Hospital, STEMI and Ultrasound - Cardiovascular Update

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Dr. Smith's ECG Blog

MAY 20, 2024

The cardiologist recognized that there were EKG changes, but did not take the patient for emergent catheterization because the EKG was “not meeting criteria for STEMI”. So the patient was admitted to the hospital with no plan for an angiogram. Most STEMI have peak troponin I over 1000 ng/L and most NSTEMI below that level.

Chest Pain

Chest Pain Blood Pressure Ischemia STEMI

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

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

The problem is difficult to study because angiographic visualization of arteries is not perfect, and not all angiograms employ intravascular ultrasound (IVUS) to assess for unseen plaque or for plaque whose rupture and ulceration cannot be seen on angiogram. Thus, intracoronary imaging modalities are crucial in this setting. From Gue at al.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Dr. Smith's ECG Blog

APRIL 22, 2024

Bedside ultrasound with no apparent wall motion abnormalities, no pericardial effusion, no right heart strain. Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). Labs ordered but not yet drawn.

Chest Pain

Chest Pain Myocardial Infarction Anatomy Angina

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

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

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. Now another, with ultrasound.

Chest Pain

Chest Pain Embolism Pulmonary 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

He had been seen several weeks ago at an outside hospital for a similar issue and had been discharged home, presumably after unremarkable workup. After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. 1] Wereski, R.,

Chest Pain

Chest Pain Ultrasound STEMI Myocardial Infarction

A 60-something with Syncope, LVH, and convex ST Elevation

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

Chest Pain STEMI Ultrasound Pulmonary

What are treatment options for this rhythm, when all else fails?

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

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

30 yo woman with trapezius pain. HEART Pathway = 0. Computer "Normal" ECG. Reality: ECG is Diagnostic of LAD Occlusion.

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 To, me these look like anterior wall motion abnormality, but I showed them to one of our ultrasound fellows who is very interested in this. She was having a transient STEMI, briefly. She called 911.

STEMI

STEMI Chest Pain Hospital Risk Factors

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

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. On arrival, GCS was 13 and the patient complained of ongoing chest pain.

Chest Pain

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

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. He was then transferred to quaternary care childrens hospital. 24 yo woman with chest pain: Is this STEMI?

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

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

Bradycardia Cardiogenic Shock STEMI Ischemia

OMI Can be Diagnosed by "Pseudonormalization of ST Segments"

Dr. Smith's ECG Blog

APRIL 20, 2018

This is her pre-hospital ECG: This is her first ECG in the ED: What do you think? Given her risk factors (HTN, HLD, ESRD from diabetes) I decided to obtain a broad cardiac workup for the patient: serial ECGs, labs, serial troponins, CXR and bedside cardiac ultrasound. Case A 30 something y.o.

Chest Pain

Chest Pain Ultrasound Risk Factors Diabetes

Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

A bedside cardiac ultrasound was normal, with no effusion. 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.

Cardiac Arrest

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock

Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

On arrival, the patient was in shock, was intubated, and had an immediate cardiac ultrasound. What does a heart look like on ultrasound when the EKG looks like that? Here you go: It's not the world's greatest cardiac ultrasound video, but it does appear to show poor function and low volume. They transported to the ED.

Cardiac Arrest

Cardiac Arrest Tachycardia Nursing Ultrasound

40-something with severe CP. True + vs. False + high lateral MI. ST depression does not localize.

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. But what we truly care about is coronary occlusion, for which STEMI is just a surrogate that is only about 75% sensitive for occlusion. Some are STEMI-equivalents.

Ischemia

Ischemia Chest Pain Stenosis STEMI

An adolescent with trauma, chest pain, and a wide complex rhythm

Dr. Smith's ECG Blog

JUNE 14, 2017

This case was sent by Dr Avinash Krishnamurthy, a fine emergency medicine resident from Australia Cairns base hospital Case : An adolescent male had a mechanical fall and injured his left shoulder and arm. A bedside cardiac ultrasound was normal. Is there STEMI? His chest was tender. What is it? What is the rhythm?

Chest Pain

Chest Pain Congenital Heart Disease Article Congenital

A man in his 40s with epigastric pain and ST Elevation

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Dr. Nossen performed a bedside ultrasound which was interpreted as normal. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI. The patient was worked up for abdominal pain with unclear diagnosis, and he was able to be discharged.

Blog

Blog Bradycardia Exercise Ischemia

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

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

Chest Pain STEMI Bradycardia Stenosis

Chest pain, and Cardiology didn't take the hint from the ICD

Dr. Smith's ECG Blog

JANUARY 23, 2023

PMID: 34775811; PMCID: PMC9075358 A bedside ultrasound was performed, shown here: Parasternal short axis view demonstrating inferior LV wall motion akinesis Apical 2 chamber view again demonstrating inferior LV wall akinesis The cath lab was not activated based on the ECG and bedside echo. J Am Heart Assoc. 2021 Dec 7;10(23):e022866.

Chest Pain

Chest Pain Blog Stenosis 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

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. These findings are diagnostic of an apical OMI as a result of LAD Occlusion.

Plaque

Plaque Chest Pain Thrombosis Stenosis

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He spent almost 2 months in the hospital, and reportedly made a full neurologic recovery. Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis Answer: pulmonary embolism. Now another, with ultrasound. This patient arrested shortly after hospital arrival. He was prescribed apixaban. This is a quiz.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

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

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Smith comment: This patient did not have a bedside ultrasound. Had one been done, it would have shown a feature that is apparent on this ultrasound (however, this patient's LV function would not be as good as in this clip): This is recorded with the LV on the right. In fact, bedside ultrasound might even find severe aortic stenosis.

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

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

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

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

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

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!

A 60-something with Syncope, LVH, and convex ST Elevation

What are treatment options for this rhythm, when all else fails?

30 yo woman with trapezius pain. HEART Pathway = 0. Computer "Normal" ECG. Reality: ECG is Diagnostic of LAD Occlusion.

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

OMI Can be Diagnosed by "Pseudonormalization of ST Segments"

Extreme shock and cardiac arrest in COVID patient

Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?

40-something with severe CP. True + vs. False + high lateral MI. ST depression does not localize.

An adolescent with trauma, chest pain, and a wide complex rhythm

A man in his 40s with epigastric pain and ST Elevation

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

Chest pain, and Cardiology didn't take the hint from the ICD

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

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

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

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