Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. What do you think?

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Chest Pain STEMI Outcomes Electrocardiogram 119

Dr. Smith's ECG Blog

NOVEMBER 17, 2014

See my formula for differentiating anterior LV aneurysm (that is to say, persistent ST elevation after old MI) from acute anterior STEMI. Here is a link to a blog post with the formula , which we have recently validated and will publish. Both support acute anterior STEMI. As for thrombolytics, that is a bit riskier. 3.0 = 0.50

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Aneurysm STEMI Chest Pain Risk Factors 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. The patient was admitted as ‘NSTEMI’ which is supposed to represent a non-occlusive MI, but the underlying pathophysiology is analogous to a transient STEMI. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

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Chest Pain STEMI Aneurysm Stents 117

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. And as we have shown before, morphine leads to slower times to treatment and worse outcomes. 414 patients were included in the analysis.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 119

Dr. Smith's ECG Blog

JUNE 17, 2016

Jason was very skeptical of STEMI. This also argues against STEMI. What was the outcome? Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them. He complained of 3 days of diarrhea and abdominal pain. What do you think? Jason, I agree.

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STEMI Chest Pain Hospital Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? This is the response he got: Interventionist: "No STEMI, no cath. After stabilizing the patient and recording more ECGs, he tried again: Interventionalist: "It isn't a STEMI." It is a STEMI equivalent. We don't know how many though.

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STEMI Hospital Blog Defibrillator 52

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Posterior leads are unnecessary if anterior leads are diagnostic According to the STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary occlusion, and if there’s no ST elevation on anterior leads you can look for it on posterior leads. Do you need posterior leads? If so, how will they change management?

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Chest Pain STEMI Atrial Flutter Ischemia 114

Dr. Smith's ECG Blog

AUGUST 2, 2024

This was a machine read STEMI positive OMI. Readers of this blog can easily appreciate the hyperacute T waves in the precordium, clearest in V1-V4. the investigators reviewed outcomes in 118 patients presenting with NSTEMI. His ECG is shown below. Pretty obvious anterior current of injury. 118.007305) from Heitner et al. ,

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STEMI Ischemia Blog Chest Pain 119

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

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Chest Pain STEMI Blog Stents 98

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. Is this acute STEMI? Is this an acute STEMI? -- Unlikely! He had no chest pain. Medications were aspirin, clopidogrel, metoprolol, and simvastatin.

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Dr. Smith's ECG Blog

APRIL 4, 2023

This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI? As cardiology documented, “possible STEMI.

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Chest Pain STEMI Ischemia Document 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

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STEMI Chest Pain Blog Pericarditis 125

Dr. Smith's ECG Blog

OCTOBER 18, 2023

1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes. Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. minutes).

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Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

APRIL 2, 2014

He had an immediate ED ECG: There is artifact, but the findings appear to be largely gone now The diagnosis is acute MI, but not STEMI. Outcome : Was it RCA or LCX with inferior MI? His pain was intermittent and he was vague about when it was present and when it was resolved. Here is his prehospital ECG: Diagnosis?

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STEMI Ischemia Chest Pain Angioplasty 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

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Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

APRIL 22, 2024

Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). As far as I can tell, there is only one randomized trial of immediate vs. delayed intervention for transient STEMI. Labs ordered but not yet drawn.

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Chest Pain Myocardial Infarction Anatomy Angina 117

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. The LAD has reperfused early. This was recorded 2.5

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STEMI Chest Pain Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

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Chest Pain Cardiac Arrest STEMI Defibrillator 98

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient has active chest pain, so if these are abnormally large T-waves This link shows 13 blog posts of Posterior Reperfusion T-waves. Is she seeing anterior hyperacute T-waves, or does she see Posterior Reperfusion T-waves? Therefore, we activate the Cath Lab. There was a 100% circumflex occlusion that was opened.

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Chest Pain Bradycardia Blog Electrocardiogram 116

Dr. Smith's ECG Blog

JANUARY 29, 2024

This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chest pain The tech came running with the ECG as the computer called "STEMI!" Tell me the outcome! So signed it NO STEMI and triaged him OK to not be in RESUS." What do you think? Sam sent this to me and asked: "What do you think, Steve?"

