Dr. Smith's ECG Blog

MARCH 22, 2024

The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible. Back to the assessment of ischemia: Returning to the ECG, the leads that catch my eye first are -- I, II, V4, V5, V6. For national registry purposes, this will be incorrectly classified as a STEMI.) < 0.049).

Chest Pain 114

Chest Pain STEMI Bradycardia Ischemia 114

Dr. Smith's ECG Blog

JUNE 27, 2021

If this STD were due to LVH or to subendocardial ischemia, rather than posterior OMI, it would be maximal in V5 and V6. If I saw this without the STD V2-V4, I would not make anything of it, and even with that precordial STD, I am not convinced that it is a manifestation of ischemia. Because we are hypnotized the STEMI paradigm. "If

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). It makes you think you have done something for the ischemia when you have not!

STEMI 78

STEMI Myocardial Infarction Ischemia Academic 78

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

The ECG in the chart was read as "no obvious ST changes," (even though no previous ECG was available) and the formal read by the emergency physicians was: "ST deviation and moderated T-wave abnormality, consider lateral ischemia." New ST elevation diagnostic of STEMI [equation value = 25.3 Computerized QTc = 417. Gottlieb SO, et al.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). While this may be change that is reciprocal to an Acute/Subacute Inferior STEMI, the problem is that LV aneurysm may also manifest with this reciprocal change. In STEMI, they are generally upright and large in proportion to the QRS. This case is tough.

Chest Pain 52

Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

MARCH 8, 2021

Prehospital ECG: Obvious anterolateral STEMI (Proximal LAD occlusion) The cath lab was activated prehospital by the medics. Perhaps they indicate an open artery with minimal flow and severe subendocardial ischemia, but not total subepicardial ischemia. Interventionalist at the Receiving Hospital: "No STEMI, no cath.

Chest Pain 52

Chest Pain STEMI Ischemia Critical Care 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

Wellens' syndrome represents the aftermath of an unrecorded occlusion (STEMI) with spontaneous reperfusion. This was my interpretation: although most ischemic T-wave inversion is post -ischemic like Wellens, sometime active ischemia results in isolated T-wave inversion. We assumed this was Wellens' syndrome and treated as such.

Chest Pain 52

Chest Pain Angina Ischemia Stenosis 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)? His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Physician interpretation: "No STEMI."

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

Dr. Smith's ECG Blog

JULY 11, 2018

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. But which myocardial walls are affected?

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

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.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Dr. Smith's ECG Blog

OCTOBER 6, 2018

He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." If the patient had been "lucky," his symptoms from the prior day might have been due to ischemia prolonged and intense enough to result in small troponin increase. Of the 418 patient with ACO, 29% did not meet “STEMI criteria.”

Chest Pain 40

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

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 4, 2019

T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH. Resolution of pain, by itself, is not reliable enough to be certain of resolution of ischemia. the ischemia has truly resolved. OMI often does not meet STEMI criteria. Circ Arrhythm Electrophysiol. 2013;6(1):76-83.

Chest Pain 52

Chest Pain STEMI Ischemia Aortic 52

Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. Weren't you taught that "new tall T wave in V1" is concerning for ischemia, and so this is the opposite? 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. Leads V4-V6 show new loss of S-wave.

Pericarditis 52

Pericarditis STEMI Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

JUNE 20, 2018

The medicine note documents that the patient had worsening pain with lying flat and relief with leaning forward. I know from reading your blog that you "diagnose pericarditis at your own peril", but are there any signs on that initial ECG that would make you think ischemia? See this case: Pericarditis, or Anterior STEMI?

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 52

Dr. Smith's ECG Blog

APRIL 8, 2016

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). There is atrial fibrillation.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

JUNE 13, 2024

Her first set of vitals were documented: BP 116/57 Pulse 94bpm Respiratory rate 24/min O2 sat 90% on room air Temp 97F She had been cleaning a Jeep in the sun, and was sunburned. V1 sits over both the RV and the septum, so transmural ischemia of either one with give OMI pattern in V1 and reciprocal STD in V5 and V6. CK MB was 1.9

Chest Pain 92

Chest Pain Document STEMI Defibrillator 92

Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI? Possible mechanisms of ventricular arrhythmias elicited by ischemia followed by reperfusion. What is the rhythm? Moffat, M.

Chest Pain 107

Chest Pain Arrhythmia Myocardial Infarction STEMI 107

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There is no definite evidence of acute ischemia. (ie, In both tracings — an exceedingly fast PMVT is documented. Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. (

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! We assume that at some point the patient's pain returned, but it is not documented, so exactly when this happened is uncertain. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. Our patient had a Brugada Type 1 pattern elicited by an elevated core temperature, which is also a documented phenomenon. So maybe she is better than I am.

Chest Pain 92

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 92

Dr. Smith's ECG Blog

JANUARY 30, 2019

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. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. Bicarb 20, Lactate 4.2,

Heart Rhythm 52

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 12, 2025

Even before we have clinical context, this ECG simply does not appear concerning for OMI, notwithstanding the machine's interpretation ** ** ACUTE MI / STEMI ** **. But in the world of STEMI, this is a challenging ECG to most. There were 80 positives by STEMI criteria, 88 by device algorithm, and 77 by AI software.

Chest Pain 82

Chest Pain STEMI Electrocardiogram Blog 82

Dr. Smith's ECG Blog

DECEMBER 31, 2024

The ECG shows sinus rhythm with normal QRS complex morphology and significant subendocardial ischemia (SEI) pattern (ST depression in many leads, worst in lateral areas including leads II, V5-6, with reciprocal STE in aVR). Here is her ECG within 30 minutes of PCI: Improved, but still with ischemia.

Ischemia 118

Ischemia Tachycardia Chest Pain STEMI 118

Dr. Smith's ECG Blog

JANUARY 13, 2025

Unexplained cardiac arrest or documented VF/polymorphic VT: +3 3. How well does the computer interpretation perform? -- in this case, the computer diagnosed STEMI but the patient had Fever with Brugada -- A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? Ischemia or infarction. Clinical History 2.a.

Chest Pain 71

Chest Pain Cardiac Arrest Ischemia Sudden Cardiac Death 71

Dr. Smith's ECG Blog

MARCH 8, 2025

It is possible there is microvascular dysfunction producing residual transmural ischemia. But this is most common when there is prolonged ischemia, and this patient had the fastest reperfusion imaginable! There was indication of parasympathetic overdrive ( the acute inferior STEMI with profound bradycardia and junctional escape ).

Cardiomyopathy 75

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia 75