Ischemia, STEMI and Thrombosis - Cardiovascular Update

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

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. 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

Ischemia Plaque Stenosis Myocardial Infarction

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. MINOCA may be due to: coronary spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis/emboli , and coronary dissection; myocardial disorders, including myocarditis, takotsubo cardiomyopathy, and other cardiomyopathies. And yet the arteries remain open.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

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." New ST elevation diagnostic of STEMI [equation value = 25.3 Computerized QTc = 417. Gottlieb SO, et al.

Chest Pain

Chest Pain Thrombosis Myocardial Infarction STEMI

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Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

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). The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. Quiz : What percent of full blown STEMI have an open artery with normal flow at angiogram? Jesse McLaren et al.

Chest Pain

Chest Pain STEMI Stents Stent

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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

Ischemia STEMI Stenosis Chest Pain

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

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. Am J Emerg Med.

Chest Pain

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

MINOCA may be due to: coronary spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis/emboli , and coronary dissection. link] We know that most type 1 acute MI due to plaque rupture and thrombosis occurs in lesions that are less than 50% (see Libby reference).

Plaque

Plaque Chest Pain Thrombosis Stenosis

Hypertrophic Cardiomyopathy

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

Cardiomyopathy Ischemia STEMI Coronary Angiogram

Formula Utilization

EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. The pathology is now painfully evident.

STEMI

STEMI Stents Stent Myocardial Infarction

Something Winter This Way Comes

EMS 12-Lead

AUGUST 14, 2022

A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. it has been subsequently deemed a STEMI-equivalent. The patient verbalized spontaneous improvement just before 324mg ASA administration. But the lesion is still active!

STEMI

STEMI Sudden Cardiac Death Thrombosis Thrombolysis

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

In terms of ischemia, there is both a signal of subendocardial ischemia (STD max in V5-V6 with reciprocal STE in aVR) AND a signal of transmural infarction of the inferior wall with Q wave and STE in lead III with reciprocal STD in I and aVL. The rhythm is atrial fibrillation. The QRS complex is within normal limits. These include.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). It was thought to be an in stent restenosis and thrombosis from a DES placed in the same region 6 months prior. In there ECG evidence of possible ongoing ischemia? (ie,

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. 24 yo woman with chest pain: Is this STEMI? This is not "diffuse", this is simply anterior, lateral, and likely apical.

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Smith15, and PERFECT Study Author Group 1 Hennepin County Medical Center, 2 Minneapolis Medical Research Foundation, 3 Background : The Smith-modified Sgarbossa criteria (MSC) are frequently recommended for diagnosing acute coronary occlusion (ACO; STEMI-equivalent) in the setting of ventricular paced rhythm (VPR).

Chest Pain

Chest Pain Myocardial Infarction STEMI Ischemia

Acute Dyspnea in a Dialysis Patient. K is 6.3 mEq/L. Are ECG findings due to hyperkalemia, or even due to Type 2 MI?

Dr. Smith's ECG Blog

JANUARY 21, 2025

Time 7 hours lead reversal There is limb lead reversal (QRS in I and aVL are now inverted), but nevertheless one can see that the ischemia appears to have resolved. Negative trops and negative angiogram does not rule out coronary ischemia or ACS. This is extremely elevated for a type 2 MI and totally consistent with STEMI.

Chest Pain

Chest Pain STEMI Tachycardia Myocardial Infarction

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

It is possible there is microvascular dysfunction producing residual transmural ischemia. But this is most common when there is prolonged ischemia, and this patient had the fastest reperfusion imaginable! There was indication of parasympathetic overdrive ( the acute inferior STEMI with profound bradycardia and junctional escape ).

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

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

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

Webinars

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Hypertrophic Cardiomyopathy

Formula Utilization

Something Winter This Way Comes

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Anterior MI in paced rhythm, dismissed by cardiologist, patient died.

Acute Dyspnea in a Dialysis Patient. K is 6.3 mEq/L. Are ECG findings due to hyperkalemia, or even due to Type 2 MI?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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