history of coronary artery disease and a STEMI two years prior that was treated with primary PCI. At the time of this initial ED ECG, his symptoms were improving ECG #1 on admission to the ED The patient was not seen quickly in the ED as it was a busy shift and the ECG did not meet STEMI criteria. The below ECG was recorded.

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Chest Pain STEMI Myocardial Infarction Ischemia 106

Dr. Smith's ECG Blog

JANUARY 31, 2025

This ECG pattern is my favorite example of how the STEMI criteria are fundamentally flawed. At cath there was a 100% proximal LAD occlusion, which was opened and stented. We have a series of 20 TIMI-0 LAD Occlusions that do meet STEMI criteria. There is a de Winter T- wave pattern also in lead I. Troponin T peaked at 9378 ng/L.

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STEMI Chest Pain Myocardial Infarction Ischemia 114

Dr. Smith's ECG Blog

JANUARY 23, 2025

He has never been poisoned by the STEMI/NSTEMI paradigm because he has never been to medical school. The Queen of Hearts recognizes this as OMI ("STEMI/STEMI Equivalent"). It was treated with a drug eluting stent. He just graduated from college. He has no medical training, but he has read this blog for years. Lucky Hans.

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Chest Pain Ischemia STEMI Blog 116

Dr. Smith's ECG Blog

MARCH 9, 2025

At 1210, the case was discussed with a cardiologist at a PCI capable facility, who accepted the patient for transfer, noting the ST depression in anterior leads as consistent with ischemia but not a STEMI. The proximal and mid LAD stenoses were stented and the OM 2 was left alone. 5 years later ( now in 2025 ) the problem remains.

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Ischemia Blog STEMI Coronary Angiogram 88

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Unfortunately, the ECG was interpreted as no significant change from prior , "no STEMI"!! Approximately 5 minutes after ROSC, this ECG was obtained (about 45 minutes after arrival): Obvious anterolateral OMI, and STEMI criteria positive for those who care or need it. He was sent back to the waiting room, where he suffered a VF arrest.

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Cardiac Arrest STEMI Blog Ischemia 86

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 November 10, 2020 post — for PTA.

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Blog Chest Pain Myocardial Infarction Critical Care 63