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. Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion.

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Dr. Smith's ECG Blog

MAY 27, 2012

Is there ischemia? Idioventricular rhythm is a common "reperfusion arrhythmia." In other words, after reperfusion therapy for STEMI, the appearance of AIVR is usually a good sign, meaning that the artery is reperfused. Exactly how they relate to ischemia, chest pain, and reperfusion can only be speculated about.

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ECG Cases

APRIL 26, 2022

This is especially problematic in the emergency department, where computer accuracy drops as clinical significance increases—with common errors for arrhythmias and ischemia. Computer interpretation of the ECG has been called a double-edged sword: when correct, it increases physician accuracy, but when incorrect it increases errors.

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Dr. Smith's ECG Blog

MARCH 1, 2023

The precordial STD persists in severity from V4-V6, rather than being maximal in V1-V4 (as in posterior OMI), and so the ECG overall best fits the subendocardial ischemia pattern (diffuse supply/demand mismatch). A "STEMI alert" was called and soon cancelled.

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Dr. Smith's ECG Blog

APRIL 22, 2019

The computer called it a normal ECG Algorithm unknown Aside : [There is some "sinus arrhythmia", which is indeed a normal finding. Sinus arrhythmia is sinus rhythm whose rate varies with respiration. If the longest P-P interval is 120 ms greater than the shortest, it is sinus arrhythmia.

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Ken Grauer, MD

FEBRUARY 18, 2023

Looking at the location of ST elevation ( ie, in the inferior leads — and in V4,5,6 ) — and the location of ST depression ( ie, in leads I,aVL; V1,V2 ) — this ECG picture suggests an ongoing acute infero - postero - lateral STEMI. What is S hark F in M orphology ? Cardiopulmonary resuscitation was promptly started — but was unsuccessful.

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Dr. Smith's ECG Blog

MAY 1, 2023

Learning Points: Atrial flutter can be very tricky to identify, and can cause all kinds of problems such as mimicking or concealing ischemia and OMI. Is this inferor STEMI? Atrial Flutter with Inferior STEMI? The reason for this is easy to understand — atrial activity is often not well seen in many instances of this arrhythmia.

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Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI. But which myocardial walls are affected?

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Dr. Smith's ECG Blog

JANUARY 6, 2024

Here, I do not see OMI (although the ECG is falsely STEMI positive with just over 1 mm STE in V1 and about 2.5 In the days before I learned to look for OMI, back when I was counting ST elevation boxes, I used to save ischemia for last.) Never forget that sinus tachycardia is the scariest arrhythmia. What do you think?

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Dr. Smith's ECG Blog

JULY 5, 2023

Here was my answer: "Not ischemia. Any objective, rule-based analysis of this ECG would scream "STEMI" or "OMI". And I recognized this as a STEMI mimic. Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. WPW Cardiac arrhythmias ( especially AFib ).

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Dr. Smith's ECG Blog

OCTOBER 13, 2022

But it doesn’t meet STEMI criteria, and was not identified by the computer or the over-reading cardiologist. Still no WPW pattern, and more obvious inferoposterior OMI, but still STEMI negative. 2] Conduction through the accessory pathway can be intermittent (with different degrees of pre-excitation), and affected by ischemia.

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Ken Grauer, MD

JULY 15, 2023

The finding of all negative QRS complexes in leads V3-thru- V6 therefore strongly suggests that the arrhythmia-associated impulse is not traveling over an AP ( Steurer et al — Clin. ie, Severe subendocardial ischemia from sustained VT in a patient severe apical cardiomyopathy resulted in a peak troponin >31,000 ng/L in today's case ).

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Dr. Smith's ECG Blog

MARCH 8, 2019

[link] Case continued: In this case, the diagnosis was much easier because there was a prehospital ECG: less than 1 mm ST Elevation in II, III, aVF, with minimal ST depression in aVL This is diagnostic of inferior OMI No clear evidence of ischemia Computer interpretation Impressive! This algorithm called it a STEMI. Learning points 1.

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Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. Weren't you taught that "new tall T wave in V1" is concerning for ischemia, and so this is the opposite? This is a high troponin (most STEMI are above 10 ng/mL for troponin I). There is no STE or STD in III an aVF. Leads V4-V6 show new loss of S-wave.

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Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. No arrhythmias occurred en route. The morphology in V2 is also concerning and it appears that the ST segment is being pushed down, as in ST depression. Repeat ECG minutes later (one shown below) showed no significant change.

