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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 A 45-year-old presented with 24 hours of intermittent chestpain. On it’s own this is nonspecific, but in the right context this could be diagonal occlusion (if active chestpain) or infero-posterior reperfusion (if resolved chestpain). #2 What was the outcome and final diagnosis?
A 50-something male had onset of chestpain 1 hour prior to ED arrival. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. It was tested on a large database of known outcomes and was more than twice as senstivity as STEMI criteria and much better than cardiologists.
Written by Jesse McLaren A 65 year old with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented with 3 days of fluctuating chestpain, which was ongoing at triage. So a patient with high pretest probability (prior CABG with new chestpain), had new ECG changes showing posterior OMI.
Sent by Magnus Nossen MD, written by Pendell Meyers A man in his 50s, previously healthy, developed acute chestpain. The primary care physician there evaluated this patient and deemed the chestpain to be due to gastrointestinal causes. link] ] Outcome The patient emerged neurologically intact.
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. They concluded, "Our findings increase confidence in the normal automated GE Marquette 12 SL ECG software interpretation to predict a benign outcome.
Written by Jesse McLaren Four patients presented with chestpain. 1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes. have published a number of warnings about the previous reassuring studies.[4,5] minutes).
Written by Jesse McLaren A previously healthy 60 year old developed exertional chestpain with diaphoresis, and called EMS. So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. What do you think?
This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chestpain The tech came running with the ECG as the computer called "STEMI!" Tell me the outcome! So signed it NO STEMI and triaged him OK to not be in RESUS." What do you think? Sam sent this to me and asked: "What do you think, Steve?"
Written by Jesse McLaren, comments by Smith A 55 year old with a history of NSTEMI presented with two hours of exertional chestpain, with normal vitals. See these posts: ChestPain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab? So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion.
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?
The patient presented to an outside hospital An 80yo female per triage “patient presents with chestpain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. HPI: Abrupt onset of substernal chestpain associated with nausea/vomiting 30 min PTA.
Theres ST elevation in V3-4 which meets STEMI criteria, which could be present in either early repolarization, pericarditis or injury. Lets see what happens in the current STEMI paradigm. Emergency physician: STEMI neg but with elevated troponin = Non-STEMI The first ECG was signed off. Chestpain still persists.
Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( ChestPain ). It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. The ECG shows ST depression in lead V3.
A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chestpain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest. At times the pain does go to his left neck. What do you think the prehospital ECG showed (with pain)?
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".
A 40-something male presented by ambulance with one hour of chestpain that was improving after sublingual nitroglycerine and 325 mg of aspirin, chewed. Here it is: Obvious Inferior Posterior STEMI (+) OMI. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%.
A 67 yo f developed chestpain this morning." Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. See this case: A man his 50s with chestpain.
Submitted by Dr. Dennis Cho (@DennisCho), written by Jesse McLaren A 70-year-old with no cardiac history presented with 2 hours of chestpain radiating to the neck, associated with shortness of breath. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI?
Written by Pendell Meyers A woman in her 70s had acute chestpain and called EMS. Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Ongoing OMI.
A 29 year old male presented with 6 hours of stuttering chestpain, constant for the last hour, worse with breathing. Diagnosis: There are Q-waves, ST elevation, and hyperacute T-waves in V2 and V3, diagnostic of acute LAD occlusion (STEMI). Take home point here : Obtain an ECG on anyone with chestpain.
A healthy 45-year-old female presented with chestpain, with normal vitals. The patient was previously healthy, with no atherosclerotic risk factors, and developed chestpain after an episode of stress. The pain was crushing retrosternal, radiated to the arms and was associated with lightheadedness.
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.
Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chestpain. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. Barely any STE, and thus not meeting STEMI criteria.
There were no injuries and no chestpain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. Jason was very skeptical of STEMI. This also argues against STEMI. What was the outcome? Look for old ECGs Do serial ECGs Do echocardiography June 17, 2016 Anterior STEMI?
