Electrocardiogram, Myocardial Infarction and STEMI

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

Chest Pain

Chest Pain STEMI Myocardial Infarction Ischemia

See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. His first electrocardiogram ( ECG) is given below: --Sinus bradycardia. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. 2021.21026.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

Which patient has the more severe chest pain?

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

See these 2 articles Association between pre-hospital chest pain severity and myocardial injury in ST elevation myocardial infarction: A post-hoc analysis of the AVOID study Author links open overlay panel [link] 1 Background We sought to determine if an association exists between prehospital chest pain severity and markers of myocardial injury.

Chest Pain

Chest Pain STEMI Myocardial Infarction Hospital

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI

STEMI Article Chest Pain Blog

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). LAFB, atrial flutter, anterolateral STEMI(+) OMI.

Chest Pain

Chest Pain Myocardial Infarction STEMI Pacemaker

Active chest pain. Fake? or Inferior OMI? Hyperacute T waves?

Dr. Smith's ECG Blog

JUNE 17, 2023

I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 mm of STE in II and III, or III and aVF, or V4 and V5, so some might say it fulfills STEMI criteria (remember, the interrater reliability of STEMI criteria is poor as shown in references below): McCabe et al.

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

STEMI

STEMI Chest Pain Myocardial Infarction Stents

How unreliable are computer algorithms in the Diagnosis of STEMI?

Dr. Smith's ECG Blog

MARCH 10, 2017

Safety of Computer Interpretation of Normal Triage Electrocardiograms. The cath lab was activated, as it should be with transient STEMI. See this case of transient STEMI: Spontaneous Reperfusion and Re-occlusion - My Bad Thinking Contributes to a Death. It is not yet available, but this is your way to get on the list.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6

Dr. Smith's ECG Blog

MARCH 13, 2013

You can see how V1, V2, aVR, and V4R would have ST elevation in either a right ventricular STEMI or with a septal STEMI, and how lateral leads, and even posterior leads, would have reciprocal ST depression. of patients with anterior STEMI, ST elevation of greater than or equal to 3.0 STE in V4R is confirmatory evidence.

STEMI

STEMI Myocardial Infarction Electrocardiogram Chest Pain

Our OMI Toolbox Application is out now !

Dr. Smith's ECG Blog

MARCH 3, 2023

As myocardial infarction (MI) and many other diagnoses (for example left ventricular hypertrophy, prior MI etc.) can cause ST-segment elevation (STE) on electrocardiogram (ECG), the distinction between them may be hard and complicated.

Chest Pain

Chest Pain STEMI Download Blog

Right precordial ST depression in a patient with chest pain

Dr. Smith's ECG Blog

AUGUST 3, 2017

The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! Posterior STEMI occurs in approximately 15-20% of acute MI, but the vast majority of the time it is seen in conjunction with inferior (Infero-Posterior) or lateral (Postero-Lateral) STEMI (1).

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

Dark Side of the Moon

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. The EMS crews were correct moving forward with STEMI activation. 1] Driver, B.

Myocardial Infarction

Myocardial Infarction Coronary Angiogram STEMI Ischemia

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. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia

Ischemia STEMI Stenosis Coronary Artery Disease

50-year old with chest pain, “no ischemic changes”

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. This confirms these Q waves are caused by an acute infarct. But the ECG still doesn’t meet STEMI criteria. Smith : Normal ST Elevation in V2-V4 never has an associated Q-wave! the computer interpretation 2.

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Literature cited In inferior myocardial infarction, neither ST elevation in lead V1 nor ST depression in lead I are reliable findings for the diagnosis of right ventricular infarction Johanna E. What is the atrial activity? Is it sinus arrest with junctional escape?

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

Should Emergency Physicians be interrupted by ECGs that are read as "Normal" by the computer?

Dr. Smith's ECG Blog

JUNE 12, 2017

This is diagnostic of inferior MI, though does not meet millimeter criteria for "STEMI." He was worried for inferior MI and ordered another, which was recorded 15 minutes later: Now clearly and obviously diagnostic of inferior STEMI. Unknown algorithm Interpretation: Inferior ST elevation, with reciprocal ST depression in aVL.

