Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). In STEMI, they are generally upright and large in proportion to the QRS. So this argues against acute STEMI.

Chest Pain 52

Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

JULY 19, 2019

Written by Pendell Meyers, with edits by Steve Smith A man in his early 40s with history of MI s/p PCI presented with bilateral anterior chest pain described as burning and belching with no radiation since last night starting around 11pm (roughly 11 hours ago). But it does not meet STEMI criteria and it was not initially recognized.

Chest Pain 52

Chest Pain STEMI Aneurysm Pericarditis 52

Dr. Smith's ECG Blog

MAY 16, 2023

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Dr. Singer sent this to me with just the information: "~40 year old with acute chest pain". Anxiety is a common cause of chest pain with tachycardia.

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Chest Pain Pericarditis Tachycardia STEMI 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin.

Chest Pain 52

Chest Pain STEMI Stents Stent 52

Dr. Smith's ECG Blog

MARCH 31, 2023

It is from a 50-something with chest pain: What do you think? This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria.

Chest Pain 52

Chest Pain STEMI Blog Academic 52

Dr. Smith's ECG Blog

JUNE 14, 2017

There was apparently no syncope and he had no bony injuries, but he did complain of left sided chest pain. His chest was tender. Is there STEMI? A bedside cardiac ultrasound was normal. An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD IVCD type rhythm ??

Chest Pain 52

Chest Pain Congenital Heart Disease Article Congenital 52

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

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STEMI Article Chest Pain Blog 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

Written by Pendell Meyers, few edits by Smith A man in his 60s with history of stroke and hypertension but no known heart disease presented with chest pain that started on the morning of presentation at around 8am. So it is very unclear to me whether or not "posterior STEMI" is actually a recognized entity under our current guidelines.

STEMI 52

STEMI Chest Pain Myocardial Infarction Document 52

Dr. Smith's ECG Blog

MARCH 4, 2024

Algorithm: Veritas (on Mortara machines) The Queen gets it right Case 2 A middle-aged woman with chest pain and a "normal" ECG in triage. Unknown algorithm The Queen gets it right Case 4 How unreliable are computer algorithms in the Diagnosis of STEMI? Pain was resolving. The OMI was not seen and she arrested in triage.

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STEMI Blog Chest Pain Webinar 126

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. Here is the clinical story: A 40 year old male with no cardiac history presented with acute substernal chest pain that started 40 minutes prior to arrival. This ECG was texted to me with no other information. What did I say?

STEMI 129

STEMI Stenosis Plaque Chest Pain 129

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). With EMS, patient had a GCS of 3 and was saturating 60% on room air. ng/mL and 0.10

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STEMI Document Blog Ischemia 114

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He was given aspirin and sublingual nitro and the pain resolved. We documented that the majority of stenotic lesions had compensatory enlargement and thus exhibited remodeling. He was started on nitro gtt.

Ischemia 121

Ischemia Plaque Stenosis Myocardial Infarction 121

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. The pain initially started the day prior to presentation. The ST elevation from today is ~0.2

Pericarditis 52

Pericarditis Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

MARCH 8, 2021

He was a 30-something with chest pain. Prehospital ECG: Obvious anterolateral STEMI (Proximal LAD occlusion) The cath lab was activated prehospital by the medics. A male in his 30's complained of sudden severe substernal chest pain. Interventionalist at the Receiving Hospital: "No STEMI, no cath.

Chest Pain 52

Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours.

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Plan was for admission for chest pain workup. Jernberg T, et al.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

This appears to be a classic Wellens' ECG, Pattern A, with terminal T-wave inversion in V2-V4, preserved R-waves, and it appears to be Wellens' syndrome, as it occurred after resolution of typical angina pain. Wellens' syndrome represents the aftermath of an unrecorded occlusion (STEMI) with spontaneous reperfusion. Learning Points: 1.

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. The day prior to presentation (about 12 hours prior to presentation) he described sudden onset chest pain and shortness of breath while gardening in his back yard. He had no further pain and went to bed that night with no complaints.

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Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

Dr. Smith's ECG Blog

JANUARY 5, 2024

Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." The following ECG was obtained.

