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. The two cases were considered: Patient 1 was recognized by the ED provider and the cardiologist as having resolved “STEMI”. Patient 1 remained in the hospital overnight.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stents 116

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). Is this inferor STEMI? Tachycardia and ST Elevation. Atrial Flutter with Inferior STEMI? The EM provider asked if the cardiologist thought it was a "STEMI." Long-term outcome is unknown.

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Atrial Flutter Ischemia STEMI Tachycardia 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 conventional computer algorithm called “ sinus tachycardia, otherwise normal EKG ”. The proximal LAD is now widely patent.

Chest Pain 120

Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

He was treated for infection and DKA and admission to hospital was planned. This is ischemic ST depression, and could be due to increasing tachycardia, with a heart rate over 130, but that is unlikely given that the patient is now complaining of crushing chest pain and that there was tachycardia all along.

Chest Pain 118

Chest Pain Ischemia Echocardiogram Myocardial Infarction 118

Dr. Smith's ECG Blog

AUGUST 6, 2024

Despite active CP — cath lab activation was deferred and this patient was transported to a local hospital without PCI capability. It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. NOTE #1: Sinus tachycardia is not usually seen in an uncomplicated acute MI.

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

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 52

Ischemia STEMI Stenosis Chest Pain 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 no hypertension, no tachycardia, a normal hemoglobin, no drug use, no hypotension/shock, no murmur of aortic stenosis. The troponin I returned at 4.1 ng/mL (ULN = 0.030 ng/mL) , diagnostic of myocardial injury. mm STE in one lead.

Chest Pain 52

Chest Pain STEMI Aortic Pulmonary 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock. Here was the ECG: There is sinus tachycardia. So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution. So this is STEMI, right? This was sent by a reader. and K was normal.

Cardiogenic Shock 52

Cardiogenic Shock STEMI Pericarditis Blog 52

EMS 12-Lead

MARCH 19, 2023

The shortened PR-interval, specifically, proved to be quite beguiling as it swept crews down a differential diagnosis of intermittent accessory pathway syndrome – insomuch as a “syndrome” of recurrent tachycardia to account for the patient’s symptoms. To which the lead paramedic replied, “Not cardiac; his symptoms are atypical. Is this OMI?

Myocardial Infarction 52

Myocardial Infarction STEMI Coronary Angiogram Coronary Artery Disease 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

Is it ventricular tachycardia (VT) due to hyperK or is it a supraventricular rhythm with hyperK? Hospital admission had been recommended, but she left that ED against medical advice. to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 There is some ST depression and peaked T-waves.

Cardiac Arrest 40

Cardiac Arrest Tachycardia Nursing Ultrasound 40

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

His initial cTnI at the receiving hospital was 27 ng/mL, and no further troponins were measured thereafter. 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. To our knowledge, the patient did well.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

JULY 12, 2020

They informed me that she had just been hospitalized 10 days ago for "some fluid around the heart" and was discharged after one day without incident. Ultimately, she spent several days in the hospital and no further fluid collected. She was diagnosed with pericarditis and spent one day in the hospital without events.

Pericarditis 40

Pericarditis Hospital Ultrasound Blood Pressure 40

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. Author continued : STE in aVR is often due to left main coronary artery obstruction (OR 4.72), and is associated with in-hospital cardiovascular mortality (OR 5.58). What do you see?

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

MAY 19, 2022

T-wave inversions and dynamic ST elevation Tachycardia, hyperthyroid, and ST elevation. Anterior STEMI? Two cases of ST Elevation with Terminal T-wave Inversion - do either, neither, or both need reperfusion? What is it? 2 Cases of Resolved Chest Pain with Dynamic Terminal T-wave Inversion Is it Wellens' Syndrome?

Chest Pain 52

Chest Pain Exercise Pacemaker Coronary Angiogram 52

Dr. Smith's ECG Blog

MARCH 11, 2019

After admission to the hospital, the patient was discharged from the hospital without any investigation of his acute MI. In such cases, it is common for tachycardia to exaggerate the ST Elevation And, in fact, there was no new acute MI at this visit - troponins did not rise again. See this case: Should Troponin be a Vital Sign?

Chest Pain 52

Chest Pain Ischemia Aneurysm Myocardial Infarction 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Admitted to the hospital service for further evaluation and management." Diagnosis: Acute non-ST segment elevation MI (Non-STEMI, or NSTEMI) Second troponin returned at around 0200: 15,894 ng/L 0245 (unclear if ongoing pain or not) Inferoposterior (and lateral V5-6) reperfusion findings. There is sinus tachycardia at 100-105/minute.

Chest Pain 52

Chest Pain Physiology Blog Stents 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

OCTOBER 25, 2023

ECG is consistent with severe hypokalemia and/or hypomagnesemia causing prolonged QT (QU) at high risk of Torsades (which is polymorphic ventricular tachycardia in the setting of a long QT interval). The patient was admitted to the ICU for close monitoring and electrolyte repletion and had an uneventful hospital course. Is it STEMI?

