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%

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Two weeks ago he had a significant MVC with many severe injuries, including aortic injury s/p endovascular repair. I sent this to our group without information and Dr. Smith responded: "Not OMI.

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Pericarditis Chest Pain Blog Aortic 117

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Ken Grauer, MD

JUNE 6, 2023

Part of the ST depression with deep T wave inversion in the lateral chest leads clearly reflects LV "strain" from the marked LVH — but despite the very large QRS amplitudes, this ST-T wave appearance looks disproportionate, suggesting at least a component of ischemia. The plan was to proceed as soon as possible with aortic valve replacement.

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Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. An elderly patient with a ruptured abdominal aortic aneurysm: Formal ECG Interpretation (final read in the chart!) : "Inferior ST elevation, lead III, with reciprocal ST depression in aVL."

STEMI 40

STEMI Chest Pain Cardiac Arrest Stent 40

EMS 12-Lead

MAY 20, 2022

There is ventricular hypertrophy in the absence of abnormal loading conditions, such as aortic stenosis, or hypertension, for example – of which the most common variant is Asymmetric Septal Hypertrophy. There is LBBB-like morphology with persistent patterns of subendocardial ischemia.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

JUNE 4, 2019

The patient arrived looking like an aortic dissection patient, so CTA was done and negative." Resolution of pain, by itself, is not reliable enough to be certain of resolution of ischemia. the ischemia has truly resolved. OMI often does not meet STEMI criteria. ST elevation at 60 ms after the J-point in lead V3 = 1.5

Chest Pain 52

Chest Pain STEMI Ischemia Aortic 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

A repeat ECG was done: Obvious anterolateral wall STEMI. On arrival his BP was 70s/40s, so an intra-aortic ballon pump was placed. This means that they occur shortly after onset of occlusion, but also may be the last remaining sign of ischemia after ST elevation resolves (after reperfusion).

Chest Pain 52

Chest Pain STEMI Defibrillator Blog 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. CT angiogram chest: no aortic dissection or pulmonary embolism. 24 yo woman with chest pain: Is this STEMI?

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

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Chest Pain STEMI Aortic Ultrasound 105

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

OCTOBER 30, 2024

Ischemia often produces a straightening of the ST segment and sometimes upward convexity. That said — the overall picture to me did not "look" acute — and the history of "chest pain radiating to the back " in this 80-something man with marked LVH — made me strongly consider an aortic dissection as a more likely cause.

Chest Pain 111

Chest Pain Aortic Myocardial Infarction STEMI 111

Dr. Smith's ECG Blog

DECEMBER 3, 2024

His initial high sensitivity troponin I returned at 1300 ng/L and given that his cardiac workup was otherwise unremarkable, a CT was obtained to evaluate for pulmonary embolism and aortic aneurysm or dissection but this too was unrevealing. Another EKG was also obtained. ECG at time 82 minutes: What do you think?

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Catheterization Laboratory STEMI Blog Ischemia 111

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). There were no other causes of dyspnea apparent and thus we can assume that myocardial ischemia started 6 days prior. See Raitt et al.:

Chest Pain 89

Chest Pain Pericarditis Myocardial Infarction Dementia 89

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. If this were ACUTE (vs. Regional wall motion abnormality--mid anterior akinesis.

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Blog Chest Pain Myocardial Infarction Critical Care 63