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. It was stented.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. Angiography : LMCA — 90-99% osteal stenosis. LCx — 50-69% stenosis of the 1st marginal branch; with 100% distal LCx occlusion. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? His response: “subendocardial ischemia.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

OCTOBER 10, 2024

Unfortunately you can see that the conventional Zoll algorithm sees nothing even to suggest AMI, let alone STEMI. Angiogram showed no significant disease of the left main, LAD, or LCX, but acute culprit lesion of the proximal RCA with "99% stenosis" and TIMI 2 flow. During EMS transport, the pain suddenly resolved.

Chest Pain 108

Chest Pain STEMI Blog Stenosis 108

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

J Electrocardiol [Internet] 2022;Available from: [link] Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%) V Fib Cardiac arrest Prolonged QTC NSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different) Moderate single-vessel CAD. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Cath at approximately 0945: "The LAD had a 90% proximal stenosis with TIMI 3 flow which corresponds to his ECG although LV function remains preserved. With nitroglycerin there is improvement in the 90% stenosis but still persistent stenosis consistent with the dynamic nature of his presentation. When is it anterior STEMI?

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

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). LAFB, atrial flutter, anterolateral STEMI(+) OMI. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 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. Left main: no significant stenosis. LAD: proximal 60% eccentric stenosis the hemodynamic significance of which is indeterminate. RCA: Dominant: Mid 50-60% stenosis. It supplies a small diagonal branch.

Chest Pain 52

Chest Pain STEMI Stenosis Blog 52

Dr. Smith's ECG Blog

MAY 10, 2023

LAD plaque with 0-25 percent stenosis. Later, she developed chest pain again, and had this ECG recorded: Obvious Anterior OMI that is also a STEMI Coronary angiogram- --Right dominant coronary artery system --The left main artery was normal in appearance and free of obstructive disease. --The A CT Coronary angiogram was ordered.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

Chest Pain 52

Chest Pain SCAD STEMI Blog 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Physician interpretation: "No STEMI." Physician: "No STEMI." Cardiologist interpretation: "Technically does not meet STEMI criteria but concerning for ischemia."

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

Dr. Smith's ECG Blog

JANUARY 12, 2023

Here is the South African Flag sign ( Figure by Ken Grauer — with the original 12-lead from Patient 1 attached below — See his Comment from the April 8, 2022 post in Dr. Smith's ECG Blog for more on this sign ). ECG read as: "Shows T wave inversions in the inferior leads and less than 1mm STE in V2, without STEMI criteria."

Chest Pain 52

Chest Pain STEMI Blog Stenosis 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. Angiogram at 4 hours after ECG 1 (and approximately 6 hours after pain onset): Culprit is 100% stenosis in the mid RCA. No wall motion abnormality.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. Chest pain is squeezing or tight in nature.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

90% stenosis of the proximal ramus intermedius, pre procedure TIMI II flow The ramus intermedius is a normal variant on coronary anatomy that arises between the LAD and LCX. 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 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 3, 2025

Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. An EKG from a year prior was available for comparison: The ED physician noted Initial EKG here read by the computer as a STEMI, however, there is a very poor baseline and a lot of artifact. See reference and discussion below.

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73

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. As a result, the diagnostic utility of posterior leads is limited ( See My Comment in the September 21, 2022 post).

Ischemia 88

Ischemia Blog STEMI Coronary Angiogram 88

Dr. Smith's ECG Blog

OCTOBER 27, 2024

The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI". First obtuse marginal also had an 80% stenosis and was stented. 2022;Available from: [link] Click here to sign up for Queen of Hearts Access. == MY Comment, by K EN G RAUER, MD ( 10/27/2024 ): == I view today's case as unfortunate.

STEMI 121

STEMI Chest Pain Myocardial Infarction Aneurysm 121