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 126

STEMI Chest Pain Myocardial Infarction Stents 126

Dr. Smith's ECG Blog

NOVEMBER 1, 2018

European Heart Journal , ehy651, [link] Published: 26 October 2018 [link] Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial. This might extend to Wellens' syndrome, which is really and transient STEMI in which the ST Elevation is not recorded.

STEMI 52

STEMI Myocardial Infarction Ischemia Outcomes 52

Dr. S. Venkatesan MD

DECEMBER 29, 2023

Cardiogenic shock (CS)is the most feared event following STEMI. We tend to perceive CS as an exclusive complication of STEMI. The incidence is half of that of STEMI, i.e., 2.5-5%. might show little elevation with considerable overlap of left main STEMI vs NSTEMI ) 2.Onset ACS pathophysiology is not that simple.

Cardiogenic Shock 52

Cardiogenic Shock STEMI Myocardial Infarction Outcomes 52

Dr. Smith's ECG Blog

JANUARY 2, 2016

There may be ischemia present, but it is not evident on the ECG. LVH and the diagnosis of STEMI - how should we apply the current guidelines? This one mimics inferior STEMI (Figure 4): Concentric LVH, NO wall motion abnormality Case 5. How about diagnosing anterior STEMI in the setting of LVH? All troponins were negative.

Ischemia 52

Ischemia Chest Pain STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 27, 2021

If this STD were due to LVH or to subendocardial ischemia, rather than posterior OMI, it would be maximal in V5 and V6. If I saw this without the STD V2-V4, I would not make anything of it, and even with that precordial STD, I am not convinced that it is a manifestation of ischemia. This is a HUGE myocardial infarction.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

Dr. Smith's ECG Blog

OCTOBER 24, 2013

Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. Ischemia on the ECG can be very subtle and is easily missed. Did the ECG offer unseen hints? Lesson : 1.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

AUGUST 24, 2012

This ECG is diagnostic of anterior STEMI. This is a good sign for myocardial infarction and does not happen in pericarditis. This is likely because 1) the ischemia to the inferior wall was only partial and 2) it reperfused quickly. The QRS is at least as important as the ST segment in diagnosing STEMI BP was 160.

Pericarditis 52

Pericarditis STEMI Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

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. That this is all demand ischemia is unlikely. Lung exam showed diffuse B lines bilaterally. Aslanger's pattern.

Ischemia 115

Ischemia Chest Pain Echocardiogram Myocardial Infarction 115

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

This is a value typical for a large subacute MI, n ormal value 48 hours after myocardial infarction is associated with Post-Infarction Regional Pericarditis ( PIRP ). Mechanical complications secondary to myocardial infarction are infrequent due to most patients receiving revascularization quite rapidly.

Cardiogenic Shock 111

Cardiogenic Shock Pericarditis Chest Pain Myocardial Infarction 111

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished.

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

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 52

STEMI Myocardial Infarction Chest Pain Angioplasty 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

Computer read: "Non-specific ST abnormality, consider anterior subendocardial ischemia" There are very poor R-waves in V1-V4 suggesting old anterior MI. Firstly, subendocardial ischemia does not localize on 12-Lead ECG. But the real question at hand is: Are these precordial ST-depressions a result of subendocardial ischemia?

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Ischemia 52

Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. J waves can also be induced by Occlusion MI (5), STEMI mimics including takotsubo and myocarditis complicated by ventricular arrhythmias (6, 7), and subarachnoid hemorrhage with VF (8). Take home : Not all STEs are STEMIs or OMIs. What do you think?

STEMI 52

STEMI Bradycardia Arrhythmia Cardiac Arrest 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. associated typical Myocardial Infarction therapies such as statins and ACE inhibitors with significantly decreased 1 year mortality in MINOCA patients, which suggests that they do indeed have a similar pathophysiology to MI patients with obstructive coronary disease. Downstream vasospasm?

Coronary Angiogram 110

Coronary Angiogram Plaque Thrombosis STEMI 110

Dr. Smith's ECG Blog

JANUARY 4, 2021

This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with reciprocal ST depression in aVL, and some STE in V1. If there is also subendocardial ischemia, the ST depression vector remains leftward, with a reciprocal ST Elevation vector also to the right.

