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ECG Cases 50 – STEMI: A Failed Paradigm, Enter Occlusion MI

ECG Cases

Jesse McLaren illustrates the paradigm shift from STEMI to Occlusion MI (OMI) through 9 cases, and drives home the points that if there is STEMI criteria, consider false positives (eg. secondary and proportional to LVH or BER); if there is no STEMI criteria, consider false negatives and look for other signs of occlusion (eg.

STEMI 125
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Is all this "ST Depression" due to ischemia?

Dr. Smith's ECG Blog

Does the ECG represent STEMI-negative OMI findings? ischemia) or it can be secondary to abnormal depolarization (e.g Discussion: The ECG in today's case does not have typical ST depression vector of diffuse subendocardial ischemia. ST depression has a variety of different causes other than ischemia.

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Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

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. He does have a recently diagnosed PE, and has not been taking his anticoagulation due to cost. He was given aspirin and sublingual nitro and the pain resolved.

Ischemia 123
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EMS told "Not a STEMI". What do you think?

Dr. Smith's ECG Blog

Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Now it even meets STEMI criteria, and HATWs continue to inflate. So the cath lab was not activated. Ongoing OMI.

STEMI 93
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Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

Dr. Smith's ECG Blog

Cath lab declined as it is not a STEMI." There is probably a trickle of flow which is why there is both subendocardial ischemia (ST depression) and early subepicardial ischemia (hyperacute T-waves). And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! It is a mass delusion.

STEMI 93
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Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Dr. Smith's ECG Blog

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

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Chest pain with anterior ST depression: look what happens if you use posterior leads.

Dr. Smith's ECG Blog

The first ECG was labeled “anterior subendocardial ischemia”, but subendocardial ischemia does not localize. If there were diffuse ischemic STD, with precordial STDmaxV5-6 and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from ACS or supply-demand mismatch. Do you need posterior leads?