Dr. Smith's ECG Blog

DECEMBER 5, 2023

Beyond STEMI: Diagnosing Acute Coronary Occlusion on the ECG. The Queen of Hearts AI app can do it for you. With explainability too.

STEMI 137

STEMI Webinar 137

Ken Grauer, MD

OCTOBER 25, 2024

As reviewed in ECG Blog #350 — t he clinical significance of Wellens' Syndrome — is that its recognition tells you that the patient has a high-grade LAD narrowing with presumably "hot" thrombus h avin g high propensity to propagate and/or totally occlude the LAD at any point in time ( including immediately ). What is W ellens’ S yndrome ?

Blog 94

Blog Chest Pain STEMI Cardiogenic Shock 94

Ken Grauer, MD

OCTOBER 21, 2023

PEARL # 1: Although seeing an elevated Troponin would provide additional support for immediate cardiac catheterization — the clinical reality is that the initial Troponin reading will not always be elevated in patients with acute coronary occlusion ( See March 24, 2023 post in Dr. Smith's ECG Blog ).

Blog 98

Blog Chest Pain Ischemia STEMI 98

Ken Grauer, MD

FEBRUARY 9, 2024

NOTE: As I've commented on in a number of previous blog posts — Wenckebach conduction may occur at more than a single level within the AV Node. R elated E CG B log P osts to Today’s Case : ECG Blog #205 — Reviews my S ystematic A pproach to 12-lead ECG Interpretation. ECG Blog #192 — The 3 Causes of AV Dissociation.

Blog 105

Blog Arrhythmia STEMI Bradycardia 105

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.

Chest Pain 122

Chest Pain STEMI Cardiogenic Shock Heart Failure 122

Ken Grauer, MD

APRIL 18, 2023

MY Thoughts on the ECG in Figure-1: As always — I like to start my interpretation of 12-lead ECGs with assessment of the rhythm ( as per my systematic approach in ECG Blog-205 ). PEARL # 3: In the absence of an anterior STEMI — acute inferior MI is the result of either acute RCA or LCx ( L eft C ircumfle x ) coronary occlusion.

Blog 78

Blog STEMI Chest Pain Physiology 78

Ken Grauer, MD

OCTOBER 29, 2023

Based on ECG Blog #351 ( www.tinyurl.com/KG-Blog-351 ) LINK to this Page — www. tinyurl.com/KG-MedAll-351 — = = ECG Blog #205 = The Systematic Approach I favor. The "formula" = [link] LINK for Blog #205 = [link] - = Figure: The Systematic Approach that I favor. The talk will be recorded and posted on-line.

Blog 78

Blog Chest Pain STEMI 78

Ken Grauer, MD

MARCH 7, 2023

R elated E CG B log P osts to Today’s Case : ECG Blog #205 — Reviews my S ystematic A pproach to 12-lead ECG Interpretation. ECG Blog #193 — illustrates use of the M irror T est to facilitate recognition of acute Posterior MI. ECG Blog #294 — How to tell IF the "culprit" artery has reperfused.

Blog 78

Blog Chest Pain STEMI Ischemia 78

Ken Grauer, MD

JULY 22, 2023

Although this " Imbalance " of precordial T waves is not see n very often — in the “right” clinical setting, it has been associated with recent OMI ( O cclusion-based MI ) , most often from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM — and ECG Blog #350 ).

Blog 78

Blog Chest Pain STEMI AFIB 78

ECG Cases

FEBRUARY 13, 2024

The post ECG Cases 48 – ECG Interpretation in Cardiac Arrest appeared first on Emergency Medicine Cases.

Cardiac Arrest 121

Cardiac Arrest STEMI Blog 121

Ken Grauer, MD

MAY 26, 2023

. = = R elated E CG B log P osts to Today’s Case : ECG Blog #205 — Reviews my S ystematic A pproach to 12-lead ECG Interpretation. ECG Blog #185 — Review of the P s, Q s, 3 R Approach for systematic rhythm interpretation. ECG Blog #271 — Reviews the concept of diffuse Subendocardial Ischemia. ECG Blog #316 — The patient died.

