Myocardial Infarction, Plaque and STEMI

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. Thus, it has recently become generally accepted that most plaque ruptures resulting in myocardial infarction occur in plaques that narrow the lumen diameter by 40% of the arterial cross section may be involved by plaque.

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

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. MINOCA I do not have the bandwidth here to write a review of MINOCA.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Dr. Smith's ECG Blog

APRIL 22, 2024

Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty.

Chest Pain

Chest Pain Myocardial Infarction Anatomy Angina

Webinars

Bridging Innovation & Patient Care: The Growing Role of AI

MORE WEBINARS

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Dr. Smith's ECG Blog

MAY 20, 2024

The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand). Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? Murakami MM.

Chest Pain

Chest Pain Blood Pressure Ischemia STEMI

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

So there is probability of myocardial injury here (and because it is in the correct clinical setting, then myocardial infarction.) Although it is statistically unlikely, multiple plaque ruptures are possible. The PDA plaque was also bulky, but was not described as inflamed or ulcerated. Heitner et al.

Angina

Angina Plaque Document Stents

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

To prove there is no plaque rupture, you need to do intravascular ultrasound (IVUS). An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!! Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS. MINOCA has many etiologies. Learning Points: 1.

Plaque

Plaque Chest Pain Thrombosis Stenosis

1 hour of CPR, then ECMO circulation, then successful defibrillation.

Dr. Smith's ECG Blog

MAY 19, 2020

This is a troponin I level that is almost exclusively seen in STEMI. In this case, profound shock for 1 hour would result in the same degree of infarction. A followup ECG was recorded 2 days later: No definite evidence of infarction. So this is either a case of MINOCA, or a case of Type II STEMI. Troponin I rose to 44.1

Defibrillator

Defibrillator Circulation Plaque Cardiac Arrest

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. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia

Ischemia STEMI Stenosis Chest Pain

ECG with Aslanger's Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory.

Dr. Smith's ECG Blog

JANUARY 4, 2021

Both of these patterns together suggest Aslanger's pattern , recently published in J Electrocardiology: A new electrocardiographic pattern indicating inferior myocardial infarction. Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), These suggest inferior OMI with possible RV involvement.

Ischemia

Ischemia Pulmonary STEMI 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 ECG was read as "No STEMI" and the patient was treated like an average chest pain patient (despite the fact that a chest pain patient with active pain and active subendocardial ischemia is very high risk). Therefore it means acute type 1 ACS plaque rupture with impeded flow and impending full occlusion until proven otherwise.

Chest Pain

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction

Is there a Right Ventricular MI in addition to Infero-postero-lateral MI?

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. But which myocardial walls are affected? Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI.

Chest Pain

Chest Pain STEMI Ischemia Blog

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion). What is it?

Chest Pain

Chest Pain SCAD STEMI Blog

An athletic 30-something woman with acute substernal chest pressure

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. This is diagnostic of myocardial infarction. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL.

SCAD

SCAD Chest Pain Myocardial Infarction Ischemia

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA. A recent study found that SCAD causes almost 20% of STEMI in young women. A study by Hassan et al. Lobo et al.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

Do you want to be interrupted to view what the computer calls normal or nonspecific ECGs? 2 cases at once!

Dr. Smith's ECG Blog

MARCH 27, 2018

Of course, it is actually clearly an acute inferior MI, even though (as is so frequent) it does not meet "STEMI criteria." It was actually a dissection, not an atherosclerotic plaque rupture. I activated the cath lab and brought her to our stabilization room. I called the cardiologists to tell them that we have 2 acute MIs in the ED.

Chest Pain

Chest Pain Myocardial Infarction Plaque STEMI

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

Dr. Smith's ECG Blog

MAY 10, 2023

ng/mL This single initial troponin at this level, in the context of chest pain, is high enough to be diagnostic of acute myocardial infarction. LAD plaque with 0-25 percent stenosis. Thus, Wellens' syndrome should be thought of as a transient OMI or transient STEMI. Transient STEMI is at high risk of re-occlusion.

Coronary Angiogram

Coronary Angiogram Chest Pain Stenosis STEMI

Is this a STEMI? No, not by definition! Why not? Why is this Important?