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Angina Plaque Document Stents 119

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Sent by anonymous, edited by Pendell Meyers A man in his 50s with history only of hypertension presented with acute chest pain that started 45 minutes prior to presentation while doing yard work. Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10."

STEMI 77

STEMI Myocardial Infarction Ischemia Academic 77

Dr. Smith's ECG Blog

JUNE 4, 2019

A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH. OMI often does not meet STEMI criteria. The patient looked ill. Circ Arrhythm Electrophysiol.

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Chest Pain STEMI Ischemia Aortic 52

Dr. Smith's ECG Blog

MARCH 19, 2023

The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. To me, that is a meaningless diagnosis. Here is the main learning point: The infarct was due to an occluded artery (Occlusion MI, OMI). In 30% of OMI, there is no significant ST Elevation.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Document 52

Dr. Smith's ECG Blog

JUNE 27, 2021

A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away. persistent pain despite medical Rx brought emergently to Cath lab." It was not a STEMI) 1.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

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.

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Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

JULY 11, 2018

A 40-something woman had sudden chest pain. This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

JULY 26, 2023

The combination of absence of chest pain and history of LV aneurysm made it easy to assess that this patient does not have acute OMI. At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. We know today's patient had a documented inferior STEMI in 2010.

Aneurysm 52

Aneurysm Chest Pain STEMI Bradycardia 52

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. She was reportedly "pacing in her room while holding her chest". See this case: Pericarditis, or Anterior STEMI?

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

A 50 something-year-old man with a history of newly diagnosed hypertension and diabetes, for which he did not take any medication, presented a non-PCI-capable center with a vague, but central chest pain. His vitals were normal and his first ECG was as shown below: There is obvious ST segment elevation (STE) in anterior leads.

Chest Pain 52

Chest Pain Myocardial Infarction Blog Pericarditis 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

This is why it is essential that the OMI/NOMI paradigm replace the STEMI/NonSTEMI paradigm. Under Non-STEMI, this patient would not have intervention until at least 20 hours (next day), after the infarct is completed. Learning Points: 1. 25-30% of OMI are not treated in a timely way.

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Chest Pain Critical Care STEMI Plaque 52

Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. This is a high troponin (most STEMI are above 10 ng/mL for troponin I). There is no STE or STD in III an aVF. Lead aVR has a bit of STD (reciprocal, as changes in lead aVR always are). There are also new very tiny Q waves in V4-6.

Pericarditis 52

Pericarditis STEMI Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Written by Pendell Meyers A man in his 40s called EMS for acute chest pain that awoke him from sleep, along with nausea and shortness of breath. Learning Points: Currently by definition, there is unfortunately no such thing as a formal diagnosis of STEMI or STEMI criteria in the setting of RBBB and LAFB.

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Chest Pain STEMI Cardiogenic Shock Heart Failure 120

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. He had no previously documented medical problems except polysubstance use. The patient continued having chest pain.

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Chest Pain Arrhythmia Myocardial Infarction STEMI 106

Dr. Smith's ECG Blog

JUNE 8, 2023

Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. The patient has a history of CABG so some of these changes could be old, but with ongoing chest pain and bradycardia in a high risk patient this is still acute OMI until proven otherwise. HR 40, BP 135/70, RR16, O2 100%.

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Chest Pain STEMI Bradycardia Myocardial Infarction 86

Dr. Smith's ECG Blog

JUNE 13, 2024

Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chest pain that started 2-3 hours earlier while sitting on a porch swing. See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6. The physician documented “normal sinus rhythm”.

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Chest Pain Document STEMI Defibrillator 91

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Triage documented a complaint of left shoulder pain. Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." See this case: Persistent Chest Pain, an Elevated Troponin, and a Normal ECG.

Myocardial Infarction 122

Myocardial Infarction Chest Pain STEMI Blood Pressure 122

Dr. Smith's ECG Blog

MAY 13, 2024

Chest Pain – Benign Early Repol or OMI? Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain.

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Chest Pain STEMI Ultrasound Heart Attack 119

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? Document in the patient's chart that rapid infusion is intentional in response to life-threatening hypokalemia." If the patient is at 1.8,

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STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52