Written by Jesse McLaren, with comments from Smith A 50-year old patient on the medical wards developed acute chestpain, with an ECG labeled (see computer interpretation at the top) and confirmed as normal. In the STEMI paradigm, patients with ischemic symptoms and ECGs that don’t meet STEMI criteria get serial ECGs.
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). Because the patient had no chestpain or shortness of breath, they were initially diagnosed as gastroenteritis. Potassium was normal. Take home 1.
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.
[link] A 30 year-old woman was brought to the ED with chestpain. She had given birth a week ago, and she had similar chestpain during her labor. She attributed the chestpain to anxiety and stress, saying "I'm just an anxious person." examined SCAD presenting as STEMI (unlike Hassan et al.
Submitted and written by Anonymous, edits by Meyers and Smith A 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chestpain. The pain was heavy, radiated to her jaw with an associated headache. Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 Lupu L, et al.
There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."
Case submitted by Rachel Plate MD, written by Pendell Meyers A man in his 70s presented with chestpain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. He also noted a bilateral "odd feeling" in his arms. He stated it was similar to prior heart attacks.
Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chestpain and normal vitals except tachycardia at about 115 bpm. Dr. Singer sent this to me with just the information: "~40 year old with acute chestpain". Other outcome information is not available.
Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chestpain for 3 hours prior to arrival. At this time he reported ongoing chestpain and was given aspirin and nitroglycerin.
There were no injuries and no chestpain and he appeared well. He complained of 3 days of diarrhea and abdominal pain. Jason was very skeptical of STEMI. This also argues against STEMI. What was the outcome? There was no chestpain. What do you think? Jason, I agree. Check for old records.
He had suffered a couple bouts of typical chestpain in the last 24 hours. This ECG (ECG #3) was recorded immediately after the last episode of pain spontaneously resolved. The pain had lasted about one hour. So you are going to get to see what the ECG would have shown had you recorded one during pain!
A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. He had no chestpain. Is this acute STEMI? Is this an acute STEMI? -- Unlikely! Medications were aspirin, clopidogrel, metoprolol, and simvastatin.
A 60-something woman called EMS for chestpain. link] Clinical Course I don't know if the medics noticed these ECG findings or not, but if not, they recognized the value of serial ECGs in a patient with chestpain. The medics administered aspirin (no Nitroglycerine), and the pain resolved. #5: mm in V2 and 0.65
Anterolateral STEMI. He underwent PCI and had a good outcome. The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. He was defibrillated. Here is his post resuscitation ECG: Now the diagnosis is obvious. Notice how visible the ST elevation is in the PVCs.
There was apparently no syncope and he had no bony injuries, but he did complain of left sided chestpain. 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 ??
This case was recently posted by Tyron Maartens on Facebook EKG club (he agreed to let me post it here), with the following clinical information: "42 year old male with two weeks of intermittent chest discomfort, awoke 4 hours prior to this ECG with a more severe, heavy chestpain (5/10). Both support acute anterior STEMI.
The Patient: A 57-year-old man who complains of a sudden onset of "sharp" chestpain while on a long bike ride. The pain does not radiate, and nothing makes it worse or better. ST depression in the setting of acute transmural ischemia (STEMI) is almost ALWAYS due to reciprocal change. He is pale, cool, and diaphoretic.
A 20-something male presented from an outside facility with Chestpain. He came with this ECG from the outside facility, recorded 1 hour after pain onset: There is at least 2 mm of inferior ST elevation, with reciprocal ST depression in aVL, ST flattening in V4-V6, and T-wave inversion in V2. Vital signs were normal.
A male in his 60's called 911 for chestpain. His pain was intermittent and he was vague about when it was present and when it was resolved. He had an immediate ED ECG: There is artifact, but the findings appear to be largely gone now The diagnosis is acute MI, but not STEMI. Outcome : Was it RCA or LCX with inferior MI?
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