Dr. Smith's ECG Blog

OCTOBER 4, 2010

There is profound LVH with anterolateral ST elevation and reciprocal ST depression in II, III, aVF, and ST depression in V5 and V6 that could all be secondary to LVH or could represent ischemia superimposed on the repolarization abnormalities of LVH: note that wherever there is ST depression, it is associated with a very high voltage R-wave.

Cardiac Arrest 52

Cardiac Arrest Ischemia Stenosis STEMI 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

In terms of ischemia, there is both a signal of subendocardial ischemia (STD max in V5-V6 with reciprocal STE in aVR) AND a signal of transmural infarction of the inferior wall with Q wave and STE in lead III with reciprocal STD in I and aVL. He had multiple cardiac arrests with ROSC regained each time.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

JANUARY 25, 2017

911 was called and the medics recorded this ECG (unfortunately, leads V4-V6 are missing) Due to marked ST Elevation, the computer read was STEMI What do you think? See this post and associated case reports: Cardiac arrest, severe acidosis, and a bizarre ECG The patient was admitted and ruled out for acute MI by serial troponins.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation.

Cardiac Arrest 98

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

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." Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest.

Ischemia 124

Ischemia Chest Pain Cardiac Arrest Blog 124

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

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 Available from: [link] 9. of Cardiology AC, Others. Troponin and BNP Use in COVID-19.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with reciprocal ST depression in aVL, and some STE in V1. If there is also subendocardial ischemia, the ST depression vector remains leftward, with a reciprocal ST Elevation vector also to the right.

Ischemia 40

Ischemia Pulmonary STEMI Chest Pain 40

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( The below ECG was recorded.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

Blog 99

Blog Chest Pain Ischemia STEMI 99

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. His response: “subendocardial ischemia. Anything more on history? POCUS will be helpful.”

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

None of these findings are diagnostic of ischemia, but they should give you a high index of suspicion and prompt serial ECGs at a minimum. The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Anterolateral STEMI. Ischemia comes and goes.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 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.

Chest Pain 98

Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

DECEMBER 15, 2015

There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. It was a PEA or bradyasystolic arrest , not a shockable rhythm. LV anterior STEMI does not give maximal ST elevation in V1. So this ECG is typical of right ventricular (RV) STEMI. Summary: 1.

STEMI 40

STEMI Embolism Pulmonary Ultrasound 40

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. On arrival, GCS was 13 and the patient complained of ongoing chest pain.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think? The ECG is consistent with high lateral STEMI. Called 911.

STEMI 40

STEMI Chest Pain Cardiac Arrest Stents 40

Ken Grauer, MD

MAY 26, 2023

This ST depression appears to be maximal in leads V3-to-V5 — which could reflect acute posterior OMI ( O cclusion-based M yocardial I nfarction ) — most probably with multi -vessel disease ( ie, diffuse subendocardial ischemia suggested by the ST depression with ST elevation in aVR>V1 ). This patient has new CP — and — he is hypotensive.

Blog 78

Blog Ischemia STEMI Cardiac Arrest 78

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.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 1, 2020

He has done a lot of great work on cardiac arrest, including as co-author of our study on esmolol in refractory cardiac arrest, and much more with Keith Lurie. The Queen was not able to see this one: Of course we do not know for certain that the inferior findings represent ischemia. It was not.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

This ECG is all but diagnostic of subepicardial ischemia of the anterior, lateral, and inferior walls, most likely due to Occlusion MI (OMI), probably of the LAD. There is a very small amount of STE in some of the anterior, lateral, and inferior leads which do NOT meet STEMI criteria. Here is his ECG on arrival: What do you think?

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Aneurysm 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

He had a previous MI with cardiac arrest 2 years prior. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. Therefore it is not a STEMI.

Ischemia 40

Ischemia Chest Pain STEMI Stenosis 40

DAIC

APRIL 8, 2024

The new trial, called DanGer Shock , is the first trial powered to examine whether the use of micro-axial flow pumps can improve survival in ST-elevation myocardial infarctions (STEMI, the most serious type of heart attack) that are complicated by cardiogenic shock. Overall, we have more complications, but we also save lives.”

