Dr. Smith's ECG Blog

MAY 20, 2024

The Queen of Hearts disagrees, diagnosing OMI with high confidence: Case Continued: The EKG was not immediately recognized by the emergency provider, who ordered a CT scan to rule out aortic dissection at 1419. Most STEMI have peak troponin I over 1000 ng/L and most NSTEMI below that level.

Chest Pain 126

Chest Pain Blood Pressure Ischemia STEMI 126

Dr. Smith's ECG Blog

MAY 5, 2024

The provider had sent the patient for an aortic dissection scan which had shown extremely heavy calcification of the LAD.

EKG Technician 124

EKG Technician Chest Pain Blog STEMI 124

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Left ventricular afterload reduction is essential to decrease the trans-se ptal pressure gradient and thus decrease shunt volume, making a larger proportion of the blood flow from the left ventricle through the aortic valve. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

SEPTEMBER 14, 2014

is very specific for STEMI , and there is some evidence, as well as rationale, that a paced rhythm behaves similarly. Here is one case of anterior STEMI in a paced rhythm. Here is a case of lateral STEMI in a paced rhythm. He has had previous angiograms showing "large vessels" and "no significant coronary disease."

Chest Pain 52

Chest Pain Pacemaker Cardiomyopathy STEMI 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

An echocardiogram confirmed aortic stenosis with a large pressure gradient. Thus, this patient had increased ST elevation (current of injury) superimposed on the ST elevation of LVH and simulating STEMI. The next day, and angiogram showed normal coronary arteries. He awoke and did well.

Cardiac Arrest 52

Cardiac Arrest Ischemia Stenosis STEMI 52

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

OCTOBER 11, 2020

The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." JAMA 2000) showed that 1/3 of patients with STEMI, and 1/3 of patients with NSTEMI, present without chest pain. The whole paradigm is literally called "STEMI" vs. "NSTEMI." Canto et al.

Chest Pain 52

Chest Pain STEMI Blog Tachycardia 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.

Pericarditis 117

Pericarditis Chest Pain Blog Aortic 117

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? J Electrocardiol 2013;46:240-8 2. Left main?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

DECEMBER 14, 2016

The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI? The patient had no hypertension, no tachycardia, a normal hemoglobin, no drug use, no hypotension/shock, no murmur of aortic stenosis. We also looked at his aortic root by both parasternal and suprasternal views, and the aorta was normal.]

Chest Pain 52

Chest Pain STEMI Aortic Pulmonary 52

Dr. Smith's ECG Blog

APRIL 24, 2015

The estimated left ventricular ejection fraction is 58 % Aortic stenosis, mild, 9.0 We found that 38% of out of hospital ventricular fibrillation was due to STEMI. Correlation of STEMI in Resuscitated Non-traumatic out-of-hospital Cardiopulmonary Arrest patients with Initial Rhythm and Cardiac Catheterization Findings (Abstract 580).

Cardiac Arrest 52

Cardiac Arrest Defibrillator Atrial Fibrillation Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Look at the aortic outflow tract. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. They also wanted an aortic CT which was negative. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE? However , there is terminal QRS distortion in lead V3.

Chest Pain 116

Chest Pain Myocardial Infarction STEMI Pericarditis 116

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 Stents 40

Circulation

NOVEMBER 11, 2024

Patients with documented STEMI, left ventricular thrombus, mechanical mitral or aortic valve replacement were excluded. ICD 10 codes were used to identify patients with documented a fib. Procedure ICD codes were used to identify patients that underwent percutaneous LAAO. 5,661 underwent percutaneous closure. years with STD 7.86.

Stroke 40

Stroke Strokes Aortic valve Document 40

Ken Grauer, MD

JUNE 6, 2023

But limitation of this ST elevation to a single lead is not consistent with any distribution of a STEMI. The plan was to proceed as soon as possible with aortic valve replacement. This patient needed prompt aortic valve replacement. Then there is the significant ST elevation we see in lead V1.

Blog 78

Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

DECEMBER 13, 2019

The next morning the patient went for his routine echocardiogram, where the operator noticed a dilated aortic root at 5.47 cm with severe aortic insufficiency. The team was notified and they ordered a stat aortagram which showed type A aortic dissection from the aortic valve to the iliacs. Pericarditis?

Pericarditis 52

Pericarditis Chest Pain Aortic Blog 52

Dr. S. Venkatesan MD

DECEMBER 2, 2023

This has important clinical significance , as many successfully lysed STEMI patient might have minimal segments of dissection/deep plaque fissures. , Mind you, even if it occurs, it is atypical, continuous, non-anginal if flow is unaffected, and not relieved by nitro-glycerine. may be misdiagnosed as post infarct angina.

SCAD 52

SCAD Plaque Angina STEMI 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. 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

Dr. Smith's ECG Blog

JUNE 4, 2019

The patient arrived looking like an aortic dissection patient, so CTA was done and negative." OMI often does not meet STEMI criteria. If you rely on STEMI criteria, or on the computer algorithm, many of your patients will progress to a completed MI. 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

MARCH 6, 2023

Due to the severity of the pain and the high BP, they obtained an aortic dissection CT. Here is the repeat ECG at 52 minutes after arrival to triage: Obvious posterolateral STEMI Angiographic findings: 1. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI.

Chest Pain 52

Chest Pain STEMI Stenosis Blog 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 rhythm reportedly produced no palpable pulse, and CPR was continued. 30 seconds later, however, the patient began spontaneously moving and CPR was discontinued.

Chest Pain 52

Chest Pain STEMI Defibrillator Blog 52

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. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

MAY 10, 2023

No signs for aortic dissection or pulmonary embolus. --"Results were discussed with the ordering physician. Thus, Wellens' syndrome should be thought of as a transient OMI or transient STEMI. Transient STEMI is at high risk of re-occlusion. A CT Coronary angiogram was ordered. LAD plaque with 0-25 percent stenosis.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 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.

Chest Pain 105

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

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

Dr. Smith's ECG Blog

OCTOBER 30, 2024

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. And, even if there was acute aortic dissection — the dissection could result in occlusion of a coronary artery.

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?

Catheterization Laboratory 111

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). Larger shunt volume means less blood exiting the left ventricle through the aortic valve and lower cardiac output. 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.

Blog 63

Blog Chest Pain Myocardial Infarction Critical Care 63

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". No thoracic aortic hematoma, aneurysm or dissection. Pt received 324 ASA and 2 sprays of nitro with improvement. Cath lab was activated by EMS and transported emergent." Pain was decreased to 2/10. CT Angio Chest IMPRESSION 1.

STEMI 121

STEMI Chest Pain Myocardial Infarction Aneurysm 121