Blog 78

Blog Ischemia STEMI Cardiac Arrest 78

Dr. Smith's ECG Blog

JANUARY 3, 2024

Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Now it even meets STEMI criteria, and HATWs continue to inflate. So the cath lab was not activated. Ongoing OMI.

STEMI 103

STEMI Chest Pain Ischemia Outcomes 103

Ken Grauer, MD

JUNE 6, 2023

== P lease N OTE : After today — No new ECG Blog posts for 2- to -3 weeks. — I will also not be prompt in replying to emails. == All material on this ECG Blog site remains open! IF you scroll down a little on the right-hand column of this blog — You'll see a lot of icons. Figure-1: The initial ECG in today's case.

Blog 78

Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

JULY 7, 2024

So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

Chest Pain 67

Chest Pain STEMI Blog Arrhythmia 67

Ken Grauer, MD

APRIL 29, 2023

Although this " Imbalance " of precordial T waves is not seen very often — in the “right” clinical setting, it has been associated with recent OMI ( O cclusion-based MI ) from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM — and ECG Blog #350 ).

Blog 78

Blog Chest Pain STEMI Ischemia 78

Ken Grauer, MD

JULY 15, 2023

By the P s, Q s, 3 R Approach ( as reviewed in ECG Blog #185 ): The Q RS complex is obviously wide. R elated E CG B log P osts to Today’s Case : ECG Blog #205 — Reviews my S ystematic A pproach to 12-lead ECG Interpretation. ECG Blog #185 — Systematic P s, Q s, 3 R Approach to Rhythm Interpretation. I do not see P waves.

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Dr. Smith's ECG Blog

JULY 9, 2024

Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen. Meyers and Smith in the October 15, 2022 post of Dr. Smith's ECG Blog ). Restoration of sinus rhythm is evident in Figure-1.

Defibrillator 117

Defibrillator STEMI Cardiac Arrest Cardiogenic Shock 117

ECG Cases

JANUARY 17, 2023

In this ECG Cases blog we look at 9 patients with possible transient STEMI and discuss pitfalls and pearls in ECG interpretation and management. The post ECG Cases 39 – Transient STEMI Pitfalls and Pearls appeared first on Emergency Medicine Cases.

STEMI 52

STEMI Blog 52

ECG Cases

OCTOBER 22, 2019

In this ECG Cases blog we present ECGs from 7 patients who presented with chest pain and mild anterior ST elevation. Can you identify which were early repolarization and which were anterior STEMI? The post ECG Cases 2: Early Repolarization or Anterior STEMI? appeared first on Emergency Medicine Cases.

STEMI 52

STEMI Chest Pain Blog 52

Dr. Smith's ECG Blog

MAY 31, 2023

Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. It is a mass delusion.

STEMI 96

STEMI Chest Pain Myocardial Infarction Ischemia 96

ECG Cases

MARCH 10, 2020

10 patients presented with the "STEMI-equivalent" ST elevation in aVR with diffuse ST depression. Jesse McLaren guides us through the differential diagnosis of ST elevation in aVR with diffuse ST depression in this ECG Cases blog. The post ECG cases 7: ST elevation in aVR, STEMI-equivalent? Which had acute coronary occlusion?

STEMI 52

STEMI Blog 52

ECG Cases

JUNE 6, 2023

In this ECG Cases blog we look at 10 patients with shortness of breath, and discuss how the ECG can be used to help diagnose cardiac, respiratory and metabolic emergencies.

STEMI 103

STEMI Pulmonary Blog Ischemia 103

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

I came to work one day and one of my partners said, "Hey, Steve, we had a STEMI this afternoon!" That is not a STEMI. More cases can be found on the blog here. They had activated the cath lab and the interventionalist did not notice that it was not a STEMI/OMI. I said, "Cool, can I see the ECG?' He said: "What?

