Dr. Smith's ECG Blog

NOVEMBER 22, 2023

He was treated for infection and DKA and admission to hospital was planned. Important point: when there is diffuse subendocardial ischemia but no OMI, a wall motion abnormality will not necessarily be present. They agreed ischemia was likely in the setting of demand given DKA and infection. 40 mg of furosemide was given.

Chest Pain 119

Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

Ken Grauer, MD

AUGUST 26, 2023

These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ). About 20 minutes later ( on the way to the hospital ) — the patient's CP resolved, and ECG #1 was recorded.

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Blog Chest Pain STEMI Ischemia 145

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. DISCUSSION: The 12-lead EKG EMS initially obtained for this patient showed severe ischemia, with profound "infero-lateral" ST depression and reciprocal ST elevation in lead aVR.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. 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. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

APRIL 24, 2015

Again, it is common to have an ECG that shows apparent subendocardial ischemia after resuscitation from cardiac arrest, after defibrillation, and after cardioversion. and repeat the ECG, to see if the apparent ischemia persists. A third ECG was done about 25 minutes after the first: This shows resolution of all apparent ischemia.

Cardiac Arrest 52

Cardiac Arrest Defibrillator Atrial Fibrillation Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

His friend was able to get him into the truck and drive him to a nearby community hospital (non-PCI center). We have also shown several cases in which atrial flutter hides true, active ischemia. Is this inferor STEMI? Atrial Flutter with Inferior STEMI? The EM provider asked if the cardiologist thought it was a "STEMI."

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Atrial Flutter Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

She presented to an outside hospital after several days of malaise and feeling unwell. It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. At the time of admission, her vital signs were normal. Heart rate was in the 80s.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Smith : the profound persistent STE suggests either persistent occlusion or " no reflow " with persistent downstream ischemia. Long term outcome unknown but obviously bleak.

STEMI 78

STEMI Myocardial Infarction Ischemia Academic 78

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 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

Chest Pain 98

Chest Pain STEMI Myocardial Infarction Blog 98

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.

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Chest Pain STEMI Echocardiogram Stent 116

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 104

Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

OCTOBER 28, 2013

STE limited to aVR is due to diffuse subendocardial ischemia, but what of STE in both aVR and V1? The last section is a detailed discussion of the research on aVR in both STEMI and NonSTEMI. Alternatively, it is a variant of diffuse subendocardial ischemia, with STE in V1 reciprocal to ST depression in inferior and lateral leads.

Cardiac Arrest 52

Cardiac Arrest Ischemia Defibrillator Electrocardiogram 52

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. The patient had ROSC and maintained it. A 12-lead ECG was obtained: What do you think?

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 98

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.

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Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

He was admitted to the hospital for evaluation of these symptoms — but no ECG was done at that time. At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). The patient’s angiogram should have been expedited, but the EKG change was not recognized as recurrence of transmural ischemia.

Chest Pain 120

Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet.

Ischemia 40

Ischemia Chest Pain STEMI Stenosis 40

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

JANUARY 1, 2024

The patient was promptly admitted to the hospital for further evaluation. 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. An initial electrocardiogram (ECG) is provided below.

Tachycardia 112

Tachycardia Blog Ischemia Heart Failure 112

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock. So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution. So this is STEMI, right? Our chief of cardiology, Gautam Shroff, interprets it differently and thinks this is indeed ischemia.

Cardiogenic Shock 52

Cardiogenic Shock STEMI Pericarditis Blog 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. Refractory ischemia or electrical/hemodynamic instability are indications for the PCI.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

EMS 12-Lead

MAY 20, 2022

There is broad subendocardial ischemia as demonstrated by STE aVR with concomitant STD that almost appears appropriately maximal in Leads II and V5. There is LBBB-like morphology with persistent patterns of subendocardial ischemia. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 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. Figure-2: TOP — Initial ECG obtained pre-hospital.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. Transmitted to hospital with PCI." "ER My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 Pattern looked to be BER.

STEMI 52

STEMI Chest Pain RN Anatomy 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

APRIL 22, 2022

The HEART and EDACS scores are helpful to risk stratify patients with chest pain, but they hinge on accurate ECG interpretation: a low score doesn’t apply if the ECG shows STEMI(+)OMI, and shouldn’t be used for STEMI(-)OMI or OMI reperfusion either 2. Was this objective evidence of inducible ischemia accompanied by chest pain?

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction Angina 52

Ken Grauer, MD

JULY 22, 2023

KEY Point: In areas of the heart where an acute STEMI produces ST elevation — reperfusion T waves ( that develop after the "culprit" artery reopens ) will appear as T wave inversion. The C ASE C ontinues : En route to the hospital — another tracing was done 2 minutes after ECG #1. ECG Blog #367 — for another example of acute LCx OMI.

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Blog Chest Pain STEMI AFIB 78

Dr. Smith's ECG Blog

JULY 31, 2018

Post by Smith, with short article by Angie Lobo ( [link] ), a third year intermal medicine resident at Abbott Northwestern Hospital Case A 30-something woman with no past history, who is very fit and athletic, presented with 1.5 It is equivalent to a transient STEMI. It they are static, then they are not due to ischemia.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. It’s important to stress the presence of a normal QRS (i.e.,

STEMI 52

STEMI Stent Stents Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

There is STE that does not meet STEMI criteria in V1-V6. This patient's ischemia was so brief that it did not cause any myocardial stunning. I focus my attention on the first 2 ECGs, both of which were done prior to arrival in the hospital. This was mistaken by the treating physicians for ST depression initially.

Chest Pain 52

Chest Pain Ischemia STEMI Stent 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Another ECG was recorded 5 minutes later just before arrival at the hospital: Similar The patient was transported to a nearby suburban hospital with PCI capabilities while my partner cared for her. These findings are diagnostic of an apical OMI as a result of LAD Occlusion. She was defibrillated and resuscitated. From Gue at al.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI. QTc is the computer measurement. 100% LAD occlusion.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

I am going to code this as an acute STEMI as he had transient ST elevation which started to evolve in the emergency department but I think this is most appropriately termed STEMI." Is this Acute Ischemia? When is it anterior STEMI? Next day ECG: 2 Very instructive posts on LVH and OMI and Pseudo-OMI 1. More on LVH.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

The morphology of STE is not diagnostic of being due to acute transmural ischemia. This one likely does meet STEMI criteria in II, III, and aVF. The development of an inferior-posterior STEMI, from prehospital to hospital Inferior hyperacute T-waves. Criteria for a STEMI are definitely not met in ECG #1.

Chest Pain 52

Chest Pain STEMI Biomarkers Article 52

Dr. Smith's ECG Blog

MARCH 11, 2019

The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." Here is the patient's troponin I profile: These were interpreted as due to demand ischemia, or type II MI. ng/mL is seldom a result of demand ischemia (type 2 MI). First was 2.9

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

These findings are concerning for inferior wall ischemia with possible posterior wall involvement. His initial cTnI at the receiving hospital was 27 ng/mL, and no further troponins were measured thereafter. The morphology in V2 is also concerning and it appears that the ST segment is being pushed down, as in ST depression.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI. Because of its potential for invoking uneeded cardiac catheterization or hospital admission — it is worth periodically reviewing this ECG pattern.

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Blog Bradycardia Ischemia Exercise 52