Cardiogenic Shock, STEMI and Ultrasound

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

STEMI

STEMI Cardiogenic Shock Tachycardia Aneurysm

Acute artery occlusion -- which one?

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). Answer : Bedside ultrasound! Smith : RV infarct may also have this appearance on ultrasound.

Cardiogenic Shock

Cardiogenic Shock Ultrasound Tachycardia Pulmonary

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

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

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock

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What are treatment options for this rhythm, when all else fails?

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

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

Two patients with chest pain and RBBB: do either have occlusion MI?

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

Chest Pain STEMI Pulmonary Embolism

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Smith comment: This patient did not have a bedside ultrasound. Had one been done, it would have shown a feature that is apparent on this ultrasound (however, this patient's LV function would not be as good as in this clip): This is recorded with the LV on the right. In fact, bedside ultrasound might even find severe aortic stenosis.

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

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

There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. RVMI explains part of the shock. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity? How would one tell?

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

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? 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

Bradycardia Cardiogenic Shock STEMI Ischemia

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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

Ischemia STEMI Stenosis Chest Pain

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

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

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock

Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

A bedside cardiac ultrasound was normal, with no effusion. 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. There is minimal, probably normal STE in V2-V6. What is it?

Cardiac Arrest

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock

Guess the culprit with ST Elevation in posterior leads

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

Ischemia Chest Pain Stenosis STEMI

Chest Pain and Inferior ST Elevation.

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

Chest Pain Pericarditis Tachycardia Myocardial Infarction

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

A recent study found that SCAD causes almost 20% of STEMI in young women. Often, intravascular ultrasound or intravascular optical coherence tomography is requeried to make the diagnosis. examined SCAD presenting as STEMI (unlike Hassan et al. were pretty sick, with mostly LM/pLAD lesions and high rates of cardiogenic shock.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

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. I suspect pulmonary edema, but we are not given information on presence of B-lines on bedside ultrasound, or CXR findings. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI).

Tachycardia

Tachycardia Pulmonary Chest Pain Stenosis

Cardiovascular Update

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

Acute artery occlusion -- which one?

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

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What are treatment options for this rhythm, when all else fails?

Two patients with chest pain and RBBB: do either have occlusion MI?

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

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

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

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

Extreme shock and cardiac arrest in COVID patient

Guess the culprit with ST Elevation in posterior leads

Chest Pain and Inferior ST Elevation.

A young peripartum woman with Chest Pain

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

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