Dr. Smith's ECG Blog

FEBRUARY 12, 2025

Even before we have clinical context, this ECG simply does not appear concerning for OMI, notwithstanding the machine's interpretation ** ** ACUTE MI / STEMI ** **. But in the world of STEMI, this is a challenging ECG to most. There were 80 positives by STEMI criteria, 88 by device algorithm, and 77 by AI software.

Chest Pain 82

Chest Pain STEMI Electrocardiogram Blog 82

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

A 12-lead was recorded, showing "STEMI," but is unavailable. Moreover, if you know that catastrophic intracranial hemorrhage can result in an ECG that mimics STEMI, then you know that this patient probably has a severe intracranial hemorrhage. She was BVM ventilated and suctioned. Shortly thereafter, pulses were lost.

STEMI 89

STEMI Hemorrhage Cardiac Arrest Tachycardia 89

Ken Grauer, MD

MARCH 22, 2025

The lack of sufficient ST elevation to fulfill STEMI criteria may be the result of some pseudo-normalization following some spontaneous reperfusion of the "culprit" artery. F or M ore M aterial regarding ECG interpretation of OMIs ( that do not satisfy millimeter-based STEMI criteria ).

Blog 156

Blog STEMI Ischemia Hospital 156

Dr. Smith's ECG Blog

FEBRUARY 16, 2025

The emergency medicine physician documented, "His initial EKG is riddled with artifact and difficult to interpret but does not look like a STEMI." The ECG remains positive for STEMI by GE. The absolute degree of ST elevation (although enough to meet STEMI criteria), was still relatively small.

STEMI 72

STEMI Pericarditis Chest Pain Echocardiogram 72

Dr. Smith's ECG Blog

MARCH 17, 2025

Limitations of registry data: This patient presented with STEMI (-) OMI and developed STEMI the following day. But the time that elapsed from first STEMI (+) ECG to balloon was 57 minutes, and THIS is what will be recorded for reporting to the National Cardiovascular Data Registry for purposes of quality improvement.

STEMI 81

STEMI Chest Pain Document Myocardial Infarction 81

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.

Chest Pain 106

Chest Pain STEMI Myocardial Infarction Ischemia 106

Dr. Smith's ECG Blog

JANUARY 18, 2025

Im changed. == MY Comment , by K EN G RAUER, MD ( 1/16 /2025 ): == It's not often that we see a clinical entity for which it seems that the patient "read the textbook" before the ECG was recorded. He wrote: OMI it was. Large diagonal. Now opened. Dr. Smithyoull change MI care, if you havent already.

Myocardial Infarction 117

Myocardial Infarction STEMI Chest Pain Download 117

Dr. Smith's ECG Blog

JANUARY 31, 2025

This ECG pattern is my favorite example of how the STEMI criteria are fundamentally flawed. We have a series of 20 TIMI-0 LAD Occlusions that do meet STEMI criteria. However, many patients with de Winter ECG pattern have TIMI 0 at angiography and the ECG pattern does not necessarily progress to STEMI. 17 have HATW. Under Review.

STEMI 114

STEMI Chest Pain Myocardial Infarction Ischemia 114

Dr. Smith's ECG Blog

JANUARY 28, 2025

His first EKG is shown below, with a lead II rhythm strip: EKG 1, 1645 A provisder who is looking for STEMI would not see much in this EKG. It is possible that the T waves in this EKG are of an intermediate morphology between full-blown STEMI and inferior reperfusion. This is the classic morphology of hyperacute T waves.

Chest Pain 105

Chest Pain STEMI Hospital Blood Pressure 105

Ken Grauer, MD

MARCH 8, 2025

PEARL # 3: Knowing there is an acute inferior STEMI I looked next to see if there is also acute posterior involvement ( which so often accompanies inferior MI ). But larger-than-expected Q waves in each of the inferior leads ( especially in lead III ) are probably the result of this patients ongoing acute inferior STEMI.

Blog 106

Blog STEMI Download Chest Pain 106

Ken Grauer, MD

FEBRUARY 1, 2025

When interpreting ECGs such as the initial tracing in today's case We need to remember that we are not trying to "rule in" an acute STEMI. It is also the best way to miss a lot of acute OMIs in need of prompt cath with PCI ( ie, See recent publications by Ricci, Smith et al Ann Emerg Med, 2025 and McClaren, Smith et al JACC Adv.

Blog 165

Blog STEMI Physiology Ischemia 165

Dr. Smith's ECG Blog

MARCH 19, 2025

STEMI criteria are only 43% sensitive for OMI. Regarding the ECG, this case shows inferior ST elevation with reciprocal depression in aVL that does not quite meet STEMI criteria, ST depression maximal in V2-V3 (>97% specific for posterior MI), and an increasingly anterior R wave progression indicating posterior wall infarction.

Chest Pain 116

Chest Pain STEMI Stents Stent 116

Dr. Smith's ECG Blog

JANUARY 11, 2025

Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin. check out the downsloping STE in this one A man in his 80s with chest pain What, besides large anterior STEMI, is so ominous about this ECG? These are often VERY difficult to recognized.

