Echocardiogram, Ischemia and STEMI - Cardiovascular Update

What do you think the echocardiogram shows in this case?

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. What do you think the echocardiogram shows? NTG drip started. Pain better still.

Echocardiogram

Echocardiogram Ischemia Chest Pain Blog

A man with chest pain off and on for two days, and "No STEMI" at triage.

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 patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. Instead we discussed 5 minute delays for the STEMI(+) OMI patients.

Chest Pain

Chest Pain STEMI Cardiogenic Shock Ischemia

Infection and DKA, then sudden dyspnea while in the ED

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

Important point: when there is diffuse subendocardial ischemia but no OMI, a wall motion abnormality will not necessarily be present. See this post: What do you think the echocardiogram shows in this case? They agreed ischemia was likely in the setting of demand given DKA and infection. 40 mg of furosemide was given.

Chest Pain

Chest Pain Ischemia Echocardiogram Myocardial Infarction

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI

STEMI Chest Pain Stents Stent

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Whether these EKGs show myocarditis, a normal variant, or something else, they are overall not typical of transmural ischemia of the anterior or high lateral walls.

Chest Pain

Chest Pain STEMI Echocardiogram Stents

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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. His response: “subendocardial ischemia. Anything more on history? POCUS will be helpful.”

Ischemia

Ischemia STEMI Stenosis Chest Pain

An elderly male with acute altered mental status and huge ST Elevation

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? or basilar ischemia. Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). EKG on arrival to the ED is shown below: What do you think?

STEMI

STEMI Document Blog Ischemia

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

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. A transthoracic echocardiogram showed an LV EF of less than 15%, critically severe aortic stenosis , severe LVH , and a small LV cavity. Look at the aortic outflow tract. What do you see?

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

LVH with anterior ST Elevation. When is it anterior STEMI?

Dr. Smith's ECG Blog

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." No prior echocardiogram was available for comparison. Can you diagnose an ACO (STEMI) when you also have LVH?

STEMI

STEMI Myocardial Infarction Chest Pain Aneurysm

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

Dr. Smith's ECG Blog

OCTOBER 26, 2010

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. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

STEMI

STEMI Cardiogenic Shock Tachycardia Aneurysm

Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04 ng/ml)

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. But it could be anterior STEMI. 40% of anterior STEMI has upward concavity in all of leads V2-V6. is likely anterior STEMI).

STEMI

STEMI Pericarditis Hospital Aneurysm

Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

AUGUST 6, 2024

In any case, the ECG is diagnostic of severe ischemia and probably OMI. So this could be myocarditis but in my opinion needs an angiogram before making that diagnosis. == Dr. Nossen Comment/Interpretation: Evaluation of ischemia on an ECG can be very challenging. Concordant STE of 1 mm in just one lead or 2a.

Chest Pain

Chest Pain Ischemia Pericarditis Tachycardia

A 40-something presented after attempted prehospital resuscitation with persistent Ventricular Fibrillation

Dr. Smith's ECG Blog

JULY 14, 2023

My interpretation was: RBBB with hyperacute T-waves in V4-V6 that are all but diagnostic of LAD occlusion vs. post ROSC ischemia. Formal Echocardiogram: Normal left ventricular size and wall thickness. The patient had ROSC and maintained it. A 12-lead ECG was obtained: What do you think?

Cardiac Arrest

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter

Precordial ST depression. What is the diagnosis?

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. I have warned in the past that one must think of other etiologies of ischemia when there is tachycardia.

STEMI

STEMI Ischemia Chest Pain Myocardial Infarction

Cardiac Arrest, acute ST elevation and depression superimposed on LVH, but NOT due to ACS

Dr. Smith's ECG Blog

OCTOBER 4, 2010

There is profound LVH with anterolateral ST elevation and reciprocal ST depression in II, III, aVF, and ST depression in V5 and V6 that could all be secondary to LVH or could represent ischemia superimposed on the repolarization abnormalities of LVH: note that wherever there is ST depression, it is associated with a very high voltage R-wave.

Cardiac Arrest

Cardiac Arrest Ischemia Stenosis STEMI

Physical Examination as a Helpful Aid in Decision-Making in Challenging ECGs

Dr. Smith's ECG Blog

JANUARY 1, 2024

A rapid echocardiogram was performed, revealing an ejection fraction of 20% with thinning of the anterior-apical walls. Learning Point: Concordant ST segment elevation can arise from profound ischemia triggered by ventricular tachycardia (VT), or it may represent an exaggerated basal ST change accompanying tachycardia.

Tachycardia

Tachycardia Blog Ischemia Heart Failure

What happens when a patient with LAD OMI does not go immediately to the cath lab?

Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio greater than 0.36, then it is STEMI, not LV aneurysm. Is this a transient STEMI? Is it normal ST elevation?