Chest Pain 137

Chest Pain Diabetes STEMI Blog 137

ECG Cases

SEPTEMBER 21, 2021

In this ECG Cases blog we look at 10 patients with potentially ischemic symptoms. Jesse McLaren explains 'Late STEMI' and how reperfusion strategies should not be based on time of symptom onset. The post ECG Cases 25: ‘Late STEMI’ – How acute is the coronary occlusion?

STEMI 52

STEMI Blog 52

ECG Cases

DECEMBER 16, 2019

In this ECG Cases blog we look at seven patients with potentially ischemic symptoms and subtle ECG changes in the lateral leads. The post ECG Cases 4: Lateral STEMI or Occlusion MI? Which had acute coronary occlusion? Introducing the concept of Occlusion MI - a paradigm shift in ECG diagnosis of MI.

STEMI 52

STEMI Blog 52

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

The biggest problem with STEMI criteria are false negatives – because this costs patient’s myocardium, with greater mortality and morbidity. For this reason, ECGs need first to be interpreted in isolation, and then applied to the patient. Could this false positive cath lab activation been prevented?

Chest Pain 111

Chest Pain STEMI Ischemia Anatomy 111

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

STEMI 122

STEMI Chest Pain Myocardial Infarction Blog 122

ECG Cases

MAY 10, 2023

In this ECG Cases blog we look at 10 cases of patients with chest pain, including false positive STEMI, false negative STEMI, and other causes to help hone your ECG interpretation skills in time-sensitive cases where those very ECG skills might save a life.

Chest Pain 52

Chest Pain STEMI Blog Embolism 52

Dr. Smith's ECG Blog

JULY 31, 2020

Meyers, Weingart and Smith published their OMI Manifesto — in which they extensively document the critically important concept that management of acute MI by separation into a “STEMI” vs “non-STEMI” classification is an irreversibly flawed approach.

STEMI 52

STEMI Article Chest Pain Blog 52

Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

Chest Pain 124

Chest Pain STEMI Myocardial Infarction Ischemia 124

Dr. Smith's ECG Blog

JUNE 7, 2024

Obvious infero-postero-lateral STEMI(+)OMI, regardless of context Now let’s put them in order: what was the sequence? With serial ECGs that are ‘STEMI negative’ the physician could have waited for serial troponin levels or referred the patient as “non-STEMI”. What was the outcome and final diagnosis?

Chest Pain 113

Chest Pain STEMI Outcomes Document 113

ECG Cases

AUGUST 8, 2023

In this ECG Cases blog with Dr. Jesse McLaren we interpret 10 ECG cases and explore cardiac, metabolic and GI causes: We consider anginal equivalents, and look for ECG signs of Occlusion MI, including subacute occlusion from delayed presentations.

STEMI 87

STEMI Blog 87

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. It was recorded at 0530: What do you think?

EKG Technician 126

EKG Technician Chest Pain Blog STEMI 126

Dr. Smith's ECG Blog

MARCH 14, 2024

This is obviously unreliable data, as Dr. Smith’s Blog has published 51 cases of OMI with ECGs labeled ‘normal’ , 35 of which were identified by the Queen of Hearts – with 10 examples here. Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.

Chest Pain 120

Chest Pain STEMI Outcomes Academic 120

ECG Cases

APRIL 2, 2024

In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chest pain. They explain complementary diagnostic insights into pericardial effusion and cardiac tamponade, occlusion MI and RV strain.

Chest Pain 131

Chest Pain Blog Embolism Pulmonary 131

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

Chest Pain 87

Chest Pain Outcomes STEMI Electrocardiogram 87

Dr. Smith's ECG Blog

AUGUST 3, 2023

Although there are more criteria to consider when looking for OMIs compared to STEMIs, anyone can learn them, and this guide is intended to help accelerate that process! Mark Hellerman — for his excellent work in producing the OMI Pocket Guide , that is the subject of today’s post on Dr. Smith’s ECG Blog.

Blog 91

Blog Myocardial Infarction STEMI Hospital 91