2022, Bradycardia and STEMI - Cardiovascular Update

See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

A 50-something with chest pain. Is there OMI? And what is the rhythm?

Dr. Smith's ECG Blog

MARCH 22, 2024

I will leave more detailed rhythm discussion to the illustrious Dr. Ken Grauer below, but this use of calipers shows that the rhythm interpretation is: Sinus bradycardia with a competing (most likely junctional) rhythm. For national registry purposes, this will be incorrectly classified as a STEMI.) Large STEMI are approximately 30-80.

Chest Pain

Chest Pain STEMI Bradycardia Ischemia

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

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”. He wrote most of it and I (Smith) edited.

Chest Pain

Chest Pain STEMI Echocardiogram Stents

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

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There was no evidence bradycardia leading up to the runs of PMVT ( as tends to occur with Torsades ). With longterm use there may be — bradycardia, AV conduction defects and risk of Torsades de Pointes ( especially in patients also on Digoxin ).

Arrhythmia

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity?

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

Why do we NOT name Occlusion MI (OMI) after an EKG finding? (In contrast to STEMI, which is named after ST Elevation)

Dr. Smith's ECG Blog

JUNE 1, 2022

This is guideline approved by both ACC/AHA and by European guidelines. == Comment by K EN G RAUER, MD ( 6/1/2022 ): == I found serial evaluation of sequential tracings in today's case to be subtle — yet highly insightful. A patient with active chest pain and an otherwise unexplained elevated troponin should go to the cath lab.

Chest Pain

Chest Pain STEMI Myocardial Infarction Bradycardia

What would you do with acute chest pain and this ECG? You might see what the Queen thinks.

Dr. Smith's ECG Blog

JUNE 19, 2024

Three months prior to this presentation, he received a pacemaker for severe bradycardia and syncope due to sinus node dysfunction. His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”.

Chest Pain

Chest Pain Pericarditis Pacemaker STEMI

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

Dr. Smith's ECG Blog

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. 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]

STEMI

STEMI Myocardial Infarction Chest Pain Ischemia

A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean. There was no OMI.

Stroke

Stroke Strokes Chest Pain Cardiomyopathy

Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia causes peaked T waves and the "killer B's of hyperkalemia", including bradycardia, broad QRS complexes, blocks of the AV node and bundle branches, Brugada morphology, and otherwise bizarre morphology including sine wave. With a twist.

Chest Pain

Chest Pain Bradycardia Cardiac Arrest STEMI

What are these hyperacute T waves, with STE and T-wave inversion in aVL, and STD in inferior leads?

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life. See these 3 other posts of sinoventricular rhythm The K came back at 6.2 The patient was treated. WHY Isn't the QRS Wide?

Tachycardia

Tachycardia Document Blog Bradycardia

A man in his 40s with epigastric pain and ST Elevation

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

After the heart rate increased slightly, here was the repeat ECG: Sinus bradycardia, only slightly faster rate than prior. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI. Nossen, who practices in Norway — today's ECG uses the Cabrera Format.

Blog

Blog Bradycardia Ischemia Exercise

Chest pain and anterior ST depression. What’s the cause(s)?

Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. What do you think?

Chest Pain

Chest Pain Myocardial Infarction Ischemia STEMI

Chest pain, and Cardiology didn't take the hint from the ICD

Dr. Smith's ECG Blog

JANUARY 23, 2023

Triage physician interpretation: -sinus bradycardia -lateral ST depressions While there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. 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

Chest Pain

Chest Pain Blog Stenosis Myocardial Infarction

75 year old with 24 hours of chest pain, STEMI negative

Dr. Smith's ECG Blog

JUNE 8, 2023

There’s sinus bradycardia, normal conduction, normal axis, delayed R wave progression, and normal voltages. The patient has a history of CABG so some of these changes could be old, but with ongoing chest pain and bradycardia in a high risk patient this is still acute OMI until proven otherwise. Sinus bradycardia.”

Chest Pain

Chest Pain STEMI Bradycardia Myocardial Infarction

Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?

Dr. Smith's ECG Blog

MAY 23, 2022

Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. Theres inferior STE which meets STEMI criteria, but this is in the context of tall R waves (18mm) and relatively small T waves, and the STD/TWI in aVL is concordant to the negative QRS. This was false positive STEMI with an ECG mimicking OMI.

Chest Pain

Chest Pain STEMI Pericarditis Arrhythmia

Unconscious + STEMI criteria: activate the cath lab?

Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. This ECG shows a sinus bradycardia with a normal conduction pattern (normal PR, normal QRS, and normal QTc), normal axis, normal R-wave progression, normal voltages. Hypothermia can also produce bradycardia and J waves, with a pseudo-STEMI pattern.

STEMI

STEMI Bradycardia Arrhythmia Cardiac Arrest

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Dr. Smith's ECG Blog

MARCH 19, 2025

Despite the baseline artifact theres sinus bradycardia, convex ST elevation in III, reciprocal ST depression in aVL and possible anterior ST depression indicating inferoposterior OMI. STEMI criteria are only 43% sensitive for OMI. Beware confusing the diagnosis of posterior STEMI by using posterior leads.

Chest Pain

Chest Pain STEMI Stents Stent

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

Dr. Smith's ECG Blog

MARCH 8, 2025

Within ten minutes, she developed bradycardia, hypotension, and ST changes on monitor. Bradycardia and heart block are very common in RCA OMI. After this ECG was obtained, the ER physician received word that the patient's husband had died in the crash. He told the patient this horrible news. link] Bai, J., Tang, Z., & Verbeek, P.

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

See OMI vs. STEMI philosophy in action

A 50-something with chest pain. Is there OMI? And what is the rhythm?

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Webinars

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

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Why do we NOT name Occlusion MI (OMI) after an EKG finding? (In contrast to STEMI, which is named after ST Elevation)

What would you do with acute chest pain and this ECG? You might see what the Queen thinks.

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

A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?

What are these hyperacute T waves, with STE and T-wave inversion in aVL, and STD in inferior leads?

A man in his 40s with epigastric pain and ST Elevation

Chest pain and anterior ST depression. What’s the cause(s)?

Chest pain, and Cardiology didn't take the hint from the ICD

75 year old with 24 hours of chest pain, STEMI negative

Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?

Unconscious + STEMI criteria: activate the cath lab?

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

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

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