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2 middle aged males presented with chestpain. Which had the more severe chestpain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chestpain at the time the ECG was recorded. 414 patients were included in the analysis.
Written by Jesse McLaren, with a very few edits by Smith A 60-year-old presented with chestpain. The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. But STEMI criteria is only 43% sensitive for OMI.[1]
Written by Jesse McLaren Four patients presented with chestpain. 4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6]
Written by Jesse McLaren A 50 year old presented to triage with one hour of chestpain, and the following ECG labeled normal by the computer (GE Marquette SL) algorithm. Smith comment: we showed that the first troponin, even in full-blown STEMI, is negative 25% of the time. What do you think?
Written by Jesse McLaren Three patients presented with acute chestpain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. What do you think?
Written by Pendell Meyers A man in his early 40s experienced acute onset chestpain. The chestpain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. And yet it still says "normal".
Written by Jesse McLaren Two 70 year olds had acute chestpain with nausea and shortness of breath, and called paramedics. There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD.
Written by Jesse McLaren A previously healthy 50 year-old presented with 24 hours of intermittent exertional chestpain, radiating to the arms and associated with shortness of breath. In a previously healthy patient with new and ongoing chestpain, this is concerning for acute occlusion of the first diagonal artery.
Written by Pendell Meyers A middle aged man called EMS for acute chestpain. I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 Physician accuracy in interpreting potential ST-segment elevation myocardial infarction electrocardiograms. I said "Not OMI. Carley et al. Emerg Med J.
A 50-something man presented in shock with severe chestpain. There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch.
Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chestpain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.
A 61 year-old with chestpain arrived to the ED by ambulance with resolving chestpain. Safety of Computer Interpretation of Normal Triage Electrocardiograms. The chestpain is resolving, so if these are resolving hyperacute T-waves, then followup ECGs should show their size diminishing.
A 70-year-old man calls 911 after experiencing sudden, severe chestpain. The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! But if there is none - then you are looking at least at an Isolated Posterior STEMI until proven otherwise.
This was sent to me by a former resident from a community hospital: A middle-aged woman complained of chestpain and was seen in triage. Comment This paper has received some press recently: Safety of Computer Interpretation of Normal Triage Electrocardiograms The algorithm used was also the GE Marquette 12 SL. Normal ECG."
Sent by anonymous A man in his 40s with no previous heart disease presented within 30 minutes of onset of acute chestpain that started while exercising. Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Chestpain and a computer ‘normal’ ECG.
Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chestpain. The chestpain started about one hour prior to arrival while bike riding.
Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chestpain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.
It is from a 50-something with chestpain: 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.
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.
Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. International Journal of Cardiology Heart & Vasculature Case A 40-year-old man presents with excruciating back pain which has started 1 hour ago. Turk Kardiyol Dern Ars.
A 36 yo male smoker presented to the ED with chestpain. It had started the night before as "indigestion" and had progressed to 8/10 substernal chest pressure radiating to the right shoulder/jaw associated with diaphoresis, nausea, and SOB. of patients with anterior STEMI, ST elevation of greater than or equal to 3.0
Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. He had been awakened by cough at 3 AM 2 days earlier.
The patient with no prior cardiac history presented in the middle of the night with acute chestpain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. This is a case I had quite a while back. See the explainability : She sees large T-waves in V2, V3.
The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction. link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. They did not find one STEMI on their triage ECGs (no surprise!
A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chestpain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.
He denied chestpain or shortness of breath. In the clinical context of weakness and fever, without chestpain or shortness of breath, the likelihood of Brugada pattern is obviously much higher. Induced Brugada-type electrocardiogram, a sign for imminent malignant arrhythmias. PM Cardio digitized version.
This was just published in JAMA Internal Medicine: The de Winter Electrocardiogram Pattern Evolving From Hyperacute T Waves It reminded me that many believe, due to the assertions in the original de Winter's article, that de Winter's waves are stable. He was a 30-something with chestpain. Here is one case of a patient I saw.
This was sent by : Jacob Smith, DO Emergency Medicine Resident Ohio Health Doctors Hospital Emergency Residency Christopher Lloyd, DO, FACEP Director of Clinical Education, USACS Midwest Case A 30 year old patient presents to triage with chestpain. This is diagnostic of inferior MI, though does not meet millimeter criteria for "STEMI."
can cause ST-segment elevation (STE) on electrocardiogram (ECG), the distinction between them may be hard and complicated. Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO). At each step, you will also find active links to the original publications.
A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chestpain and shortness of breath. This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline."
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 chestpain, lasting 5 minutes at a time, with several episodes over the past couple of months. Plan was for admission for chestpain workup. Patel DJ, et al.
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?
An initial electrocardiogram (ECG) is provided below. Although the patient reported experiencing mild pressure-like chestpain, there was suspicion among clinicians that this might be indicative of an older change. The patient was promptly admitted to the hospital for further evaluation. What do you think? What is the rhythm?
When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?
He was asked multiple times about chestpain or dyspnea, but repeatedly denied any such symptoms. Patient denied chestpain on initial review of symptoms. Was now endorsing chestpain which began 30 minutes ago. Upon further questioning, he states that he has had intermittent chestpain since yesterday.
She went on to describe her chestpain as a "buffalo sitting on my chest" and a "weird" sensation in her jaw for 1 hour prior to arrival, associated with lightheadedness and diaphoresis. The patient was given fentanyl initially for chestpain with minimal effect and then vomited which was followed by zofran and famotidine.
A 40 something otherwise healthy man presented with substernal chestpain. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. These include about 60 occlusion MI (OMI) with clear ST segment elevation (none of which would be called “Normal” by the computer) and about 165 Non-STEMI.
This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. Cardiology felt her chestpain to be, most likely, the result of coronary supply-demand mismatch in the context of HCM endothelial remodeling (i.e.
A Deep Neural Network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation. But lead V2 has a worrisome amount of ST elevation, and in a chestpain patient, I would be worried about STEMI. I do research on Cardiologs' algorithm: Smith SW et al. What an honor.
The patient contacted EMS after a few hours of chestpain that started 5:30 AM. The pain was described as 6/10 radiating to the right shoulder. The chestpain was described as both sharp and pressure like. Below is the post -PCI electrocardiogram. He is otherwise healthy.
male with a history of HTN and ETOH developed squeezing epigastric abdominal pain with associated vomiting and diaphoresis, followed by a syncopal episode which lasted about 10 seconds. When medics arrived, he denied any chestpain, shortness of breath, or palpitations prior to the syncopal episode.
A middle-aged woman had intermittent angina for 48 hours, then onset of constant, crushing chestpain for 1.5 cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." hours when she called 911. LV Thrombus , 1.5 0 0 1 95 544 MMRF 4 1 638 14.0 GUSTO-I Investigators.
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. It was from a patient with chestpain: Note the obvious Brugada pattern. Bicarb 20, Lactate 4.2,
Written by Jesse McLaren Two patients presented with acute chestpain, and below are the precordial leads V1-6 for each. Patient 1 Patient 2 STEMI criteria is based only ST elevation millimeter criteria measured in isolation from the QRS and stratified by age/sex, so this is the only information provided above.
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