Ken Grauer, MD

JULY 15, 2023

CT coronary angiogram — No obstructive coronary disease. CT coronary angiogram showed no obstructive coronary disease. But immediate resolution of chest pain once VT was converted — and — the normal CT coronary angiogram — essentially ruled out acute coronary disease as the cause.

Blog 78

Blog Coronary Angiogram Cardiomyopathy Ischemia 78

Dr. Smith's ECG Blog

JUNE 19, 2024

His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. Surely, he should be given heparin and taken for an emergent angiogram, right? The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”. The patient started receiving medications for “STEMI” (including heparin!!!)

Chest Pain 60

Chest Pain Pericarditis Pacemaker STEMI 60

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? Incidence of an acute coronary occlusion.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

EMS 12-Lead

MARCH 19, 2023

It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. Learning points 1] Acute Coronary Syndrome has many shades of clinical manifestation. To which the lead paramedic replied, “Not cardiac; his symptoms are atypical. The shortened PR-interval is probably an accessory pathway.”

Myocardial Infarction 52

Myocardial Infarction STEMI Coronary Angiogram Coronary Artery Disease 52

Ken Grauer, MD

FEBRUARY 24, 2023

Hospital evaluation for this patient was negative for an acute coronary syndrome ( ie, CT coronary angiogram was normal — troponin was not elevated — and Echo was negative, with no sign of pericardial effusion ). CT Coronary Angiogram showed no sign of underlying coronary disease.

Pericarditis 78

Pericarditis Blog Chest Pain Coronary Angiogram 78

EMS 12-Lead

MAY 20, 2022

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. Type II MI), however decided to pursue coronary angiogram out of an abundance of caution.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

MAY 16, 2023

Here is the Queen of Heart's interpretation: The cath lab had been activated for concern of STEMI. Learning Points: This is one of many examples of false positive STEMI criteria, which is distinguishable by expert humans, and now by AI such as QOH. Emergent CT coronary angio also likely has a role in such cases.

Chest Pain 52

Chest Pain Pericarditis Tachycardia STEMI 52

Dr. Smith's ECG Blog

JUNE 20, 2020

The medics were worried about STEMI, as it meets STEMI criteria. Discussion Thus, no further ECGs were recorded and there was no angiogram or stress test or CT coronary angiogram. The troponins are NOT consistent with STEMI (OMI), which typically has a troponin I of at least 5 ng/mL. What do you think?

STEMI 52

STEMI Hospital Coronary Angiogram Dysrhythmia 52

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. Anterior STEMI? He was given aspirin and heparin and transferred to the local cardiac center for further evaluation. What is it? Activate the Cath Lab?

Chest Pain 52

Chest Pain Exercise Pacemaker Coronary Angiogram 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve. Look at the aortic outflow tract.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Here is the coronary angiogram: A distal thrombotic right coronary artery (RCA) occlusion ! Here is the post-intervention angiogram and post-PCI ECG. The pain was completely resolved after coronary intervention. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. doi: 10.5543/tkda.2021.21026.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Do you think we discussed this patient's 2-3 hour delay to reperfusion in our quarterly "STEMI meeting"?

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

EMS 12-Lead

APRIL 8, 2022

BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI. Cardiology admitted him for observation with plans for next-day coronary angiogram.

Myocardial Infarction 52

Myocardial Infarction Coronary Angiogram STEMI Ischemia 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. 24 yo woman with chest pain: Is this STEMI? This is not "diffuse", this is simply anterior, lateral, and likely apical.

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. It’s judicious, then, to arrange for coronary angiogram. Coronary occlusion, however, might be present concurrently with subendocardial ischemia on the time-zero ECG, or evolve into such. Does the ECG normalize?

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

Chest Pain 105

Chest Pain STEMI Aortic Ultrasound 105

Dr. S. Venkatesan MD

JANUARY 22, 2025

The fear comes built in with the diagnosis often amplified by young felllows on call (& often times by senior consultants as well) It may appear real, from a clinical angle, but trust, when we deal with the whole gamut of so-called ACS (other than STEMI), there is indeed a benign face in many of them.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Anatomy Angina 52

Dr. Smith's ECG Blog

MARCH 3, 2025

Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. An EKG from a year prior was available for comparison: The ED physician noted Initial EKG here read by the computer as a STEMI, however, there is a very poor baseline and a lot of artifact. See reference and discussion below.

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73

Dr. Smith's ECG Blog

MARCH 9, 2025

At 1210, the case was discussed with a cardiologist at a PCI capable facility, who accepted the patient for transfer, noting the ST depression in anterior leads as consistent with ischemia but not a STEMI. This was likely a case of wrong-vessel PCI. This is surprisingly common. 5 years later ( now in 2025 ) the problem remains.

Ischemia 88

Ischemia Blog STEMI Coronary Angiogram 88