Dr. Smith's ECG Blog

OCTOBER 1, 2023

This is a re-post of an excellent case from 2021. She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. Chest x-ray was normal.

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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]

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Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

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Chest Pain Outcomes STEMI Electrocardiogram 89

Frontiers in Cardiovascular Medicine

MARCH 10, 2024

Background Hyperglycemia, characterized by elevated blood glucose levels, is frequently observed in patients with acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). There are conflicting sources regarding the relationship between hyperglycemia and outcomes in STEMI patients. 3.45) and 4.47 (95% CI: 2.54–7.87),

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Myocardial Infarction Cardiogenic Shock Article STEMI 59

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

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. Circulation. 2017;135(16):1490–3.

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Open Heart

JANUARY 29, 2024

Objectives This study aimed to perform a meta-analysis of the short-term impact of ischaemic postconditioning (IPoC) on myocardial injury in ST elevation myocardial infarction (STEMI) using surrogate cardiac biomarkers. Conclusions IPoC does not seem to protect against myocardial injury in STEMI, except possibly in smokers.

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Myocardial Infarction STEMI Article Biomarkers 52

Frontiers in Cardiovascular Medicine

MARCH 3, 2024

Background Early ventricular tachycardia/fibrillation (VT/VF) in patients with ST-elevation myocardial infarction (STEMI) has higher morbidity and mortality. This study examines gender-differentiated risk factors and underlying mechanisms for early onset VT/VF in STEMI. vs. 61.0 ± 13.0 years old, P  = 0.008) with a male predominance.

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Myocardial Infarction STEMI Defibrillator Diet 59

Open Heart

NOVEMBER 20, 2023

Methods and results Data for all patients admitted to hospital care for acute coronary syndromes in Slovenia (nationwide cohort) between 2014 and 2021 were obtained by merging the national hospital database, national medicines reimbursement database and population mortality registry using unique identifying numbers.

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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.

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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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Coronary Artery Disease Journal

APRIL 24, 2024

Purpose Construction of a prediction model to predict the risk of major adverse cardiovascular events (MACE) in the long term after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI).

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Myocardial Infarction STEMI Diabetes Hypertension 40

Ken Grauer, MD

APRIL 18, 2023

P utting I t A ll T ogether : After correcting for LA-LL lead reversal — ECG # 1a shows sinus rhythm — LVH — and an acute infero-postero STEMI with acute RV involvement. PEARL # 3: In the absence of an anterior STEMI — acute inferior MI is the result of either acute RCA or LCx ( L eft C ircumfle x ) coronary occlusion.

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Blog STEMI Chest Pain Physiology 78

Heart BMJ

JANUARY 29, 2024

Objectives To ascertain whether invasive assessment of coronary physiology soon after recanalisation of the culprit artery by primary percutaneous coronary intervention is associated with the development of microvascular obstruction by cardiac magnetic resonance in patients with ST-segment elevation myocardial infarction (STEMI).

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Myocardial Infarction Physiology STEMI 40

Dr. Smith's ECG Blog

JULY 14, 2023

So we activated the Cath Lab Angiogram: Impression and Recommendations: Culprit for the patient's anterior ST segment myocardial infarction and out of hospital V-fib cardiac arrest is a thrombotic occlusion of the mid LAD The first troponin returned barely elevated at 36 ng/L (URL = 35) In our study of initial troponin in STEMI, 26.8%

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

Ken Grauer, MD

JANUARY 20, 2024

Another overlooked OMI ( Cardiologist limited by STEMI Definition — OMI evident by Mirror Test ) — See My Comment at the bottom of the page in the September 21, 2020 post on Dr. Smith’s ECG Blog. ECG Media Pearl # 8 ( 8:20 minutes Video ) — ECG Blog #191 — Distinguishing between A V D issociation vs Complete AV Block ( 2/6/2021 ).

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Blog Bradycardia STEMI Download 94

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. The November 27, 2021 post ( LA-RA reversal ). What is the atrial activity?

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

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). Annals of Emergency Medicine 2021. Triage ECG: What do you think?

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Chest Pain Myocardial Infarction STEMI Pacemaker 52

Circulation

NOVEMBER 11, 2024

Patients were selected from the HCA database (Jan 2021-Jul 2023). Patients with documented STEMI, left ventricular thrombus, mechanical mitral or aortic valve replacement were excluded. ICD 10 codes were used to identify patients with documented a fib. Procedure ICD codes were used to identify patients that underwent percutaneous LAAO.

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Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The below ECG was recorded.

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Circulation

FEBRUARY 26, 2024

The primary safety end point was Bleeding Academic Research Consortium 3 to 5 bleeding at 30 days.RESULTS:Between January 10, 2019, and September 18, 2021, a total of 2989 patients were randomized. The primary efficacy end point occurred in 37 patients (2.5%) in both the PPA and placebo groups (hazard ratio, 1.00 [95% CI, 0.63 to 1.57]).