Heart attacks 52

Heart attacks Heart Attack Cardiogenic Shock Catheterization Laboratory 52

Ken Grauer, MD

JUNE 6, 2023

Part of the ST depression with deep T wave inversion in the lateral chest leads clearly reflects LV "strain" from the marked LVH — but despite the very large QRS amplitudes, this ST-T wave appearance looks disproportionate, suggesting at least a component of ischemia. Then there is the significant ST elevation we see in lead V1.

Blog 78

Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern). Code STEMI was activated. This is "shark fin" morphology.

Chest Pain 52

Chest Pain Cardiogenic Shock Tachycardia Ischemia 52

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia mimics STEMI and OMI in many distributions, but probably the most common is the Brugada morphology in V1-V2 which mimics anterior OMI for those who cannot recognize the Brugada pattern. HyperKalemia with Cardiac Arrest.

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). In there ECG evidence of possible ongoing ischemia? (ie, IMPRESSION: I’d interpret this tracing as consistent with LVH and/or “strain” and/or ischemia. ie , Is it more than 50-60% likely? ).

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

A repeat ECG was done: Obvious anterolateral wall STEMI. This means that they occur shortly after onset of occlusion, but also may be the last remaining sign of ischemia after ST elevation resolves (after reperfusion). This rhythm reportedly produced no palpable pulse, and CPR was continued.

Chest Pain 52

Chest Pain STEMI Defibrillator Blog 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

It is apparently fortunate that she had a cardiac arrest; otherwise, her ECG would have been ignored. Then they did an MRI: Patient underwent cardiac MRI on 10/4 that showed mildly reduced BiV systolic function. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

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. BOTTOM Line: It can at times be extremely challenging to distinguish between anterior ST elevation from a benign Brugada Phenocopy pattern vs an acute anteroseptal STEMI.

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

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. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. Bicarb 20, Lactate 4.2,

Heart Rhythm 52

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

DECEMBER 22, 2010

There is ST depression in II, III, and aVF that is concerning for reciprocal depression from high lateral STEMI in aVL, where there is some ST elevation. There is also ST depression in precordial leads, greatest in V3 and V4, concerning for posterior STEMI. What was the inciting factor? The diagnosis is in doubt.

Cardiac Arrest 40

Cardiac Arrest Tachycardia STEMI Chest Pain 40

Dr. Smith's ECG Blog

JANUARY 28, 2012

A middle aged patient who was 3 weeks s/p STEMI came from cardiac rehab where he developed some chest pain, dyspnea and weakness on the treadmill. There is no acute STEMI. This is diagnostic of recent, reperfused STEMI. This is diagnostic of recent, reperfused STEMI. Acute STEMI would have upright T-waves.

Chest Pain 40

Chest Pain STEMI Pericarditis Ultrasound 40

Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. J waves can also be induced by Occlusion MI (5), STEMI mimics including takotsubo and myocarditis complicated by ventricular arrhythmias (6, 7), and subarachnoid hemorrhage with VF (8). Take home : Not all STEs are STEMIs or OMIs. What do you think?

STEMI 52

STEMI Bradycardia Arrhythmia Cardiac Arrest 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Unfortunately, the ECG was interpreted as no significant change from prior , "no STEMI"!! He was sent back to the waiting room, where he suffered a VF arrest. Approximately 5 minutes after ROSC, this ECG was obtained (about 45 minutes after arrival): Obvious anterolateral OMI, and STEMI criteria positive for those who care or need it.

Cardiac Arrest 86

Cardiac Arrest STEMI Blog Ischemia 86

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

A 12-lead was recorded, showing "STEMI," but is unavailable. The patient was unconscious BEFORE the cardiac arrest, at the same time that she had strong pulses. Therefore, cardiac arrest is NOT the etiology of the coma. She was BVM ventilated and suctioned. Shortly thereafter, pulses were lost.

STEMI 89

STEMI Hemorrhage Cardiac Arrest Tachycardia 89

Dr. Smith's ECG Blog

JANUARY 11, 2025

The ECG shows sinus tachycardia, RBBB+LAFB, and signs of anterolateral acute transmural ischemia (most likely due to acute coronary occlusion), with concordant STE in I and aVL, inappropriate STE in V4-6 (though limited a bit by motion, still definite). Plus recommendations from a 5-member panel on cardiac arrest.

Cardiogenic Shock 137

Cardiogenic Shock Chest Pain Tachycardia Cardiac Arrest 137