Dr. Smith's ECG Blog

MAY 20, 2024

This EKG is diagnostic of transmural ischemia of the inferior wall. Smith: note also the terminal QRS distortion in lead III (absence of S-wave without a prominent J-wave). . __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand).

Chest Pain 120

Chest Pain Blood Pressure Ischemia STEMI 120

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 52

Ischemia Pulmonary STEMI Chest Pain 52

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 114

STEMI Chest Pain Myocardial Infarction Stent 114

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

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 97

Cardiogenic Shock Pericarditis Chest Pain Myocardial Infarction 97

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

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 Chest Pain Ischemia 52

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

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 80

STEMI Myocardial Infarction Ischemia Academic 80

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 Coronary Artery Disease 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 91

STEMI Document Ischemia Blog 91

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

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

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 87

Chest Pain Document STEMI Defibrillator 87

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 95

Coronary Angiogram Plaque Thrombosis STEMI 95

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 85

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 85

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 82

Chest Pain Arrhythmia Myocardial Infarction STEMI 82

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

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

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 78

Chest Pain STEMI Myocardial Infarction Blog 78

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

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 52

STEMI Angina Myocardial Infarction Plaque 52

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. This confirms that the pain was ischemia and is now resovled. Furthermore, in studies reporting progression of insignificant lesions to total thrombotic occlusions, the mean interval between angiography and acute myocardial infarction is 2.5

Ischemia 110

Ischemia Plaque Stenosis Myocardial Infarction 110

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

DAIC

APRIL 8, 2024

The new trial, called DanGer Shock , is the first trial powered to examine whether the use of micro-axial flow pumps can improve survival in ST-elevation myocardial infarctions (STEMI, the most serious type of heart attack) that are complicated by cardiogenic shock.

Heart attacks 52

Heart attacks Heart Attack Cardiogenic Shock Catheterization Laboratory 52

Dr. Smith's ECG Blog

JUNE 1, 2022

Here is his ECG: There is no clear evidence of OMI or ischemia. A 40-something male with no previous cardiac disease presented with chest pain. There is a tiny amount of STE in aVL, but it is NOT in the context of a tiny R-wave. There is a tiny amount of STD in lead III, with some non-specific T-wave flattening. Cath lab was activated.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

While this ECG is negative for “posterior STEMI”, the resolution of anterior ST depression (accompanied by the troponin elevation) confirms posterior OMI with spontaneous reperfusion. The second opportunity to make the diagnosis and expedite angiography was missed because the ECG never met STEMI criteria and continued to be labeled ‘normal.’

STEMI 40

STEMI Myocardial Infarction Chest Pain Angina 40

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

MARCH 19, 2023

Angiogram: Culprit for the patient's inferior ECG changes and non-ST elevation myocardial infarction is a 100% acute thrombotic occlusion of the proximal RCA. The patient was diagnosed with a"Non-STEMI." Here is the main learning point: The infarct was due to an occluded artery (Occlusion MI, OMI).

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Document 52

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 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?

Cardiac Arrest 81

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 81

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

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. Troponin T peaked at 38,398 ng/L ( = a very large myocardial infarction, but not massive-- thanks to the pre-PCI spontaneous reperfusion, and rapid internvention!! ). There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

Arrhythmia 108

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 108

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

SEPTEMBER 24, 2023

A very large myocardial infarction. The next day the ECG not unexpectedly shows a completed transmural inferior and posterior wall infarction. The delayed activation of the cath lab would have been avoided had the treating physicians been trained in recognizing occlusion myocardial infarction.

Chest Pain 88

Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 88

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

NOVEMBER 12, 2020

Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. In normal times, the most common use of cTni is in diagnosing, or ruling out, acute myocardial infarction (AMI, a subcategory of acute myocardial injury.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52