Dr. Smith's ECG Blog

AUGUST 28, 2020

Now appears to be in cardiogenic shock." However, cardiogenic shock usually takes some time to develop, so it is probably subacute." This can only be due to STEMI. Cardiogenic shock and ACS is an indication for the cath lab, even if you don't think there is OMI. I was texted these ECGs.

Cardiogenic Shock 40

Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. The patient in today’s case presented in cardiogenic shock from proximal LAD occlusion, in conjunction with a subtotally stenosed LMCA. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., A temporary pacemaker was implanted, and she was admitted to the ICU with cardiogenic shock. In our study, there were 20/53 complete LAD OMI (TIMI-0 flow) which did not meet STEMI criteria. None of the 20 ever evolved to STEMI criteria. This one is easy for the Queen.

Cardiac Arrest 123

Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 123

Dr. Smith's ECG Blog

JULY 18, 2014

Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. the presence of such well developed, wide, anterior Q-wave suggests completed transmural STEMI. Could it be acute (vs.

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Do you think we discussed this patient's 2-3 hour delay to reperfusion in our quarterly "STEMI meeting"?

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

NOVEMBER 16, 2010

He was in cardiogenic shock. As you will see, this results in the discovery of ST elevation in V2-V4 and I and aVL, diagnostic of anterolateral STEMI. The ED providers activated the cath lab, but the interventionalist refused to come in because it was "not a STEMI". The patient died 8 hours later of cardiogenic shock.

Tachycardia 52

Tachycardia Cardiogenic Shock Chest Pain STEMI 52

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 74

Chest Pain STEMI Pulmonary Embolism 74

Dr. Smith's ECG Blog

OCTOBER 1, 2024

These were catastrophically missed (EM cath lab activation cancelled both times by the interventionalist) Here is a case of Sinus with RBBB and LAFB that was diagnosed correctly by the emergency physicians as acute STEMI. The patient died of cardiogenic shock: Go to the post to see the full explanation.

Tachycardia 113

Tachycardia Cardiogenic Shock Arrhythmia STEMI 113

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. What is the atrial activity? Is it sinus arrest with junctional escape?

Chest Pain 97

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The ECG was read as "No STEMI" and the patient was treated like an average chest pain patient (despite the fact that a chest pain patient with active pain and active subendocardial ischemia is very high risk). The notes now refer to the patient being in cardiogenic shock, on pressors.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). Post PCI the patient became gravely hypotensive and "shocky". She stabilized on dobutamine and levosimendan infusions that could be discontinued after 24 hours. The tricuspid annular plane systolic excursion (TAPSE) improved from 15mm to 19mm within the first 24 hours.

Pulmonary 117

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 117

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. 2 The astute paramedic recognized this possibility and announced a CODE STEMI. Authors' commentary: Cardiogenic shock in the setting of severe aortic stenosis. What do you see?

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

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 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

MARCH 30, 2014

My most talented blog readers are paramedics because they have to put themselves on the line every time they activate the cath lab. Then the notes mention "cardiogenic shock" but without any reference to a cardiac echo or to a chest x-ray. Cardiologist note says: "Elevated troponin explained by type II MI due to her shock."

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Why is the patient in shock? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. He was in profound cardiogenic shock. This STE is diagnostic of Right Ventricular STEMI (RV MI). A right sided ECG was not recorded.

Bradycardia 40

Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Assessment was severe sudden cardiogenic shock. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 They recorded an EC G: New ST Elevation.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

This pattern is essentially always accompanied by cardiogenic shock and high rates of VT/VF arrest, etc. The patient arrived to the ED in cardiogenic shock but awake. Code STEMI was activated. A man in his 80s with chest pain What, besides large anterior STEMI, is so ominous about this ECG?

Chest Pain 52

Chest Pain Cardiogenic Shock Tachycardia Ischemia 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

MAY 8, 2023

Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). LAFB, atrial flutter, anterolateral STEMI(+) OMI. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

APRIL 24, 2020

When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. ST depression maximal in V5 and V6 cannot be reciprocal to subepicardial, transmural ischemia under aVR because, as stated above, there is no ventricular myocardium beneath that lead, no STEMI under aVR. I just read Ken's comments before publishing.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. But by this time the patient went into cardiogenic shock and passed away.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

A recent study found that SCAD causes almost 20% of STEMI in young women. examined SCAD presenting as STEMI (unlike Hassan et al. were pretty sick, with mostly LM/pLAD lesions and high rates of cardiogenic shock. I had no idea SCAD was so common a cause of acute STEMI in younger women, even when they are non-smokers.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

He was in cardiogenic shock requiring an impella for several days after cath. We've shown many cases on Dr. Smith's ECG Blog of subtle ECG findings that rapidly evolve into dramatic ST-T wave changes. No further troponins were measured. But we should not be surprised.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart attacks 52

Dr. Smith's ECG Blog

AUGUST 13, 2020

Because of the tachcardia, I would expect her to be very poor left ventricular function and maybe Cardiogenic shock. Dyspnea, Right Bundle Branch block, and ST elevation Here are two more cases where the differential diagnosis is acute OMI vs. LV aneurysm: Is this acute STEMI? Not all anterior LV aneurysm has a QS-wave.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 17, 2018

I have always said that tachycardia should argue against acute MI unless there is cardiogenic shock or 2 simultaneous pathologies. Exclusion criteria were age less than 18, SBP less than 100 mmHg, echocardiogram with EF less than 50%, STEMI, pregnancy, and trauma. PR depression, which suggests pericarditis 4.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

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. Is that an obvious STEMI underneath that rhythm? Is this inferor STEMI? Atrial Flutter with Inferior STEMI? If I fix the rhythm will the ST changes resolve?

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. The patient went into cardiogenic shock and ultimately died of this MI. Angiogram: LM 30% ostial. LAD 80% mid LCx occluded mid (acute infarct lesion) RCA 80% mid. Sandoval Y.

Myocardial Infarction 52

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI 52

Dr. Smith's ECG Blog

JANUARY 11, 2025

See our other cases with similar patters, to burn this deep into your brain files: Smith : In my experience, these cases of LAD OMI with RBBB and LAFB are either about to arrest, post-arrest, and/or in cardiogenic shock. Acute chest pain, right bundle branch block, no STEMI criteria, and negative initial troponin. To quote Drs.

Cardiogenic Shock 137

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137

Dr. Smith's ECG Blog

MARCH 3, 2025

Whenever there is tachycardia, I am skeptical of OMI unless it has led to severely compromised ejection fracction with cardiogenic shock. 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.

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73