Bradycardia, STEMI and Stents - Cardiovascular Update

Serial ECGs for chest pain: at what point would you activate the cath lab?

Dr. Smith's ECG Blog

AUGUST 11, 2024

There’s competing sinus bradycardia and junctional rhythm, with otherwise normal conduction, borderline right axis, normal R wave progression and voltages. While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky.

Chest Pain

Chest Pain STEMI Bradycardia Stent

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. EKG is pictured below: What do you think?

Bradycardia

Bradycardia Cardiogenic Shock STEMI Ischemia

A man with chest pain off and on for two days, and "No STEMI" at triage.

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 Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria.

Chest Pain

Chest Pain STEMI Cardiogenic Shock Bradycardia

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See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. The lesion was successfully stented. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. Blood pressure: 130/80 mmHg, heart rate: 45/min, respiratory rate: 18/min, SaO2: %98, body temperature: normal. Turk Kardiyol Dern Ars.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

A 50-something with chest pain. Is there OMI? And what is the rhythm?

Dr. Smith's ECG Blog

MARCH 22, 2024

I will leave more detailed rhythm discussion to the illustrious Dr. Ken Grauer below, but this use of calipers shows that the rhythm interpretation is: Sinus bradycardia with a competing (most likely junctional) rhythm. For national registry purposes, this will be incorrectly classified as a STEMI.) Large STEMI are approximately 30-80.

Chest Pain

Chest Pain STEMI Bradycardia Ischemia

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

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? There is also bradycardia. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. Bradycardia puts patients at risk for "pause-dependent" Torsades de Pointes. This was stented.

STEMI

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia

ECG Blog #392 — Repolarization T Waves?

Ken Grauer, MD

AUGUST 26, 2023

I see the following: The rhythm is sinus bradycardia at ~55-60/minute. These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ).

Blog

Blog Chest Pain STEMI Ischemia

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

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. The two cases were considered: Patient 1 was recognized by the ED provider and the cardiologist as having resolved “STEMI”. It was stented.

Chest Pain

Chest Pain STEMI Echocardiogram Stent

A 50-something with chest pain.

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. Sensitivity was 87% for OMI in our validation study (it was 34% for STEMI criteria). He has a h/o of 3 vessel disease and stents and his pain has been on and off for days.

Chest Pain

Chest Pain Defibrillator STEMI Coronary Artery Disease

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

The ECG shows sinus bradycardia but is otherwise normal. On the combined basis of angiography and IVUS, this patient received stents to his mid RCA, proximal PDA, and OM. RCA and PDA before and after, arrows indicating stented regions. OM before and after, arrow indicating stented region. The following ECG was obtained.

Angina

Angina Plaque Document Stents

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. Angiogram: Culprit Lesion (s): Thrombotic occlusion of the proximal RCA -- stented. What is the atrial activity?

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

7 steps to missing posterior Occlusion MI, and how to avoid them

Dr. Smith's ECG Blog

JANUARY 3, 2022

Sinus bradycardia, normal conduction, normal axis, normal R wave progression, no hypertrophy. 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]

STEMI

STEMI Myocardial Infarction Chest Pain Ischemia

Distractions

EMS 12-Lead

MARCH 19, 2023

He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myocardial infarction, or any prior PCI/stent. It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. No appreciable skin pallor. Is this OMI?

Myocardial Infarction

Myocardial Infarction STEMI Coronary Angiogram Coronary Artery Disease

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI. Why bradycardia? QTc is the computer measurement.

Chest Pain

Chest Pain STEMI Bradycardia Stenosis

Is this ECG diagnostic of coronary occlusion? Also: Inferior de Winter's T-waves on prehospital ECG??

Dr. Smith's ECG Blog

JANUARY 28, 2018

Here is his previous ECG: This was my interpretation of the first ECG: Sinus bradycardia with less than 1mm ST elevation in V4-V6, elevated compared to the previous ECG, suggestive of lateral MI. Both were stented. Moreover, T-wave inversion in aVL was also found to be 100% sensitive and 86% specific for inferior STEMI.

Pericarditis

Pericarditis Ischemia STEMI Chest Pain

A female in her 60s who was lucky to get expert ECG interpretation

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

Here are inferior leads, and aVL, magnified: A closer inspection of the inferior leads and aVL Sinus bradycardia. The patient was then taken to the cath lab an found to have a proximal RCA 100% thrombotic occlusion which was successfully stented. 3) STEMI criteria failed to identify this acute coronary occlusion, like many others.

Chest Pain

Chest Pain Critical Care Article Pacemaker

A woman in her 50s with chest pain and lightheadedness and "anterior subendocardial ischemia"

Dr. Smith's ECG Blog

JULY 30, 2023

It does not meet STEMI criteria. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). She was taken to cath and found to have total mid RCA occlusion, TIMI 0 flow, stented with excellent result. Anyway, she does say OMI. Easy for anyone. AI can do it too.

Chest Pain

Chest Pain Ischemia STEMI Arrhythmia

Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?

Dr. Smith's ECG Blog

MAY 23, 2022

Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. Theres inferior STE which meets STEMI criteria, but this is in the context of tall R waves (18mm) and relatively small T waves, and the STD/TWI in aVL is concordant to the negative QRS. This was false positive STEMI with an ECG mimicking OMI.

Chest Pain

Chest Pain Pericarditis STEMI Arrhythmia

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. STEMI criteria are only 43% sensitive for OMI.

Chest Pain

Chest Pain STEMI Stents Stent

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

Within ten minutes, she developed bradycardia, hypotension, and ST changes on monitor. Bradycardia and heart block are very common in RCA OMI. After stent deployment, we often see improvement in the ST-T within seconds or minutes. Here is the final angiogram following placement of a stent in the ostial RCA.

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

Serial ECGs for chest pain: at what point would you activate the cath lab?

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

A man with chest pain off and on for two days, and "No STEMI" at triage.

Webinars

See OMI vs. STEMI philosophy in action

A 50-something with chest pain. Is there OMI? And what is the rhythm?

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

ECG Blog #392 — Repolarization T Waves?

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

A 50-something with chest pain.

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

7 steps to missing posterior Occlusion MI, and how to avoid them

Distractions

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Is this ECG diagnostic of coronary occlusion? Also: Inferior de Winter's T-waves on prehospital ECG??

A female in her 60s who was lucky to get expert ECG interpretation

A woman in her 50s with chest pain and lightheadedness and "anterior subendocardial ischemia"

Inferior ST elevation with reciprocal change: which of these 4 patients has Occlusion MI?

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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