Chest Pain 123

Chest Pain Ischemia Cardiac Arrest Blog 123

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. The patient was extubated on Day-3 of the hospital stay. The patient improved, and on Day-11 of the hospital stay — he was off inotropes and on a small dose of a ß-blocker. The below ECG was recorded.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

There is sinus tachycardia (do not be fooled into thinking this is VT or another wide complex tachycardia!) Code STEMI was activated. A man in his 80s with chest pain What, besides large anterior STEMI, is so ominous about this ECG? in-hospital mortality was 18.8% Protocols can be overridden by Physician Judgment.

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Chest Pain Cardiogenic Shock Tachycardia Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

3 studied 416 patients hospitalized with COVID in China, of whom 82 had an initial cTn(I) above the upper reference limit. 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. 3–8 Shi et al. Clin Chem [Internet] 2017;63(1):101–7.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 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." Given his exertional chest pain and elevated troponin, the patient was admitted to the hospital for "NSTEMI" with a plan for left heart catheterization the next day. and tachycardia, 1.8.

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Chest Pain Embolism Pulmonary Tachycardia 138

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. EKG is pictured below: What do you think?

Bradycardia 40

Bradycardia STEMI Cardiogenic Shock Ischemia 40

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Other than tachycardia, Other than slight tachycardia, vitals were within normal limits (including oxygen saturation). The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." The whole paradigm is literally called "STEMI" vs. "NSTEMI."

Chest Pain 52

Chest Pain STEMI Blog Tachycardia 52

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 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He spent almost 2 months in the hospital, and reportedly made a full neurologic recovery. This patient arrested shortly after hospital arrival. His course remained complicated — but amazingly, he was discharged from the hospital some 2 months later with intact neurologic status! He was prescribed apixaban.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

EMS 12-Lead

MAY 8, 2022

The attending crews were concerned for SVT with corresponding ischemic hyperacute T waves (HATW) and subsequently activated STEMI pre-hospital. 2] But there is also Sinus Tachycardia! No calcium was administered during pre-hospital transport. A finger-stick glucose resulted 551 mg/dL, and the following ECG was recorded.

ACE Inhibitor 52

ACE Inhibitor Ischemia STEMI Physiology 52

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". After initiating treatment for hyperkalemia, repeat ECG showed resolution of Brugada pattern: The ECG shows sinus tachycardia. A Very Wide Complex Tachycardia. From Ken Grauer ( See below ) — with this Figure adapted from LITFL.

Chest Pain 52

Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

MARCH 3, 2025

The status of the patients chest pain at this time is unknown : EKG 1, 1300: There is sinus tachycardia and artifact of low and high frequency. However, there is also significant tachycardia , with heart rate of 116, and known hypoxia. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). An EKG was immediately recorded.

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73

Dr. Smith's ECG Blog

JANUARY 28, 2025

His first EKG is shown below, with a lead II rhythm strip: EKG 1, 1645 A provisder who is looking for STEMI would not see much in this EKG. It is possible that the T waves in this EKG are of an intermediate morphology between full-blown STEMI and inferior reperfusion. Cardiology was consulted at a PCI-capable hospital.

Chest Pain 105

Chest Pain STEMI Hospital Blood Pressure 105

Dr. Smith's ECG Blog

JANUARY 24, 2025

Ventricular tachycardia?) Why is a patient allowed to present in the hyperacute phase of LAD OMI and complete his infarct in the hospital under physician care? Learning points: 40% of LAD OMI with TIMI-0 flow do NOT meet STEMI criteria (manuscript under consideration at Eur Ht. What do you think? Proximal LAD."

Chest Pain 124

Chest Pain STEMI Risk Factors Coronary Artery Disease 124

Dr. Smith's ECG Blog

JANUARY 21, 2025

This ECG was recorded: It is difficult to appreciate P-waves, but I believe this is sinus tachycardia. It is correct that he did not have chest pain, but we must remember that fully 1/3 of full blown STEMI do not present with chest pain. This is extremely elevated for a type 2 MI and totally consistent with STEMI.

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Chest Pain STEMI Tachycardia Myocardial Infarction 61

Dr. Smith's ECG Blog

NOVEMBER 8, 2024

However, due to the nature of the symptoms, the patient was treated for ACS and admitted to the hospital. Smith comment: Approximately 33% of cases that everyone would call STEMI reperfuse spontaneously (TIMI-1, 2, 3 flow) before they undergo emergent angiogram (usually under 90 minute door to balloon time) 20% have TIMI-3 flow.

Chest Pain 101

Chest Pain Myocardial Infarction Hypertension Hospital 101

Dr. Smith's ECG Blog

APRIL 9, 2025

The paramedics diagnosis was "Possible Anterolateral STEMI." More proof that a huge STEMI may have normal or near normal initial troponin. A retrospective 'target trial emulation' comparing amiodarone and lidocaine for adult out-of-hospital cardiac arrest resuscitation. The final angiographic result is very good.

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Defibrillator Cardiac Arrest Myocardial Infarction STEMI 63

Dr. Smith's ECG Blog

APRIL 16, 2025

Vitals were reported as within normal limits except for tachycardia. Side note: I think the rhythm is probably sinus tachycardia, but I can't easily point out the sinus P waves. ( Without the RBBB, I think most everyone would call this "STEMI." She survived the hospitalization, but long term outcome is not available.

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Chest Pain STEMI Tachycardia Cardiac Arrest 68