Dr. Smith's ECG Blog

MAY 27, 2024

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]

Chest Pain 119

Chest Pain STEMI Myocardial Infarction Ischemia 119

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

The admission and discharge diagnosis both attributed the ECG changes and echo findings to ischemia. The biggest problem with STEMI criteria are false negatives – because this costs patient’s myocardium, with greater mortality and morbidity. baseline ECGs may fluctuate over time, and not necessarily represent dynamic ischemia 4.

Chest Pain 88

Chest Pain STEMI Ischemia Anatomy 88

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

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?

Chest Pain 112

Chest Pain STEMI Atrial Flutter Ischemia 112

ECG Cases

JUNE 6, 2023

We discover that for STEMI/OMI vs subendocardial ischemia, we should look for STEMI(-)OMI, subacute OMI, and OMI in the presence of LBBB and RBBB, and consider the differential for diffuse ST depression with reciprocal ST elevation in aVR.

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STEMI Pulmonary Ischemia Blog 94

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

MARCH 31, 2024

The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). I advised that perhaps posterior leads would help to persuade the interventionalist, since the 2022 ACC recommendations include posterior STEMI as a formal STEMI equivalent, but only officially by 0.5

Chest Pain 91

Chest Pain STEMI Ischemia Myocardial Infarction 91

Dr. Smith's ECG Blog

MAY 20, 2024

This EKG is diagnostic of transmural ischemia of the inferior wall. If it is angina, lowering the BP with IV Nitroglycerine may completely alleviate the pain and the (unseen) ECG ischemia. Transmural ischemia (as seen with the OMI findings on ECG) is not very common with demand ischemia, but is possible.

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Chest Pain Blood Pressure Ischemia STEMI 124

Dr. Smith's ECG Blog

JULY 25, 2024

The ECG shows severe ischemia, possibly posterior OMI. But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. It takes time for that ischemia to resolve. Cardiac arrest #3: ST depression, Is it STEMI? And what do you want to do?

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Cardiac Arrest Ischemia Tachycardia Defibrillator 110

Dr. Smith's ECG Blog

JULY 30, 2023

The STD maximal in V1-V4 is diagnostic of acute transmural posterior wall ischemia, most likely due to posterior OMI. Subendocardial ischemia does not localize, and subendocardial ischemia presents with STD maximal in V5-6, II, and STE in aVR. It does not meet STEMI criteria. Subendocardial ischemia does not localize.

Chest Pain 52

Chest Pain Ischemia STEMI Arrhythmia 52

ECG Cases

SEPTEMBER 23, 2019

And guess what.they all show acute ischemia! The post ECG Cases 1: Missed Ischemia – Never Trust the ECG Computer Interpretation appeared first on Emergency Medicine Cases.

Ischemia 52

Ischemia Chest Pain Blog STEMI 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

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 118

STEMI Chest Pain Myocardial Infarction Stents 118

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

ECG Cases

DECEMBER 20, 2022

In patients with chest pain + ST elevation, consider false positive STEMI including early repolarization, LVH and Brugada-pattern. In patients with cocaine chest pain who are STEMI negative, beware STEMI(-)OMI including subtle ST elevation, hyperacute T waves, reciprocal change, and refractory ischemia.

Chest Pain 52

Chest Pain STEMI Ischemia Blog 52

Ken Grauer, MD

DECEMBER 15, 2023

mmm ECG Blog #193 — Reviews the concept of why the term “OMI” ( = O cclusion-based MI ) should replace the more familiar term STEMI — and — reviews the basics on how to predict the " culprit " artery. ECG Blog #271 — Reviews determination of the ST segment baseline ( with discussion of the entity of diffuse Subendocardial Ischemia).

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Blog STEMI Ischemia Chest Pain 127

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. Because we are hypnotized the STEMI paradigm. "If

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Myocardial Infarction Ischemia STEMI Pulmonary 52

Dr. Smith's ECG Blog

AUGUST 11, 2024

Below is the first ECG recorded by paramedics after 2 hours of chest pain, interpreted by the machine as “possible inferior ischemia”. While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. What do you think?

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Chest Pain STEMI Bradycardia Stents 74

Dr. Smith's ECG Blog

AUGUST 2, 2024

This was a machine read STEMI positive OMI. In this patient's case, the RV ischemia manifested as dramatic anterior hyperacute T waves. This degree of STE is a bit atypical for LAD ischemia. Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain. His ECG is shown below.

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STEMI Ischemia Blog Chest Pain 108

Ken Grauer, MD

DECEMBER 1, 2023

Figure-4: ECG findings to look for when your patient with new-onset cardiac symptoms does not manifest STEMI-criteria ST elevation on ECG. This blog post reviews the basics for predicting the " C ulprit" A rtery ( as well as reviewing why the term "STEMI" — should replaced by " OMI" = O cclusion-based MI ). Smith’s ECG Blog.

