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

NOVEMBER 29, 2023

Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

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STEMI Chest Pain Blog Pericarditis 125

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

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.,

Myocardial Infarction 123

Myocardial Infarction Chest Pain STEMI Blood Pressure 123

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

JULY 14, 2024

The cath lab was activated, and then not cancelled, and the angiogram showed 99% TIMI 2 flow proximal LAD culprit lesion, stented in less than 90 minutes of arrival. Cath days later showed complete occlusion of the LAD, stented. Another missed OMI by the False STEMI-NonSTEMI Dichotomy Don't miss them!!! Normal vitals.

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AFIB Stent Stents Chest Pain 105

Ken Grauer, MD

OCTOBER 25, 2024

P.S.: Cardiac cath was performed — and showed a distal LA D "culprit" lesion that was successfully stented. It may look identical t o the ST-T wave appearance seen after a STEMI with marked troponin elevation, that has now reperfused ( be this reperfusion spontaneous — or by treatment with PCI or thrombolytics ).

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Blog Chest Pain STEMI Cardiogenic Shock 94

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

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 70

Dr. Smith's ECG Blog

OCTOBER 22, 2024

Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." Successful primary angioplasty of the mid-circumflex artery towards the main marginal branch with the implantation of a drug-eluting stent. Good angiographic result.

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Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

MARCH 20, 2023

Since then, I started looking for OMI EKG findings and not just STEMI. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. mm in lead I, thus not STEMI criteria) and was finally understood by the cardiologist.

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Chest Pain STEMI Blog Cholesterol 52

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. Published 2022 Feb 20. As per Drs.

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Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

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

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

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

FEBRUARY 4, 2022

They were stented. 2022 Jan;51:384-387. 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. The peak troponin was 1863 ng/L.

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Chest Pain STEMI Article Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

Opened and stented. This is why it is essential that the OMI/NOMI paradigm replace the STEMI/NonSTEMI paradigm. Under Non-STEMI, this patient would not have intervention until at least 20 hours (next day), after the infarct is completed. Angiogram: Occlusion of branch of First Obtuse Marginal. Learning Points: 1.

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Chest Pain Critical Care STEMI Plaque 52

Dr. Smith's ECG Blog

MAY 10, 2023

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 Thus, Wellens' syndrome should be thought of as a transient OMI or transient STEMI.

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Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

The lesion was successfully stented, but it was unfortunately done after a significant myocardial loss. 2022 Mar-Apr;71:44-46. Epub 2022 Jan 31. PMID: 34523597. == MY Comment by K EN G RAUER, MD ( 11/13/2022 ): == Highly interesting case by Emre Aslanger. References Aslanger EK. J Electrocardiol. 2022.01.006. 2021.21026.

Chest Pain 52

Chest Pain Myocardial Infarction Blog Pericarditis 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Diagnosis: Acute non-ST segment elevation MI (Non-STEMI, or NSTEMI) Second troponin returned at around 0200: 15,894 ng/L 0245 (unclear if ongoing pain or not) Inferoposterior (and lateral V5-6) reperfusion findings. Admitted to the hospital service for further evaluation and management." No further ECG were ever recorded.

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Chest Pain Physiology Blog Stent 52

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.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

He was taken to the cath lab where he was found to have acute total occlusion of his saphenous vein graft to his RCA, which was stented. His second troponin was 46 ng/L. No further troponins were measured. He was in cardiogenic shock requiring an impella for several days after cath. Such is the situation in today's post by Drs.

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Chest Pain Cardiac Arrest Cardiogenic Shock Heart attacks 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Compare to the anatomy after stenting: The lower of the 2 now easily seen branches is the circumflex, now with excellent flow. 2022 Mar-Apr;71:44-46. Epub 2022 Jan 31. Comment by K EN G RAUER, MD ( 12/18 /2022 ): = Important case with numerous diagnostic Pearls presented by Dr. Aslanger. The patient recovered well.

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Clin Cardiol 2022; [link] Labs included: hsTnI 156 ng/L, Hb 12 g/dL, WBC 12x10^9/L, Cr. A single DES stent was placed, and the patient did well post-procedure. Lupu L, et al. mg/dL, K 3.5

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

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.

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Chest Pain Pericarditis STEMI Arrhythmia 52

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

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Chest Pain STEMI Stent Stents 121

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

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.

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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

APRIL 2, 2025

Here is the prehospital ECG, recorded in the presence of pain: Hyperacute anterolateral STEMI The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. A stent was placed. Serial ECGs demonstrated dynamic changes diagnostic of ACS (transient STEMI) 4.

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Chest Pain STEMI Myocardial Infarction Stent 76

Dr. Smith's ECG Blog

MARCH 8, 2025

After stent deployment, we often see improvement in the ST-T within seconds or minutes. Here is the final angiogram following placement of a stent in the ostial RCA. 2:04 PM, post stent deployment You can see that even after complete restoration of flow, the ECG still looks terrible, V most of all. link] Bai, J., Tang, Z., &

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Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75

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

DECEMBER 3, 2024

The first EKG was concerning for a Wellen’s-like pattern of subtle reperfusion changes in the setting of stuttering anginal-equivalent symptoms, but none were diagnostic of STEMI or OMI. Later in the night, the patient became bradycardic and developed a Mobitz II pattern , but he remained asymptomatic and hemodynamically stable.

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Catheterization Laboratory STEMI Blog Ischemia 111

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. There are new Q-waves in aVL, V5-6.

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Blog Chest Pain Myocardial Infarction Critical Care 63

Dr. Smith's ECG Blog

OCTOBER 30, 2024

At cath later the same day, a proximal 99% RCA culprit lesion was stented. Following the improvement in the ECG the patient's pain too improved drastically. This of course proves that the initial ECG was OMI and that the artery has reperfused. Troponin T peaked at 4051 ng/L. The difference is only 30 degrees and up to 45 degrees is normal.

Chest Pain 111

Chest Pain Aortic Myocardial Infarction STEMI 111

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.

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STEMI Chest Pain Myocardial Infarction Aneurysm 121