STEMI

STEMI Ischemia Chest Pain Aneurysm

Posterior leads can give false reassurance

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

Does this mean that the ST depression in V3 represents "anterior" subendocardial ischemia, and not posterior OMI? Echocardiogram: The estimated left ventricular ejection fraction is 34% Regional wall motion abnormality-lateral, akinetic. non-occlusive ischemia) 2. Thus, they have much less voltage. They have ZERO ST Elevation.

Chest Pain

Chest Pain Blog Ischemia STEMI

First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

Dr. Smith's ECG Blog

MARCH 9, 2013

Here is the prehospital ECG, with pain: Hyperacute anterolateral STEMI The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering. A stent was placed. Lessons: 1.

Myocardial Infarction

Myocardial Infarction Chest Pain Ischemia Angina

The Computer and Overreading Cardiologist call this completely normal. Is it?

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

EKG initially negative but repeat shows a few T wave abnormalities… There is a chance this could be non-cardiac pain” At 1518, an echocardiogram showed normal LV size and systolic function with hypokinesis of the mid and distal anterior wall and the mid and distal septum. At 1605, another repeat troponin resulted at 5.271 ng/mL.

Chest Pain

Chest Pain Blog Hospital Tachycardia

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! He underwent formal echocardiogram several days later, which confirmed the findings of anterior, and apical wall motion abnormalities. Smith comment: this patient might have been sent home because of the poor sensitivity of this Point of Care (POC) assay. Chapman, A.

Chest Pain

Chest Pain Ultrasound STEMI Myocardial Infarction

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Here is the cath report: Echocardiogram: There is severe hypokinesis of entire LV apex and apical segment of all the walls. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. From Gue at al.

Plaque

Plaque Chest Pain Thrombosis Stenosis

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. A recent study found that SCAD causes almost 20% of STEMI in young women. Lobo et al.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

An athletic 30-something woman with acute substernal chest pressure

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. These are reperfusion T-waves (the same thing as Wellens' waves) Echocardiogram Regional wall motion abnormality-distal septum and apex. Again, cath lab was not activated.

SCAD

SCAD Chest Pain Myocardial Infarction Ischemia

A young patient with diminishing pain with a subtle but diagnostic ECG.

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Next day echocardiogram showed inferolateral hypokinesia with an EF of %45-50. On echocardiogram you will not see a "posterior" hypokinesia (will see "inferolateral") and, as in this case, LCx may not give the blood supply of basal inferior segment (formerly called "posterior"). The patient recovered well. J Am Heart Assoc. 121.022866.

Myocardial Infarction

Myocardial Infarction Chest Pain Blog Echocardiogram

Syncope and Prehospital Cath Lab activation -- What do you think?

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

They recorded a prehospital ECG and diagnosed STEMI and activated the cath lab prehospital. Next day, a stress echo was done: The exercise stress echocardiogram is normal. This ST-T wave appearance in the lateral chest leads of ECG #2 is consistent with L V “ S train” vs ischemia. No wall motion abnormality at rest.

Chest Pain

Chest Pain Ischemia Angina Electrocardiogram

A man in his 70s with weakness and syncope

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. Formal echocardiogram showed normal EF, no wall motion abnormalities, no pericardial effusion. So maybe she is better than I am. No more troponins were done.

Chest Pain

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). I think a good start would be a posterior EKG and a high quality contrast echocardiogram read by an expert. In there ECG evidence of possible ongoing ischemia? (ie,

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

2 days later This is a typical LVH pattern, without ischemia Patient underwent 4 vessel CABG. After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time."

Chest Pain

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog

A man in his 70s with chest pain during a bike ride

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. Unfortunately there is no echocardiogram accessible because the patient checked himself out of the hospital in order to get back to his home state before it could be completed. No significant changes, ongoing pain.

Chest Pain

Chest Pain Pulmonary ACE Inhibitor Pacemaker

Hyperthermia and ST Elevation

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

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI

What do you think the echocardiogram shows in this case?

A man with chest pain off and on for two days, and "No STEMI" at triage.

Infection and DKA, then sudden dyspnea while in the ED

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

An elderly male with acute altered mental status and huge ST Elevation

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

LVH with anterior ST Elevation. When is it anterior STEMI?

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

Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04 ng/ml)

Three prehospital ECGs in patients with chest pain

A 40-something presented after attempted prehospital resuscitation with persistent Ventricular Fibrillation

Precordial ST depression. What is the diagnosis?

Cardiac Arrest, acute ST elevation and depression superimposed on LVH, but NOT due to ACS

Physical Examination as a Helpful Aid in Decision-Making in Challenging ECGs

What happens when a patient with LAD OMI does not go immediately to the cath lab?

Posterior leads can give false reassurance

First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

The Computer and Overreading Cardiologist call this completely normal. Is it?

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

A young peripartum woman with Chest Pain

An athletic 30-something woman with acute substernal chest pressure

A young patient with diminishing pain with a subtle but diagnostic ECG.

Syncope and Prehospital Cath Lab activation -- What do you think?

A man in his 70s with weakness and syncope

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

A man in his 70s with chest pain during a bike ride

Hyperthermia and ST Elevation

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