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Dr. Smith's ECG Blog

AUGUST 28, 2020

This is ischemia until proven otherwise. This can only be due to STEMI. A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock. By the ECG, it is not necessarily subacute, but could be.

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Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished.

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Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? Comments: STEMI with hypokalemia, especially with a long QT, puts the patient at very high risk of Torsades or Ventricular fibrillation (see many references, with abstracts, below). There is atrial fibrillation.

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Dr. Smith's ECG Blog

AUGUST 9, 2024

There are three mechanisms of arrhythmia: automatic, re-entry, and triggered. The most common triggered arrhythmia is Torsades de Pointes. It is a benign arrhythmia which requires no specific treatment. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Moffat, M.

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Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. However, he suddenly developed a series of malignant ventricular arrhythmias. Below are printouts of some of the arrhythmias recorded. There is no definite evidence of acute ischemia. (ie, The below ECG was recorded. What do you think?

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Dr. Smith's ECG Blog

OCTOBER 25, 2023

A prior ECG was available for comparison: Normal One might be tempted to interpret the ST depression as ischemia, but as Smith says, "when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave." Is it STEMI? Instead — it commonly reflects ischemia from severe underlying coronary disease.

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Dr. Smith's ECG Blog

OCTOBER 24, 2018

This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF.

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Dr. Smith's ECG Blog

MARCH 24, 2023

There’s minimal concave ST elevation in III which does not meet STEMI criteria, so this ECG is "STEMI negative". Use STEMI criteria to identify acute coronary occlusion: the ECG was STEMI negative 2. A repeat ECG was done on way to cath lab: "STEMI negative" again. The cath lab was activated. Take home 1.

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Dr. Smith's ECG Blog

JUNE 13, 2024

V1 sits over both the RV and the septum, so transmural ischemia of either one with give OMI pattern in V1 and reciprocal STD in V5 and V6. See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6. However, the pattern is also seen in inferior OMI with right ventricular OMI. (V1

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Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada.

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Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. Prior to Mizusawa's study, it was thought that the incidence of syncope, arrhythmia, or SCD in this cohort was low [7]. So maybe she is better than I am. There was a 0.9%

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Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. Induced Brugada-type electrocardiogram, a sign for imminent malignant arrhythmias. Bicarb 20, Lactate 4.2,

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Dr. S. Venkatesan MD

AUGUST 19, 2024

Relationship between Ischemia and arrhythmia While the relationship between Ischemia and VT is really complex, the term “Ischemic VT” itself adds more twists. Even here, it is the associated factors, like hypoxia or acidosis are the triggers which of course are resultant of Ischemia.

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Dr. Smith's ECG Blog

OCTOBER 31, 2024

But it does not meet the ridiculous "STEMI criteria" since there is not 1 mm of STE in any lead. The fact that there is variation in the R-R interval for the first 4 sinus-conducted beats suggests the possibility of a marked sinus arrhythmia — but I would not expect this degree of variable P wave morphology and such group beating.

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Ken Grauer, MD

FEBRUARY 21, 2025

PEARL # 2: Despite the challenge of assessing a ventricular rhythm for underlying ischemia and/or infarction there are primary ST-T wave changes that are seen in Figure-3 that suggest an ongoing acute event. I represent this in the laddergam shown in Figure-6.

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Ken Grauer, MD

FEBRUARY 1, 2025

The rhythm is sinus ( small, but upright P wave in lead II ) with some R-R interval variability ( probable sinus arrhythmia ). 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. And the initial ECG in Figure-1 is not normal.

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Dr. Smith's ECG Blog

JANUARY 9, 2025

Smith : I recognize this as a STEMI mimic. Doesn't this necessarily mean that he was having ischemia? Overnight telemetry showed no arrhythmias ( important to reduce the risk of worrisome arrhythmia given this patient's chief complaint of sudden syncope without prodrome ). I was not alarmed. Troponins were negative.

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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.

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Dr. Smith's ECG Blog

DECEMBER 31, 2024

The ECG shows sinus rhythm with normal QRS complex morphology and significant subendocardial ischemia (SEI) pattern (ST depression in many leads, worst in lateral areas including leads II, V5-6, with reciprocal STE in aVR). Here is her ECG within 30 minutes of PCI: Improved, but still with ischemia.

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Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. While traditionally described as “benign early repolarization”, they have been associated with J wave syndromes along with Brugada syndrome, causing ventricular arrhythmias (1, 2). Take home : Not all STEs are STEMIs or OMIs. What do you think?

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