Cardiogenic Shock 137

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137

Dr. Smith's ECG Blog

JANUARY 23, 2025

He has never been poisoned by the STEMI/NSTEMI paradigm because he has never been to medical school. The Queen of Hearts recognizes this as OMI ("STEMI/STEMI Equivalent"). He just graduated from college. He has no medical training, but he has read this blog for years. He is an ECG tech who hopes to go to medical school.

Chest Pain 116

Chest Pain Ischemia STEMI Blog 116

Dr. Smith's ECG Blog

MARCH 1, 2025

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 Comment: The first ECG is diagnostic of OMI that does not meet STEMI criteria. NSTEMI-OMI").

Chest Pain 121

Chest Pain STEMI Stents Stent 121

Dr. Smith's ECG Blog

JANUARY 24, 2025

Learning points: 40% of LAD OMI with TIMI-0 flow do NOT meet STEMI criteria (manuscript under consideration at Eur Ht. 20/53 did not meet STEMI criteria, but all showed OMI diagnosed by both Smith and the Queen of Hearts. Another left ventricle sacrificed at the alter of ST elevation. J Cardiovascular Interventions.--20/53

Chest Pain 125

Chest Pain STEMI Risk Factors Coronary Artery Disease 125

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Unfortunately, the ECG was interpreted as no significant change from prior , "no STEMI"!! Approximately 5 minutes after ROSC, this ECG was obtained (about 45 minutes after arrival): Obvious anterolateral OMI, and STEMI criteria positive for those who care or need it. He was sent back to the waiting room, where he suffered a VF arrest.

Cardiac Arrest 86

Cardiac Arrest STEMI Blog Ischemia 86

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. 5 years later ( now in 2025 ) the problem remains. 5 years later ( now in 2025 ) the problem remains.

Ischemia 88

Ischemia Blog STEMI Coronary Angiogram 88

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. So even a massive STEMI, if it reperfused quickly, can result in a relatvely low troponin (in contrast to the next case!)

Chest Pain 68

Chest Pain STEMI Myocardial Infarction Stents 68

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 74

Tachycardia Pulmonary Chest Pain Stenosis 74

Dr. Smith's ECG Blog

FEBRUARY 8, 2025

This was interpreted as "inferior STEMI" and the cath lab was activated. Discharge diagnosis was Non-STEMI. The STEMI/NSTEMI dichotomy can make it difficult to identify the culprit lesion, which can be spontaneously reperfused at the time of the angiogram 3. The patient had no further episodes of chest pain.

Chest Pain 64

Chest Pain Stents Stent STEMI 64

Dr. Smith's ECG Blog

JANUARY 21, 2025

It is correct that he did not have chest pain, but we must remember that fully 1/3 of full blown STEMI do not present with chest pain. This is extremely elevated for a type 2 MI and totally consistent with STEMI. As per Dr. Smith the Troponin peak of 16,000 is much more suggestive of a STEMI than of a Type II MI.

Chest Pain 62

Chest Pain STEMI Tachycardia Myocardial Infarction 62

Dr. Smith's ECG Blog

FEBRUARY 14, 2025

The ECG meets STEMI criteria objectively. Abdominal Pain in a middle-aged patient True Positive ST elevation in aVL vs. False Positive ST elevation in aVL == MY Comment, by K EN G RAUER, MD ( 2/10/2025 ): == I find cases like today's challenging. PM Cardio QOH says No signs of OMI. AMI was ruled out.

Bradycardia 62

Bradycardia STEMI Arrhythmia 62

Dr. Smith's ECG Blog

FEBRUARY 10, 2025

Peaked T waves: Hyperacute (STEMI) vs. Early Repolarizaton vs. Hyperkalemia Recognize subtle findings of hyperK and, if present, treat with Calcium immediately! HyperKalemia with Cardiac Arrest. References 1. Lindner et al. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference.

Bradycardia 118

Bradycardia Cardiac Arrest Hypertension ICU 118

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

50% of LAD STEMI have Q-waves by one hour. Smith : In limb leads, the ST vector is towards lead II (STE lead II STE lead III, which is more likely with pericarditis than with STEMI). link] == MY Comment , by K EN G RAUER, MD ( 1/14 /2025 ): == I found today's case highly insightful with regard to many aspects. See Raitt et al.:

Chest Pain 89

Chest Pain Pericarditis Myocardial Infarction Dementia 89

Dr. Smith's ECG Blog

MARCH 8, 2025

link] == MY Comment , by K EN G RAUER, MD ( 1/20 /2025 ): == If you Google, Broken Heart Syndrome you will immediately see reference to many pages of Patient Education news briefs and informationals, in which the questions addressed are, Can You Really Die of a Broken Heart? & Dawson, D. Circulation , 145 (13), 10021019.

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75

Dr. Smith's ECG Blog

JANUARY 13, 2025

How well does the computer interpretation perform? -- in this case, the computer diagnosed STEMI but the patient had Fever with Brugada -- A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? Diphenhydramine toxicity?

Chest Pain 71

Chest Pain Cardiac Arrest Ischemia Sudden Cardiac Death 71