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

Chest Pain

Chest Pain STEMI Blog Stents

Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

Chest Pain

Chest Pain STEMI Myocardial Infarction Electrocardiogram

The Bleeding Heart

EMS 12-Lead

APRIL 21, 2022

His father and brother both died of myocardial infarction at ages 61 and 45, respectively. STEMI was activated and the patient went to Cath on arrival. New insights into the use of the 12 Lead Electrocardiogram for diagnosing Acute Myocardial Infarction in the emergency department. 2] Aslanger, E.,

Ischemia

Ischemia Myocardial Infarction Blog Coronary Angiogram

Initial Reperfusion T-waves, Followed by Pseudonormalization. Diagnosis?

Dr. Smith's ECG Blog

MARCH 11, 2016

Appearance of abnormal Q waves early in the course of acute myocardial infarction: implications for efficacy of thrombolytic therapy. cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." These do NOT indicate late, subacute MI. Raitt MH, et al. LV Thrombus , 1.5

Myocardial Infarction

Myocardial Infarction Pericarditis Angina STEMI

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

Dr. Smith's ECG Blog

JANUARY 17, 2024

The limb leads have been removed because there was no ST elevation in those leads, the QRS complexes have been obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation. But STEMI criteria ignore all this and look at ST segments in isolation.

Chest Pain

Chest Pain STEMI Myocardial Infarction Blog

Hypertrophic Cardiomyopathy

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. New insights into the use of the 12-lead electrocardiogram for diagnosing acute myocardial infarction in the emergency department.

Cardiomyopathy

Cardiomyopathy Ischemia STEMI Coronary Angiogram

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Available from: [link] Excerpt: "To illustrate the limitations imposed by sample size, recent data from our institution reveal that we identify approximately 225 type I myocardial infarctions (MI) in a typical year. Am J Emerg Med.

Chest Pain

Chest Pain STEMI Article Myocardial Infarction

What will you do for this patient transferred to you who is now asymptomatic?

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI

STEMI Chest Pain Myocardial Infarction Ischemia

Four anterior STEMIs: acute and reperfused vs. won't reperfuse, subacute and reperfused vs. not reperfused

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. Zwolle Myocardial Infarction Study Group.

STEMI

STEMI Myocardial Infarction Chest Pain Angioplasty

How does Acute Total Left Main Coronary occlusion present on the ECG?

Dr. Smith's ECG Blog

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Myocardial Infarction

Myocardial Infarction Ischemia STEMI Cardiogenic Shock

Another Inadequate Paper Published on Triage ECGs, whose Conclusions Need Scrutiny.

Dr. Smith's ECG Blog

OCTOBER 9, 2018

The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction. link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. Am J Emerg Med 36(10):1771-1774. October 2018.

Chest Pain

Chest Pain STEMI Cardiac Arrest Heart Failure

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

LAD 80% mid LCx occluded mid (acute infarct lesion) RCA 80% mid. PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. Cardiac Troponin Changes to Distinguish Type 1 and Type 2 Myocardial Infarction and 180-Day Mortality Risk.

Myocardial Infarction

Myocardial Infarction Chest Pain Cardiogenic Shock STEMI

Cardiovascular Update

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

See OMI vs. STEMI philosophy in action

Which patient has the more severe chest pain?

OMI-NOMI paradigm established as better than STEMI-NSTEMI with new article

A man in his 70s with acute chest pain and paced rhythm.

Active chest pain. Fake? or Inferior OMI? Hyperacute T waves?

Is OMI an ECG Diagnosis?

How unreliable are computer algorithms in the Diagnosis of STEMI?

Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6

Our OMI Toolbox Application is out now !

Right precordial ST depression in a patient with chest pain

Dark Side of the Moon

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

50-year old with chest pain, “no ischemic changes”

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Should Emergency Physicians be interrupted by ECGs that are read as "Normal" by the computer?

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

Two 70 year olds with chest pain, and 3 pitfalls of the STEMI paradigm

The Bleeding Heart

Initial Reperfusion T-waves, Followed by Pseudonormalization. Diagnosis?

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

Hypertrophic Cardiomyopathy

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

What will you do for this patient transferred to you who is now asymptomatic?

Four anterior STEMIs: acute and reperfused vs. won't reperfuse, subacute and reperfused vs. not reperfused

How does Acute Total Left Main Coronary occlusion present on the ECG?

Another Inadequate Paper Published on Triage ECGs, whose Conclusions Need Scrutiny.

Should Troponin be a Vital Sign? Perhaps, but only if Interpreted Using Pre-test Probability.

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