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Chest Pain STEMI Blog Outcomes 96

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al. References: 1. Available from: [link] [link] 2.

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Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). Regular readers of this ECG Blog will be well familiar with many of these points. Nevertheless, cases like the one presented today — illustrate the continued need for review of these points that are KEY to attaining a good outcome.

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Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

JUNE 5, 2023

Here it is: Obvious Inferior Posterior STEMI (+) OMI. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) The cath lab was activated prehospital But imagine if the patient had walked in.

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Chest Pain STEMI Physiology Research 96

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

. #5: 18 minutes after #4: STE is resolved #6: 4 minutes after #5: And remains resolved Case Outcome Because of ST resolution, the patient was not taken that night to the cath lab. Waiting to cath a transient STEMI can be hazardous. See this case in which I made that mistake.

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Chest Pain STEMI Stents Stent 121

Dr. Smith's ECG Blog

JULY 14, 2023

Non-randomized trials show better outcomes (neurologic survival) using this device; see this article in Resuscitation: Head and Thorax Elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Finally, head-up CPR (which was not used here), makes for better resuscitation.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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%

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STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Day 12 ECG: FINAL DIAGNOSIS: "NSTEMI" Despite the fact that his day 4 ECG easily meets STEMI criteria, the patient is diagnosed as NSTEMI. Long term outcome unknown but obviously bleak.

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STEMI Myocardial Infarction Ischemia Academic 78

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. Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI. Outcome and Analysis: ECG 1 is diagnostic of inferior and right ventricular MI. And they teach me a lot.

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Dr. Smith's ECG Blog

DECEMBER 13, 2023

Outcome: 100% LAD Occlusion Here the Queen explains why: The dark blue tells us that she is looking especially at the QRS in V3 and the T-wave in V2 and V3. Not OMI, and we (Pendell and I) always take proportionality into account. So we taught the Queen on cases with very low voltage that were OMI.

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Blog Chest Pain Cardiac Arrest Cardiomyopathy 123

Dr. Smith's ECG Blog

MARCH 9, 2023

Barely any STE, and thus not meeting STEMI criteria. Annals of Emergency Medicine Cardiology was called to evaluate the patient immediately for emergent cath, but they stated that the ECG did not meet STEMI criteria and elected to wait for further information before proceeding with cath. He was given 6mg IV morphine for ongoing pain.

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Chest Pain STEMI Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

MARCH 19, 2024

The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Most large STEMI have peak troponin I in the 20.0 Inability to recognize OMI in LBBB led to a poor outcome Learning points: 1. Next trop in AM.

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Chest Pain Myocardial Infarction Stents Stent 111

Dr. Smith's ECG Blog

JUNE 18, 2013

His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI. It is not a missed STEMI, but it is a missed coronary occlusion. The peak troponin I was over 100.

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STEMI Chest Pain Myocardial Infarction Webinar 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! Posterior STEMI occurs in approximately 15-20% of acute MI, but the vast majority of the time it is seen in conjunction with inferior (Infero-Posterior) or lateral (Postero-Lateral) STEMI (1).

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Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

JANUARY 2, 2016

LVH and the diagnosis of STEMI - how should we apply the current guidelines? In this paper, Dr. Birnbaum writes: "In patients with ACS without LVH, ST depression with negative T waves in the lateral leads is a sign of sub-endocardial ischemia and is an independent predictor of adverse outcome [11 – 13]. For details, read this post.

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Ischemia Chest Pain STEMI Myocardial Infarction 52

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?

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

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?

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

APRIL 21, 2023

Now let’s compare this with the existing paradigm to identify multiple preventable delays to reperfusion, which can be improved through the paradigm shift from STEMI to OMI. In the STEMI paradigm, patients with ischemic symptoms and ECGs that don’t meet STEMI criteria get serial ECGs. There are no measurements that are reliable.

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