2022, STEMI and Ultrasound - Cardiovascular Update

Acute artery occlusion -- which one?

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. Answer : Bedside ultrasound! Smith : RV infarct may also have this appearance on ultrasound. So hypoxia without B lines on lung ultrasound strongly weights toward PE. So hypoxia without B lines on lung ultrasound strongly weights toward PE.

Cardiogenic Shock

Cardiogenic Shock Ultrasound Tachycardia Pulmonary

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

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]

Chest Pain

Chest Pain STEMI Electrocardiogram Ischemia

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Dr. Smith's ECG Blog

APRIL 22, 2024

Bedside ultrasound with no apparent wall motion abnormalities, no pericardial effusion, no right heart strain. Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). Labs ordered but not yet drawn.

Chest Pain

Chest Pain Myocardial Infarction Anatomy Angina

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Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. Bedside cardiac ultrasound with no obvious wall motion abnormalities. . — He had a previous ECG on file: Proving the findings are new The cath lab was activated. He was given aspirin and sublingual nitro and the pain resolved.

Ischemia

Ischemia Plaque Stenosis Myocardial Infarction

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

The problem is difficult to study because angiographic visualization of arteries is not perfect, and not all angiograms employ intravascular ultrasound (IVUS) to assess for unseen plaque or for plaque whose rupture and ulceration cannot be seen on angiogram. Thus, intracoronary imaging modalities are crucial in this setting. From Gue at al.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

Two patients with chest pain and RBBB: do either have occlusion MI?

Dr. Smith's ECG Blog

OCTOBER 17, 2024

The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Vitals were normal except for oxygen saturation of 94%. Vitals were normal.

Chest Pain

Chest Pain STEMI Pulmonary Embolism

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

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? Is it sinus arrest with junctional escape? How would one tell?

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia

Ischemia STEMI Stenosis Chest Pain

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. Another approach is sympathetic chain (stellate ganglion) blockade if you have the skills to do it: it requires some expertise and ultrasound guidance. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck.

Arrhythmia

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Takotsubo is a sudden event, not one with crescendo angina.

Plaque

Plaque Chest Pain Thrombosis Stenosis

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

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. Regional wall motion abnormality-inferolateral (this is the formal ultrasound location of a posterior wall motion abnormality). After return from CT, the patient's pain was severe again. 2022.08.750 Section 5.2.2,

Chest Pain

Chest Pain STEMI Stenosis Blog

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis Answer: pulmonary embolism. Now another, with ultrasound. NOTE: For more on the ECG diagnosis of acute RV "strain" ( and acute PE ) — Please check out My Comment at the bottom of the page in the March 28, 2022 post in Dr. Smith's ECG Blog.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

A 20-something with intermittent then acute chest pain

Dr. Smith's ECG Blog

APRIL 25, 2023

No pericardial effusion on ultrasound." Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. Healthy male under 25 years old with a pretty good story for acute onset crushing chest pain relieved with nitro. He had another episode the day before after exerting himself. What do you think? It was trained by Drs.

Chest Pain

Chest Pain Pericarditis Blog Cardiomyopathy

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

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Dr. Nossen performed a bedside ultrasound which was interpreted as normal. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI. The patient was worked up for abdominal pain with unclear diagnosis, and he was able to be discharged.

Blog

Blog Bradycardia Ischemia Exercise

A woman in her 50s with acute chest pain

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. 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.

Chest Pain

Chest Pain Ischemia Myocardial Infarction ICU

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

Dr. Smith's ECG Blog

JANUARY 23, 2023

PMID: 34775811; PMCID: PMC9075358 A bedside ultrasound was performed, shown here: Parasternal short axis view demonstrating inferior LV wall motion akinesis Apical 2 chamber view again demonstrating inferior LV wall akinesis The cath lab was not activated based on the ECG and bedside echo. J Am Heart Assoc. 2021 Dec 7;10(23):e022866.

Chest Pain

Chest Pain Blog Stenosis Myocardial Infarction

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Dr. Smith's ECG Blog

MARCH 3, 2025

I suspect pulmonary edema, but we are not given information on presence of B-lines on bedside ultrasound, or CXR findings. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. Truly, the Marquette 12 SL algorithm correctly identifies this STEMI. Management?

Tachycardia

Tachycardia Pulmonary Chest Pain Stenosis

What can you find with continuous ST monitoring in the ED?

Dr. Smith's ECG Blog

DECEMBER 3, 2024

Case continued A bedside cardiac ultrasound revealed grossly preserved left ventricular function, no appreciable wall motion abnormality, pericardial effusion, or obvious valvular abnormality. The terminal part of the T-wave is inverted in lead III, and reciprocally terminally upright in lead aVL.

Catheterization Laboratory

Catheterization Laboratory STEMI Blog Ischemia

Acute artery occlusion -- which one?

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

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Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Two patients with chest pain and RBBB: do either have occlusion MI?

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

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

A 20-something with intermittent then acute chest pain

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

A woman in her 50s with acute chest pain

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

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

What can you find with continuous ST monitoring in the ED?

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