Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Smith comment: This patient did not have a bedside ultrasound. Had one been done, it would have shown a feature that is apparent on this ultrasound (however, this patient's LV function would not be as good as in this clip): This is recorded with the LV on the right. What should be done? Should the cath lab be activated?

Ischemia 52

Ischemia Cardiogenic Shock Aortic Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

This suggests further severe ischemia. The problem is difficult to study because angiographic visualization of arteries is not perfect, and not all angiograms employ intravascular ultrasound (IVUS) to assess for unseen plaque or for plaque whose rupture and ulceration cannot be seen on angiogram. And yet the arteries remain open.

Coronary Angiogram 101

Coronary Angiogram Plaque Thrombosis STEMI 101

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. At first glance, it seems the patient is having a STEMI. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock.

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

APRIL 24, 2020

When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Subendocardial ischemia results in ST depression, but unfortunately, and rather mysteriously, it does not localize to the ischemic wall.

Ischemia 52

Ischemia Chest Pain Stenosis Cardiogenic Shock 52

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. This was a point of care ultrasound, not a bubble contrast echo.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. But it could be anterior STEMI. 40% of anterior STEMI has upward concavity in all of leads V2-V6. is likely anterior STEMI).

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

Dr. Smith's ECG Blog

DECEMBER 15, 2015

There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. A bedside cardiac ultrasound was recorded: Here is a still image of the echo: The red arrows outline the right ventricle and the yellow arrows outline the left ventricle chamber. There is no ST elevation.

STEMI 52

STEMI Embolism Pulmonary Ultrasound 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). I performed a bedside cardiac ultrasound and the posterior wall appeared to be contracting and shortening normally. The ECG normalized overnight. Maximum troponin was 2.1

STEMI 52

STEMI Chest Pain Ultrasound Blood Pressure 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. This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. But maybe not.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 52

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. Now another, with ultrasound. The rhythm is atrial fibrillation. What is the Diagnosis?

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( The below ECG was recorded.

Arrhythmia 113

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 113

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. Refractory ischemia or electrical/hemodynamic instability are indications for the PCI.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

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. Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Lupu L, et al. mg/dL, K 3.5 Abstract 556.

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. However the patient continued to have chest pain and bedside ultrasound showed hypokinesis of the septum with significantly reduced LVEF. Is there STEMI? The patient continued having chest pain. What is the rhythm?

Chest Pain 84

Chest Pain Arrhythmia Myocardial Infarction STEMI 84

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Takotsubo is a sudden event, not one with crescendo angina.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 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. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

APRIL 26, 2017

This meets "STEMI criteria" However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4. The morphology is not right for STEMI. My interpretation: LVH with secondary ST-T abnormalities, exaggerated by stress, not a STEMI. This is very good evidence that the ST elevation is not due to STEMI.

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

This proves that the first one was, surprisingly, due to ischemia!! After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. A second troponin had been drawn 3 hours after arrival and was again less than 0.30ng/mL.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio greater than 0.36, then it is STEMI, not LV aneurysm. These ultrasounds confirm LAD occlusion. How do I know?

STEMI 52

STEMI Ischemia Chest Pain Aneurysm 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

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. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think? The ECG is consistent with high lateral STEMI. Called 911.

STEMI 52

STEMI Chest Pain Cardiac Arrest Stent 52

Dr. Smith's ECG Blog

OCTOBER 24, 2013

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. An emergency cardiac ultrasound could be very useful. 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

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. EKG is pictured below: What do you think?

Bradycardia 52

Bradycardia Cardiogenic Shock STEMI Ischemia 52

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? Beware a negative Bedside ultrasound. Pericarditis?

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 52

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Dr. Nossen performed a bedside ultrasound which was interpreted as normal. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI.

Blog 52

Blog Bradycardia Ischemia Exercise 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

This strongly suggests reperfusing RCA ischemia. Troponins, echocardiogram An echocardiogram showed inferobasilar hypokinesis, further supporting a diagnosis of regional ischemia , likely of the area supplied by the RCA. A recent study found that SCAD causes almost 20% of STEMI in young women. There is also a Q-wave in III.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

A bedside cardiac ultrasound was normal, with no effusion. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0 Available from: [link] 9.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

They recorded a prehospital ECG and diagnosed STEMI and activated the cath lab prehospital. ALL TROPS WERE UNDETECTABLE A formal ultrasound was done: Normal estimated left ventricular ejection fraction at rest. This ST-T wave appearance in the lateral chest leads of ECG #2 is consistent with L V “ S train” vs ischemia.

Chest Pain 52

Chest Pain Ischemia Angina Electrocardiogram 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

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). His ED cardiac ultrasound (which is not at all ideal for detecting wall motion abnormalities, and is also very operator dependent for this finding) was significant for depressed global EF.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia). Recall that air is a poor conductor of electricity and will, therefore, generate smaller amplitudes on posterior leads (hence why STEMI criteria requires only >0.5

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 20, 2018

I know from reading your blog that you "diagnose pericarditis at your own peril", but are there any signs on that initial ECG that would make you think ischemia? However, in almost every case, one should confirm absence of OMI (Occlusion MI) at least by contrast ultrasound. See this case: Pericarditis, or Anterior STEMI?

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 52