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Myocardial Infarction Academic Thrombosis STEMI 40

Ken Grauer, MD

OCTOBER 21, 2023

That said, when you do see inverted U waves ( as we do in ECG #1 ) — this is a significant marker of severe ischemia ( Duque-Gonzálex et al — Cardiovascular Metal Sci 32(4), 2021 ). T oday's C ASE C ontinues: The worrisome findings in ECG #1 were recognized. The initial Troponin came back significantly elevated.

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Blog Chest Pain Ischemia STEMI 98

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

20% of cases that everyone would call a STEMI have a competely open artery by the time of angiogram 60-90 minutes later. PEARL #2: = Aslanger's Pattern: Examples of Aslanger's Pattern appear in a number of cases in Dr. Smith's ECG Blog ( This pattern is very nicely described by Dr. Smith in the January 4, 2021 post).

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Chest Pain Ischemia Echocardiogram Myocardial Infarction 118

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 Med 2021 5. Moumneh T, Sun BC, Baecker A, et al. Lancet 2015 6.

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

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. Circulation. 2017;135(16):1490–3.

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Plaque Chest Pain Thrombosis Stenosis 52

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.

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Myocardial Infarction Coronary Angiogram STEMI Ischemia 52

EMS 12-Lead

MAY 8, 2022

The attending crews were concerned for SVT with corresponding ischemic hyperacute T waves (HATW) and subsequently activated STEMI pre-hospital. Then, three minutes later… Crews activated STEMI as she deteriorated into PEA arrest. A finger-stick glucose resulted 551 mg/dL, and the following ECG was recorded. & Schocken, D.

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ACE Inhibitor Ischemia STEMI Physiology 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

From My Comment in the November 15, 2023 post in Dr. Smith's ECG Blog: Clinical Points about MINOCA: Given the literature citing a 5-15% estimated incidence of MINOCA in patients initially diagosed as having a STEMI or "NSTEMI" — it is important to be aware of the more common entities associated with this entity ( See Figure-2 ).

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Dr. Smith's ECG Blog

FEBRUARY 4, 2022

Epub 2021 Nov 17. 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. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. Am J Emerg Med. 2022 Jan;51:384-387. doi: 10.1016/j.ajem.2021.11.023.

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Chest Pain STEMI Article Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Here is the repeat ECG at 52 minutes after arrival to triage: Obvious posterolateral STEMI Angiographic findings: 1. page 1932 • “The application of STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. (21) Left main: no significant stenosis.

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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 The November 27, 2021 post ( LA-RA reversal ). What do you think? Although not necessarily intentional, the first processing that I do when I see an ECG is to categorize as OMI or not. mm STE in V2).

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Blog Ischemia Tachycardia STEMI 111

Dr. Smith's ECG Blog

APRIL 25, 2023

Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. NOTE: For detailed review regarding use of Cardiac MRI in acute chest pain evaluation — See the extensive article by Broncano et al ( RadioGraphics 41:8-31, 2021 ). It was trained by Drs. The young age always makes one suspicious of myocarditis.

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Chest Pain Pericarditis Blog Cardiomyopathy 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

2021 Dec 7;10(23):e022866. Epub 2021 Nov 15. Recall that air is a poor conductor of electricity and will, therefore, generate smaller amplitudes on posterior leads (hence why STEMI criteria requires only >0.5 J Am Heart Assoc. doi: 10.1161/JAHA.121.022866. 121.022866. mm in any posterior lead to be considered positive).

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Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia mimics STEMI and OMI in many distributions, but probably the most common is the Brugada morphology in V1-V2 which mimics anterior OMI for those who cannot recognize the Brugada pattern. The November 27, 2021 post ( LA-RA reversal ).

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EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. The distribution of findings is consistent with the LAD, of which is now open with improved TIMI flow. The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. Journal of Electrocardiology, 61 ; 41-46. [3]

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Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

2021 Sep;49(6):488-500. Aslanger EK, Meyers HP, Smith SW. Recognizing electrocardiographically subtle occlusion myocardial infarction and differentiating it from mimics: Ten steps to or away from cath lab. Turk Kardiyol Dern Ars. doi: 10.5543/tkda.2021.21026. 2021.21026. Among the important points brought out by Dr.

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Chest Pain Myocardial Infarction Blog Pericarditis 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

2021 Dec 7;10(23):e022866. Epub 2021 Nov 15. Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). J Am Heart Assoc. doi: 10.1161/JAHA.121.022866. 121.022866. PMID: 34775811; PMCID: PMC9075358. Aslanger EK. J Electrocardiol.

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Myocardial Infarction Chest Pain Blog Echocardiogram 40

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.

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Chest Pain STEMI Myocardial Infarction Blog 118