Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later? This caused a type 2 anterior STEMI.

Cardiac Arrest 109

Cardiac Arrest STEMI Ischemia SCAD 109

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. In patients with narrow QRS ( not this patient), this pattern is highly suggestive of acute pulmonary embolism. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. When EMS found her, she was dyspneic and diaphoretic.

Cardiogenic Shock 127

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 127

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 98

Chest Pain STEMI Blog Stents 98

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Transient and partial thrombosis at the site of a non-obstructive plaque with subsequent spontaneous fibrinolysis and distal embolization may be one of the mechanisms responsible for the occurrence of MINOCA. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al. Circulation.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

JANUARY 8, 2024

Smith interpretation: This is highly likely to be due to extreme right heart strain and is nearly diagnostic of pulmonary embolism. She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. Medics recorded the above ECG and called a STEMI alert. It is of course pulmonary embolism.

Chest Pain 71

Chest Pain Pulmonary Embolism STEMI 71

Dr. Smith's ECG Blog

JUNE 11, 2011

Is this an anterior STEMI with LBBB? Explanation : The patient had a worrisome history: 59 yo with significant substernal chest pressure, so his pretest probability of MI (and even of STEMI) is reasonably high. Additionally, appropriate discordance is common in NonSTEMI, but very unusual in coronary occlusion (STEMI).

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

APRIL 26, 2017

This meets "STEMI criteria" However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4. The morphology is not right for STEMI. My interpretation: LVH with secondary ST-T abnormalities, exaggerated by stress, not a STEMI. This is very good evidence that the ST elevation is not due to STEMI.

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

DECEMBER 14, 2016

The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI? The patient had been on a long drive, suggesting possible pulmonary embolism (this was unlikely given absence of tachyardia, hypoxia, or any other feature of PE), so we sent a d dimer. The troponin I returned at 4.1 mm STE in one lead. This includes: 1.

Chest Pain 52

Chest Pain STEMI Aortic Myocardial Infarction 52

Circulation

NOVEMBER 11, 2024

In patients with nonvalvular A fib, the majority of embolic strokes are caused by thrombi development in the left atrial appendage. Patients with documented STEMI, left ventricular thrombus, mechanical mitral or aortic valve replacement were excluded. A fib is a well-established risk factor for ischemic strokes.

Stroke 40

Stroke Strokes Aortic valve Document 40

Dr. Smith's ECG Blog

DECEMBER 17, 2011

There is inferior STEMI. He took another look and realized that the culprit was indeed in the proximal RCA and that the thrombus had embolized distally. For those who don't have time to watch a video, you'll have to read the ECG as shown on this still frame because I lost it and cannot post it. There was no right sided ECG.

Chest Pain 40

Chest Pain Embolism STEMI Stent 40

Dr. Smith's ECG Blog

FEBRUARY 29, 2016

It is uncommon in the age of reperfusion therapy, as most STEMI get treated reasonably early, before transmural infarct. LV aneurysm puts them at risk for a mural thrombus, which puts them at risk for embolism, especially embolic stroke. Most STEMI peak at over 10 ng/mL; most NonSTEMI at less than 10 ng/mL.

Aneurysm 52

Aneurysm Ischemia Embolism STEMI 52

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). and therefore highly unlikely to be STEMI. Does subsegmental pulmonary embolism matter?

Pericarditis 52

Pericarditis Chest Pain Pulmonary STEMI 52

Dr. Smith's ECG Blog

MAY 19, 2020

This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI. I believe the latter (type II STEMI) is most likely.

Defibrillator 52

Defibrillator Circulation Plaque Cardiac Arrest 52

Dr. Smith's ECG Blog

MAY 10, 2023

Later, she developed chest pain again, and had this ECG recorded: Obvious Anterior OMI that is also a STEMI Coronary angiogram- --Right dominant coronary artery system --The left main artery was normal in appearance and free of obstructive disease. --The Thus, Wellens' syndrome should be thought of as a transient OMI or transient STEMI.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

ECG Cases

APRIL 2, 2024

In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chest pain. They explain complementary diagnostic insights into pericardial effusion and cardiac tamponade, occlusion MI and RV strain.

Chest Pain 133

Chest Pain Blog Embolism Pulmonary 133

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. However, by the time of the angiogram it had embolized distally, and had only done so after the right sided ECG was recorded. This prehospital ECG was recorded: Here are limb leads: Here are precordial leads: Diagnosis?

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Transient and partial thrombosis at the site of a non-obstructive plaque with subsequent spontaneous fibrinolysis and distal embolization may be one of the mechanisms responsible for the occurrence of MINOCA. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al. Circulation.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction.

Plaque 127

Plaque Angina Blog Stents 127

Dr. Smith's ECG Blog

JANUARY 12, 2023

ECG read as: "Shows T wave inversions in the inferior leads and less than 1mm STE in V2, without STEMI criteria." CT pulmonary angiogram was negative for pulmonary embolism. All very very subtle. So the patient was placed back in the waiting room like many others. Aspirin was given. Second troponin T resulted at 1,318 ng/L.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

You may see a filling defect in distal LAD, most probably due to an embolization from proximal lesion. The "occlusion pattern" on ECG may change during the course of evolution ( in today's case — from a proximal LAD OMI to a more distal LAD OMI pattern, presumably due to embolization from a proximal lesion ).