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Blog STEMI Ischemia 147

Dr. Smith's ECG Blog

AUGUST 15, 2019

Over the next few hours, four other general cardiologists "signed off on the initial ECG without recognizing STEMI." Learning Points: STEMI criteria misses 25-40% of OMI, like this case for example. A millimeter definition of acute STEMI should not be needed to justify the need for prompt cardiac catheterization.

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STEMI Chest Pain Risk Factors Anatomy 52

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.”

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Ischemia STEMI Stenosis Coronary Artery Disease 52

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. years old ± 13.7

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Chest Pain STEMI Myocardial Infarction Hospital 107

Dr. Smith's ECG Blog

JANUARY 25, 2017

911 was called and the medics recorded this ECG (unfortunately, leads V4-V6 are missing) Due to marked ST Elevation, the computer read was STEMI What do you think? A 20-something male drank heavily of ethanol and used cocaine, then was involved in a stressful verbal altercation, at which time he developed chest pain.

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Chest Pain STEMI Cardiac Arrest Ischemia 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%

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STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

AUGUST 10, 2023

This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. Even though they were passed the 12 hour mark traditionally associated with reperfusion benefits, ongoing ischemia requires emergent angiogram On assessment, the patient appeared uncomfortable, leaning forward in his chair.

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Chest Pain STEMI Ischemia Nursing 86

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

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Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

APRIL 2, 2014

He had an immediate ED ECG: There is artifact, but the findings appear to be largely gone now The diagnosis is acute MI, but not STEMI. There is about 1 mm of STE in aVR I con sidered but rejected subendocardial ischemia. Is it subendocardial ischemia, or inferior MI? Here is his prehospital ECG: Diagnosis?

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STEMI Ischemia Chest Pain Angioplasty 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

We have also shown several cases in which atrial flutter hides true, active ischemia. Is this inferor STEMI? Atrial Flutter with Inferior STEMI? The EM provider asked if the cardiologist thought it was a "STEMI." Christmas Eve Special Gift!! Prehospital Cath Lab Activation: What do you think? Tachycardia and ST Elevation.

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Atrial Flutter Ischemia STEMI Tachycardia 52

ECG Guru

JULY 24, 2023

ST depression in the setting of acute transmural ischemia (STEMI) is almost ALWAYS due to reciprocal change. The elevation is higher in Lead III than in Lead II, a reliable sign of RCA occlusion. Reciprocal depression in Leads aVL and I. Reciprocal depression in V1 - V3.

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Chest Pain STEMI Ischemia Outcomes 98

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

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Chest Pain Cardiac Arrest STEMI Defibrillator 95

Dr. Smith's ECG Blog

APRIL 20, 2019

There is sinus rhythm with minimal STE in V1-V3, not meeting STEMI criteria. V2 never has this appearance in the absence of full thickness ischemia. The delay between OMI and STEMI sometimes causes unacceptable loss of myocardium or worse. There is a small amount of reciprocal STD in V6 with a negative T-wave.

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STEMI Chest Pain ECG Technician Physiology 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Smith : the profound persistent STE suggests either persistent occlusion or " no reflow " with persistent downstream ischemia. Long term outcome unknown but obviously bleak.

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STEMI Myocardial Infarction Ischemia Academic 81

Dr. Smith's ECG Blog

MARCH 22, 2024

The fact that R waves 2 through 6 are junctional does make ischemia more difficult to interpret -- but not impossible. Back to the assessment of ischemia: Returning to the ECG, the leads that catch my eye first are -- I, II, V4, V5, V6. For national registry purposes, this will be incorrectly classified as a STEMI.) < 0.049).

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Chest Pain Bradycardia STEMI Ischemia 111

Dr. Smith's ECG Blog

MARCH 1, 2023

The precordial STD persists in severity from V4-V6, rather than being maximal in V1-V4 (as in posterior OMI), and so the ECG overall best fits the subendocardial ischemia pattern (diffuse supply/demand mismatch). A "STEMI alert" was called and soon cancelled.

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Chest Pain Ischemia Stenosis Tachycardia 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 90

Chest Pain Document STEMI Defibrillator 90

Dr. Smith's ECG Blog

AUGUST 24, 2012

This ECG is diagnostic of anterior STEMI. 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 It has been constant since then. He looked ill and diaphoretic. BP was 160. Lessons: 1.

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Pericarditis STEMI Chest Pain Myocardial Infarction 52

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

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Blog Chest Pain Ischemia STEMI 102