Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. ECG#1 Assessing ischemia on an ECG with wide QRS complexes (AIVR, ventricular pacing, BBB, etc) can be challenging. What do you think?

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Dr. Smith's ECG Blog

MARCH 9, 2013

A stent was placed. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering. In this case, the duration of ischemia was so brief that there was no such evolution, and there was near-normalization. Wellens' syndrome represents a state of reperfusion of the infarct related artery 2.

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Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. But no ECG met STEMI criteria so the patient was referred to cardiology as Non-STEMI. Clin Cardiol 2022 4. McLaren and Smith.

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Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. I have warned in the past that one must think of other etiologies of ischemia when there is tachycardia. The OM-1 was opened and stented, then the LAD was stented 3 days later. There is no ST elevation. How can we tell the difference?

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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.

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Dr. Smith's ECG Blog

DECEMBER 27, 2023

The pain will resolve and you will think the ischemia is gone when it is only hidden ! Just before 10 AM, the patient received a stent to the culprit OM. Immediate and early percutaneous coronary intervention in very high‐risk and high‐risk non‐st segment elevation myocardial infarction patients. & Griffin, J.

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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." Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction.

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Dr. Smith's ECG Blog

OCTOBER 26, 2011

An open 90% LAD was stented. Here is the ECG the next AM: There was so little infarction that there are lateral, but no anterior reperfusion T-waves (normally, there would be Wellens' type waves after LAD reperfusion). Here is some older but very interesting literature on TIMI myocardial perfusion grade and ST resolution : 1.

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STEMI Chest Pain Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain. 2] Here there is no posterior ST elevation, but the anterior ST depression is also less—so it is dynamic, confirming acute ischemia. But it is still STEMI negative.

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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 patient, albeit very delayed was referred for angiography where a 99% stenosed pRCA was stented. No further episodes of atrial fibrillation occurred during monitoring.

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Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 86

Dr. Smith's ECG Blog

DECEMBER 29, 2015

All these factors, again, support an ECG diagnosis of LVH The patient was nonetheless taken for emergency angiography, and a 99% mid-LAD lesion was found and stented. However, the ST segments in patients with LVH may show significant variation over time in the absence of ischemia. Interestingly, few signs of LVH at this point.

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Dr. Smith's ECG Blog

JANUARY 6, 2023

I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Association between opioid analgesia and delays to cardiac catheterization of patients with occlusion Myocardial Infarctions. Abstract 556.

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Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

JULY 31, 2018

This is diagnostic of myocardial infarction. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. The lesion was stented. It they are static, then they are not due to ischemia. This is better evidence for ischemia than any other data point.

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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. A mid-LAD culprit lesion was identified and stented. Pacing Clin Electrophysiol. 40; 1234-1241.

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Dr. Smith's ECG Blog

DECEMBER 18, 2022

Although not striking, this is clearly a diagnostic ECG for infero"posterior" myocardial infarction due to coronary occlusion (OMI), most likely due to left circumflex (LCx) artery occlusion. mm STE even in the fourth universal definition of myocardial infarction. Considerations on the naming of myocardial infarctions.

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Myocardial Infarction Chest Pain Blog Echocardiogram 40

Dr. Smith's ECG Blog

JULY 11, 2018

He did, found the true culprit, and went back in to stent it. His astute observation is worthy of brief discussion: Rituparna et al document a case study report, in which J waves appeared to be induced by ischemia ( Pacing Clin Electrophysiol 30(6):817-819, 2007 ). You can listen to my explanation by playing the video.

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EMS 12-Lead

JUNE 20, 2022

He was rushed to the Cath Lab where an LAD culprit lesion was stented. Here is the LAD after stent placement. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. It’s important to stress the presence of a normal QRS (i.e., References 1] Smith, S.

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Dr. Smith's ECG Blog

FEBRUARY 10, 2022

In the STEMI/NSTEMI dichotomy, NSTEMI is supposed to mean non-occlusive myocardial infarction, but this patient had transient Occlusion MI that was at risk for re-occlusion (like ‘transient STEMI’). Notice also that there is new T-wave inversion in III with upright T-wave in aVL, confirming inferior infarction.

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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. It was opened and stented. Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI.

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Chest Pain STEMI Myocardial Infarction Document 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. A 99% LAD occlusion was stented. Terminal QRS distortion is present in anterior myocardial infarction but absent in early repolarization. 3] Smith, S.