Ischemia 40

Ischemia Pulmonary STEMI Chest Pain 40

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Triage ECG (no prior for comparison): Computer algorithm read: "Sinus rhythm, low voltage QRS, inferior myocardial infarction, probably old." Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). He reported a normal stress test a few years ago.

STEMI 84

STEMI Myocardial Infarction Ischemia Academic 84

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. I have warned in the past that one must think of other etiologies of ischemia when there is tachycardia.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." Can you diagnose an ACO (STEMI) when you also have LVH? The criteria of Armstrong et al. References 1.

STEMI 40

STEMI Myocardial Infarction Chest Pain Aneurysm 40

Dr. Smith's ECG Blog

JUNE 13, 2024

V1 sits over both the RV and the septum, so transmural ischemia of either one with give OMI pattern in V1 and reciprocal STD in V5 and V6. See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6. However, the pattern is also seen in inferior OMI with right ventricular OMI. (V1

Chest Pain 96

Chest Pain Document STEMI Defibrillator 96

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

STEMI 52

STEMI Myocardial Infarction Ischemia Chest Pain 52

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. No labs were performed.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" All are, however, clearly massive STEMI. Total LM occlusion can present with STE or STD in aVR.

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 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. Circulation 2007 2. Khan et al.

Chest Pain 92

Chest Pain STEMI Myocardial Infarction Blog 92

Dr. Smith's ECG Blog

MARCH 9, 2013

Here is the prehospital ECG, with pain:  Hyperacute anterolateral STEMI  The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering. Type B waves are deeper and symmetric.

Myocardial Infarction 52

Myocardial Infarction Chest Pain Ischemia Angina 52

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? or basilar ischemia. Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). EKG on arrival to the ED is shown below: What do you think?

STEMI 110

STEMI Document Ischemia Hemorrhage 110

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The baseline ECG is basically normal with no ischemia. You can see in the lead-specific analysis that she "sees" the STD in V5, V5, and II, with STE in aVR as signs of "Not OMI", because subendocardial ischemia pattern is not the same as OMI. In my opinion, I think it looks more like subendocardial ischemia. Eur J Emerg Med.

Chest Pain 89

Chest Pain Ischemia Cardiogenic Shock Myocardial Infarction 89

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

Chest Pain 67

Chest Pain Aortic STEMI Ultrasound 67

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

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. AIVR is not always the result of significant pathology, but is classically associated with the reperfusion phase of acute myocardial infarction. Is there STEMI? The patient continued having chest pain. Moffat, M.

Chest Pain 95

Chest Pain Arrhythmia Myocardial Infarction STEMI 95

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

NOVEMBER 15, 2013

The ECG in the chart was read as "no obvious ST changes," (even though no previous ECG was available) and the formal read by the emergency physicians was: "ST deviation and moderated T-wave abnormality, consider lateral ischemia." New ST elevation diagnostic of STEMI [equation value = 25.3 Computerized QTc = 417. Gottlieb SO, et al.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

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. The ECG is diagnostic of occlusion myocardial infarction (OMI).

Chest Pain 95

Chest Pain Ischemia Pericarditis Tachycardia 95

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 52

STEMI Chest Pain Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. But maybe not. Why is this important?

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

EMS 12-Lead

APRIL 21, 2022

His father and brother both died of myocardial infarction at ages 61 and 45, respectively. There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1]

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. Nevertheless, the clinical situation made other etiologies unlikely. NTG drip started.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

EMS 12-Lead

APRIL 8, 2022

When “spot diagnosing” precordial ST-depression I instinctively evaluate aVR for any corresponding ST-elevation to see if an emerging pattern of broad subendocardial ischemia can be appreciated, in which the ST-depression should be otherwise global and demonstrably maximal in Leads II and V5. However, in this context (i.e. is present.

Myocardial Infarction 52

Myocardial Infarction Coronary Angiogram STEMI Ischemia 52