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

Dr. Smith's ECG Blog

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. Then ACS (STEMI) might be primary; this might be cardiogenic shock.

STEMI 52
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STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

Dr. Smith's ECG Blog

Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? Comments: STEMI with hypokalemia, especially with a long QT, puts the patient at very high risk of Torsades or Ventricular fibrillation (see many references, with abstracts, below). Crit Care Med.

STEMI 52
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A 50-something with chest pain.

Dr. Smith's ECG Blog

He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. Sensitivity was 87% for OMI in our validation study (it was 34% for STEMI criteria). He reports feeling nauseated with emesis. The Queen was not used in real time. Even the Queen can be wrong.

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A prehospital ECG in a patient with chest pain. The paramedics tell me it is normal.

Dr. Smith's ECG Blog

I took the patient to the critical care area and questioned him more on the way. Another ECG was recorded while awaiting the cath team: Now there is STEMI Let's look at that first (prehospital ECG) again: Very subtle! The pain had been intermittent until an hour before arrival, when he called 911. We activated the cath lab.

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A middle-aged man with acute chest pain.

Dr. Smith's ECG Blog

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. The patient was moved to the critical care area (stabilization room). This is the first version of the AI system. Accuracy was 91% and AUC was 0.95. Cath lab was activated.

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An elderly male with shortness of breath

Dr. Smith's ECG Blog

Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE? The computer thinks so, and the physician thinks that is quite possible. However , there is terminal QRS distortion in lead V3.

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De Winter's T-waves are Not a Stable ECG condition. Upright T-waves in Posterior OMI are Distinct from de Winter's waves.

Dr. Smith's ECG Blog

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