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Dr. Smith's ECG Blog

FEBRUARY 15, 2018

The patient was then taken to the cath lab an found to have a proximal RCA 100% thrombotic occlusion which was successfully stented. Progression of V2 showing posterior involvement. J Electrocardiology January–February, 2018; Volume 51, Issue 1, Pages e5–e6.

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Dr. Smith's ECG Blog

DECEMBER 16, 2019

Chest pain with New LBBB: It helps to actually measure the ST/S ratio A Fascinating Demonstration of ST/S Ratio in LBBB and Resolving LAD Ischemia The cath lab was activated. It was opened and stented. Shortly thereafter, the first troponin I returned at 0.689 ng/mL (URL = 0.034), all but diagnostic of acute MI.

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Chest Pain Myocardial Infarction Stents Stent 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Electrocardiographic Differentiation of Early Repolarization FromSubtle Anterior ST-Segment Elevation Myocardial Infarction. After many hours, the decided that it was appropriate to do an angiogram and they found a distal LAD occlusion which was opened and stented. It was stented. There was no wall motion abnormality.

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DAIC

APRIL 2, 2025

Stone, MD Mount Sinai Health System tim.hodson Wed, 04/02/2025 - 15:26 March 31, 2025 Using intravascular imaging (IVI) to guide stent implantation during complex stenting procedures is safer and more effective for patients with severely calcified coronary artery disease than conventional angiography, the more commonly used technique.

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Stent Stents Outcomes Coronary Angiogram 40

Circulation

FEBRUARY 12, 2024

The 2 coprimary outcomes were target lesion revascularization and myocardial infarction. The secondary outcomes included ischemia-driven target lesion revascularization, target vessel myocardial infarction, death, cardiac death, target vessel revascularization, stent thrombosis, and major adverse cardiac events.

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Dr. Smith's ECG Blog

NOVEMBER 26, 2018

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. First , there can simply be diffuse ST depressions (which obligates reciprocal STE in aVR) associated with tachycardia which are not indicative of ischemia.

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All About Cardiovascular System and Disorders

APRIL 21, 2024

indicates inducible ischemia while an FFR above 0.80 excludes ischemia in 90% of cases. If the FFR normalizes after stenting, the restenosis rates at six months is less than 5%. If the FFR normalizes after stenting, the restenosis rates at six months is less than 5%. myocardial infarction rate and 3.2%

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DAIC

MAY 14, 2024

The impact of this narrowing can ultimately result in angina (chest pain), which has been shown to double the risk of major cardiovascular events,1 as well as myocardial infarction ( heart attack ) or even death.

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Coronary Artery Disease Journal

MARCH 7, 2024

Background Untreated multivessel disease (MVD) in acute myocardial infarction (AMI) has been linked to a higher risk of recurrent ischemia and death within one year. The immediate non-IRA PCI is associated with a significantly lower occurrence of unplanned ischemia-driven PCI (OR 0.60; confidence interval [CI] 0.44–0.83)

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Dr. Smith's ECG Blog

APRIL 8, 2016

This was stented. If there is polymorphic VT with a long QT on the baseline ECG, then generally we call that Torsades, but Non-Torsades Polymorphic VT can result from ischemia alone. I have read articles that say that patients without ischemia are at low risk of complications from hypokalemia, But it is not entirely without risk.

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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]

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Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

MAY 8, 2023

Diagnosis of Acute Myocardial Infarction in the Presence of Left Bundle Branch Block using the ST Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

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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?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.

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Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Stroke Journal

JANUARY 30, 2025

Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We versus 18.8%

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Atrial Fibrillation Stents Stent Outcomes 40

Stroke Journal

FEBRUARY 1, 2024

Objective:To compare the 1-month stroke, myocardial infarction (MI), and/or death rates among symptomatic patients undergoing either CAS or CEA according to the timing of the procedure in Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).Methods:We

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Stents Stent Stenosis Myocardial Infarction 40

Dr. Smith's ECG Blog

MARCH 11, 2016

Appearance of abnormal Q waves early in the course of acute myocardial infarction: implications for efficacy of thrombolytic therapy. It was treated with and dual "kissing balloons" and drug eluting stents. Midlateral wall rupture secondary to infero-postero-lateral infarction from circumflex occlusion was most common (34%).

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Dr. Smith's ECG Blog

FEBRUARY 5, 2019

LAD 80% mid LCx occluded mid (acute infarct lesion) RCA 80% mid. distal stent patent. PCI mid LCx So this is an OMI (Occlusion Myocardial Infarction), but not a STEMI Echo: Decreased left ventricular systolic performance, mild/moderate. Repeat ECG shows modest ST elevation in I and aVL and depression in inferior leads."

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