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. As there was ruptured plaque, this is NOT Prinzmetal's angina. First, the name (Myocardial Infarction or Not) is not important. It was stented.

STEMI

STEMI Angina Myocardial Infarction Plaque

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

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

Bradycardia STEMI Cardiogenic Shock Ischemia

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

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. Is that an obvious STEMI underneath that rhythm? Is this inferor STEMI? Atrial Flutter with Inferior STEMI? If I fix the rhythm will the ST changes resolve?

Ischemia

Ischemia Atrial Flutter Arrhythmia Tachycardia

Chest pain and this ECG. Angiogram totally normal. Is this myocarditis?

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? Here it is annotated in red: Our extremely smart radiologist, Gopal Punjabi , assures me that this finding can only be due to myocardial infarction, not myocarditis. Myocardial Infarction with Non-Obstructive Coronary Arteries. He called 911.

Chest Pain

Chest Pain Embolism STEMI Plaque

Normal ACS care, everything by the book! But normal ACS care could be much better. This post explains everything.

Dr. Smith's ECG Blog

MARCH 17, 2025

Nevertheless, the operator performed intravascular ultrasound and saw erupted calcium nodule consistent with plaque erosion. Limitations of registry data: This patient presented with STEMI (-) OMI and developed STEMI the following day. In the world of STEMI, we are incapable of recognizing the first ECG as a false negative.

STEMI

STEMI Chest Pain Myocardial Infarction Document

Which patient needs a CT scan?

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This was ruptured plaque with thrombus. She was a walk-in at triage.

Chest Pain

Chest Pain STEMI Aortic Ultrasound

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Dr. Smith's ECG Blog

MARCH 19, 2025

Influenza-like illness can also trigger plaque rupture. STEMI criteria are only 43% sensitive for OMI. Prevalence and outcome of patients with non-ST segment elevation myocardial infarction with occluded culprit artery - a systemic review and meta-analysis. But in 34% there is persistent occlusion at next day angiogram.

Chest Pain

Chest Pain STEMI Stents Stent

Pay now (in the evening) or pay later with interest (in the middle of the night).

Dr. Smith's ECG Blog

MARCH 1, 2025

Note: the 2022 ACC Expert consensus Chest pain guidelines state that "posterior STEMI-Equivalent" is a sign of acute coronary occlusion. 2/3 of STEMI have a peak 4th generation troponin I greater than 10.0 Comment: The first ECG is diagnostic of OMI that does not meet STEMI criteria. NSTEMI-OMI").

Chest Pain

Chest Pain STEMI Stents Stent

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

This was attributed to a "Type 2 MI", which is acute MI that is not due to ruptured plaque, but rather due to "supply demand oxygen mismatch". Most MINOCA is due to ruptured plaque with thrombus that lyses and does not leave behind a visible culprit. They made a final diagnosis of type II myocardial infarction.

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

The authors describe a case with some features in common with our patient -- a stressful event followed by a stress cardiomyopathy/acute myocardial infarction overlap syndrome. Acute myocardial infarction: an uncommon complication of takotsubo cardiomyopathy. Mechanisms of plaque formation and rupture. SanzRuiz, R.,

Cardiomyopathy

Cardiomyopathy Myocardial Infarction Defibrillator Bradycardia

Cardiovascular Update

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?

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Webinars

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

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

1 hour of CPR, then ECMO circulation, then successful defibrillation.

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

ECG with Aslanger's Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory.

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

Is there a Right Ventricular MI in addition to Infero-postero-lateral MI?

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

An athletic 30-something woman with acute substernal chest pressure

A young peripartum woman with Chest Pain

Do you want to be interrupted to view what the computer calls normal or nonspecific ECGs? 2 cases at once!

A 30-something woman with intermittent CP, a HEART score of 2 and a Negative CT Coronary Angiogram on the same day

Is this a STEMI? No, not by definition! Why not? Why is this Important?

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

Chest pain and this ECG. Angiogram totally normal. Is this myocarditis?

Normal ACS care, everything by the book! But normal ACS care could be much better. This post explains everything.

Which patient needs a CT scan?

Is it possible that this patient with acute chest pain and this ECG does not need emergent intervention?

Pay now (in the evening) or pay later with interest (in the middle of the night).

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?

Stay Connected