Chest Pain 52

Chest Pain Myocardial Infarction Blog Pericarditis 52

ECG Cases

APRIL 14, 2020

In this ECG Cases blog we look at 6 patients who presented with cardiorespiratory symptoms, possibly from COVID and illustrate the dangers of anchoring, being hypervigilant for cardiovascular complications, and why testing for COVID in patients being admitted for ACS is important.

COVID-19 52

COVID-19 Blog Embolism Pulmonary 52

ECG Cases

MARCH 29, 2022

In this ECG Cases blog we review 10 cases of possible artifact, lead reversal and lead misplacement. Can you spot the abnormalities and avoid the misdiagnosis? The post ECG Cases 29 Misdiagnosis from Lead Misplacement, Artifact and Lead Reversal appeared first on Emergency Medicine Cases.

Blog 52

Blog Embolism Pulmonary STEMI 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Patients with pulmonary embolism or aortic dissection who have normal variant ST elevation are at high risk of being diagnosed with pericarditis when what they have is far more serious!! normal variant, not pericarditis) A Young Man with Sharp Chest pain (normal variant, not pericarditis) 24 yo woman with chest pain: Is this STEMI?

Pericarditis 52

Pericarditis Chest Pain Aortic Blog 52

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 118

Chest Pain STEMI Myocardial Infarction Blog 118

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Bi-phasic scan showed no dissection or pulmonary embolism. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." He was started on a heparin drip and CTA of the chest was ordered to rule out pulmonary embolism. Unfortunately, there was a long wait and the patient left before being seen by a provider.

Chest Pain 138

Chest Pain Embolism Pulmonary Tachycardia 138

Dr. Smith's ECG Blog

MAY 13, 2024

This ECG is highly concerning for LAD occlusion despite it not showing a STEMI criteria. You can find the variables used to calculate the value on MD calc here: [link] Utilizing Dr. Smith’s Subtle Anterior STEMI Calculator (4-Variable), the value is greater than 18.2 which is concerning for LAD occlusion.

Chest Pain 120

Chest Pain STEMI Ultrasound Heart attacks 120

Dr. Smith's ECG Blog

DECEMBER 15, 2015

It makes pulmonary embolism (PE) very likely. Although most cardiac arrest from MI is due to ventricular fibrillation, some is due to high grade AV block, and so this could indeed be due to large acute STEMI. LV anterior STEMI does not give maximal ST elevation in V1. So this ECG is typical of right ventricular (RV) STEMI.

STEMI 40

STEMI Embolism Pulmonary Ultrasound 40

Dr. Smith's ECG Blog

OCTOBER 10, 2022

The morphology of V2-V4 is very specific in my experience for acute right heart strain (which has many potential etiologies, but none more common and important in EM than acute pulmonary embolism). CT angiogram showed extensive saddle pulmonary embolism. He had multiple cardiac arrests with ROSC regained each time. This is a quiz.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 Smith ) — the overall impression was that ECG #1 did not suggest findings suggestive of OMI.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

MARCH 11, 2016

Both of these are very suggestive of " No-Reflow ," or poor microvascular reperfusion due to downstream embolization of microscopic platelet-fibrin aggregates. cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." LV Thrombus , 1.5 0 0 1 95 544 MMRF 4 1 638 14.0

Myocardial Infarction 52

Myocardial Infarction Pericarditis Angina STEMI 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. CT angiogram chest: no aortic dissection or pulmonary embolism. 24 yo woman with chest pain: Is this STEMI?

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2025

The emergency medicine physician documented, "His initial EKG is riddled with artifact and difficult to interpret but does not look like a STEMI." The ECG remains positive for STEMI by GE. Even if it is not atherosclerotic, young people can have embolic OMIs. In fact, even the GE algorithm got this one (partially) right.

STEMI 72

STEMI Pericarditis Chest Pain Echocardiogram 72

Dr. Smith's ECG Blog

MARCH 1, 2025

Note: the 2022 ACC Expert consensus Chest pain guidelines state that "posterior STEMI-Equivalent" is a sign of acute coronary occlusion. 2/3 of STEMI have a peak 4th generation troponin I greater than 10.0 Comment: The first ECG is diagnostic of OMI that does not meet STEMI criteria. NSTEMI-OMI").

Chest Pain 121

Chest Pain STEMI Stents Stent 121

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? The patient was found to have an embolic source. Embolism with lysis. Need to find an embolic source. Notes never having symptoms like this before, pain is so severe its causing SOB. He called 911. Medics recorded a BP of 79/52 with pulse of 47.

Chest Pain 60

Chest Pain Embolism STEMI Plaque 60

Dr. Smith's ECG Blog

DECEMBER 3, 2024

His initial high sensitivity troponin I returned at 1300 ng/L and given that his cardiac workup was otherwise unremarkable, a CT was obtained to evaluate for pulmonary embolism and aortic aneurysm or dissection but this too was unrevealing. Another EKG was also obtained. ECG at time 82 minutes: What do you think?

Catheterization Laboratory 110

Catheterization Laboratory STEMI Blog Ischemia 110

Dr. Smith's ECG Blog

APRIL 9, 2025

The paramedics diagnosis was "Possible Anterolateral STEMI." LAD: type III-IV vessel with a proximal thrombotic or embolic occlusion (TIMI 0 flow). More proof that a huge STEMI may have normal or near normal initial troponin. Taken together, these findings suggest an ongoing extensive antero-lateral STEMI. Angiogram: 2.

Defibrillator 63

Defibrillator Cardiac Arrest Myocardial Infarction STEMI 63