Dr. Smith's ECG Blog

MAY 5, 2024

He interprets here: "This EKG is diagnostic of right bundle branch block and transmural ischemia of the anterior wall, most likely from an occlusion of the proximal LAD. There was a 100% proximal LAD occlusion that was opened and stented. It was recorded at 0530: What do you think? The young ED tech immediately suspected LAD OMI.

EKG Technician 117

EKG Technician Chest Pain Blog STEMI 117

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." They found 100% acute mid-LAD Occlusion MI, stented with excellent angiographic result. Learning Points: STEMI criteria misses 25-40% of OMI, like this case for example. mm of the "required" 1.0

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STEMI Chest Pain Risk Factors Anatomy 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.

Chest Pain 89

Chest Pain STEMI Ischemia Nursing 89

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).

Chest Pain 113

Chest Pain STEMI Bradycardia Ischemia 113

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 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The baseline ECG is basically normal with no ischemia. In my opinion, I think it looks more like subendocardial ischemia.

Chest Pain 87

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 87

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.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

I would expect TIMI-3 flow (normal flow, no persistent ischemia) with a culprit in the RCA (or possibly Circumflex). I would expect that a stent would be placed. The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. What would I expect the angiogram to show? Jesse McLaren et al.

Chest Pain 82

Chest Pain STEMI Stents Stent 82

EMS 12-Lead

AUGUST 14, 2022

One stent was deployed with restorative TIMI-0 flow. link] deWinter first reported his unique characteristics of LAD occlusion in 2008, and since the respective ECG changes do not fit the conventional STEMI paradigm (as he even stated – “instead of signature ST-segment elevation” ….) it has been subsequently deemed a STEMI-equivalent.

STEMI 52

STEMI Sudden Cardiac Death Thrombosis Thrombolysis 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. It was stented. This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. Values: STE60V3 = 2.0, QRS V2 = 10, RAV4 = 15.5, There was good flow.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So the RCA was stented. Vitals were HR 58 BP 167/70 R20 sat 96%.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

JULY 14, 2024

The cath lab was activated, and then not cancelled, and the angiogram showed 99% TIMI 2 flow proximal LAD culprit lesion, stented in less than 90 minutes of arrival. Cath days later showed complete occlusion of the LAD, stented. Another missed OMI by the False STEMI-NonSTEMI Dichotomy Don't miss them!!! Normal vitals.

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AFIB Stents Stent Chest Pain 76

EMS 12-Lead

APRIL 21, 2022

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] STEMI was activated and the patient went to Cath on arrival.

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

DECEMBER 6, 2010

This is all suggestive of posterior STEMI, but not definitely diagnostic. mm in only one posterior lead is highly sensitive and specific for posterior STEMI). Two stents were placed. ST depression in V1-V4, isolated, may be either posterior STEMI or NSTEMI. The ECG normalized overnight. Maximum troponin was 2.1

STEMI 52

STEMI Chest Pain Ultrasound Blood Pressure 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. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. It was opened and stented. Therefore it is not a STEMI. Some are STEMI-equivalents. RCA: dominant.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

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

JUNE 12, 2016

Just as hyperacute T-waves can be reciprocal to T-wave inversion ( last case ),T-wave inversion can be reciprocal to STEMI of opposite wall! Answer : There is very abnormal T-wave inversion in aVL which is typical of subtle transmural/subepicardial (due to occlusion) ischemia to the inferior wall. An 80% thrombotic RCA was stented.

Chest Pain 52

Chest Pain Ischemia STEMI Stents 52

Dr. Smith's ECG Blog

MARCH 20, 2023

Since then, I started looking for OMI EKG findings and not just STEMI. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. mm in lead I, thus not STEMI criteria) and was finally understood by the cardiologist.

Chest Pain 52

Chest Pain STEMI Blog Cholesterol 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.’

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STEMI Myocardial Infarction Chest Pain Angina 40

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. So there is pathologic ST elevation here, consistent with anterolateral STEMI. Called 911.

STEMI 52

STEMI Chest Pain Cardiac Arrest Stents 52

Dr. Smith's ECG Blog

MARCH 19, 2023

It was opened and stented. The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. 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.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Document 52

Dr. Smith's ECG Blog

JANUARY 28, 2018

More Smith comment: it is true that ST depression (STD) due to subendocardial ischemia does not localize [it is usually diffuse ST depression, in multiple leads and not reciprocal to ST elevation in an opposite territory], this ST depression is different! Both were stented. Subsequent echo showed no wall motion abnormality.

Pericarditis 52

Pericarditis Ischemia STEMI Chest Pain 52

EMS 12-Lead

JUNE 20, 2022

A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. He was rushed to the Cath Lab where an LAD culprit lesion was stented. Here is the LAD after stent placement. It’s important to stress the presence of a normal QRS (i.e., The pathology is now painfully evident.

STEMI 52

STEMI Stents Stent Myocardial Infarction 52

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI 52

STEMI Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

The patient, albeit very delayed was referred for angiography where a 99% stenosed pRCA was stented. Notice that much of the dark blue is concentrated on the QRS (R-wave); the QRS is totally ignored in the STEMI paradigm!! There is early R/S transition occurring by V2 (analogous to posterior Q waves).

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Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 90

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. He was successfully stented.

Bradycardia 52

Bradycardia Cardiogenic Shock STEMI Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 24, 2013

He underwent coronary stenting (uncertain which artery). 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. Lesson : 1.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 29, 2016

Normal RBBB, no evidence of ischemia. It was opened and stented. It is uncommon in the age of reperfusion therapy, as most STEMI get treated reasonably early, before transmural infarct. Most STEMI peak at over 10 ng/mL; most NonSTEMI at less than 10 ng/mL. Here is the patient's previous ECG (Figure 2): Previous ECG.

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Aneurysm Ischemia Embolism STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 6, 2011

Thus, there are some suspicious abnormalities, but no definite signs of ischemia. Because of persistent symptoms, another ECG was recorded 30 minutes later: There is only one new finding on this ECG which suggests ischemia. The difference is significant and highly suggests posterior ischemia. It is very subtle but real.

Chest Pain 52

Chest Pain Ischemia STEMI Stents 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! He was successfully treated with one drug eluting stent. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities. Clinical concern and gestalt should ultimately guide management.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

There is STE that does not meet STEMI criteria in V1-V6. Troponin profile The patient underwent angiography and had a 90% thrombotic proximal LAD lesion that was stented. This patient's ischemia was so brief that it did not cause any myocardial stunning. This was mistaken by the treating physicians for ST depression initially.

Chest Pain 52

Chest Pain Ischemia STEMI Stents 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

The ECG was incorrectly interpreted as no signs of ischemia. Diagnosis: Acute non-ST segment elevation MI (Non-STEMI, or NSTEMI) Second troponin returned at around 0200: 15,894 ng/L 0245 (unclear if ongoing pain or not) Inferoposterior (and lateral V5-6) reperfusion findings. No further ECG were ever recorded.

Chest Pain 52

Chest Pain Physiology Stents Stent 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. 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.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI. QTc is the computer measurement. 100% LAD occlusion.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

JULY 11, 2019

These findings are very subtle but suspicious for LAD occlusion, as we have seen in many similar (but less difficult) cases on this blog: A man in his sixties with chest pain at midnight with undetectable troponin How long would you like to wait for your Occlusion MI to show a STEMI? Learning Points: Not all OMI will present as STEMIs.

Chest Pain 52

Chest Pain STEMI Stents Stent 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.

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Chest Pain Ischemia Echocardiogram Myocardial Infarction 105