Dr. Smith's ECG Blog

OCTOBER 27, 2024

The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI". First obtuse marginal also had an 80% stenosis and was stented. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

STEMI 116

STEMI Chest Pain Myocardial Infarction Aneurysm 116

Coronary Artery Disease Journal

NOVEMBER 20, 2023

The purpose of this report is to use propensity score matching to determine gender-specific differences in clinical outcomes after percutaneous coronary interventions with polymer-free sirolimus-coated stents. In the unmatched STEMI subgroup, all-cause mortality was significantly higher in females driven by older age (P < 0.001).

Stents 52

Stents Stent Outcomes Coronary Artery Disease 52

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. Smith: This is an enormous myocardial infarction. Most large STEMI have peak troponin I in the 20.0

Chest Pain 89

Chest Pain Myocardial Infarction Stents Stent 89

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. The lesion was successfully stented. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. Here is the post-intervention angiogram and post-PCI ECG.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 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 92

Chest Pain STEMI Ischemia Myocardial Infarction 92

Frontiers in Cardiovascular Medicine

JANUARY 15, 2024

of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. Approximately 48.5% and 1.3%, respectively.

SCAD 75

SCAD Coronary Artery Bypass Graft Outcomes Myocardial Infarction 75

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.

STEMI 118

STEMI Chest Pain Myocardial Infarction Stents 118

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., She was taken to the cath lab, where she was found to have 100% in-stent restenosis of the proximal LAD. In our study, there were 20/53 complete LAD OMI (TIMI-0 flow) which did not meet STEMI criteria. None of the 20 ever evolved to STEMI criteria. This one is easy for the Queen. 2012;1:344–348.

Cardiac Arrest 108

Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 108

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.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

The British Journal of Cardiology

NOVEMBER 10, 2023

The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug-eluting stent, drug-coated balloon, or both in different combinations and permutations.

Stents 40

Stents Stent Coronary Artery Disease Myocardial Infarction 40

The British Journal of Cardiology

APRIL 16, 2024

Intra-procedural data included access route, coronary anatomy, lesion complexity, number of stents deployed, door-to-balloon time for primary PCI, and any intra-procedural complications. and the average number of stents 2.6. The radial approach was used in 544/567 (95.94%), the average SYNTAX score was 34.8 ± 9.6,

Outcomes 52

Outcomes Cardiogenic Shock Angina STEMI 52

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 117

Chest Pain Myocardial Infarction Anatomy Angina 117

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

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." Can you diagnose an ACO (STEMI) when you also have LVH? The criteria of Armstrong et al. References 1.

STEMI 52

STEMI Myocardial Infarction Chest Pain Aneurysm 52

Dr. Smith's ECG Blog

OCTOBER 24, 2013

He underwent coronary stenting (uncertain which artery). He underwent immediate CPR, was found to be in ventricular fibrillation, and was successfully resuscitated. I do not have the post-resuscitation ECG. He underwent months of rehabilitation and was able to return to work part time. Could this have been avoided?

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 22, 2024

Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." Successful primary angioplasty of the mid-circumflex artery towards the main marginal branch with the implantation of a drug-eluting stent. Good angiographic result.

Chest Pain 66

Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

MAY 20, 2024

The cardiologist recognized that there were EKG changes, but did not take the patient for emergent catheterization because the EKG was “not meeting criteria for STEMI”. Diagnosis of Type I vs. Type II Myocardial Infarction in Emergency Department patients with Ischemic Symptoms (abstract 102). Murakami MM.

Chest Pain 123

Chest Pain Blood Pressure Ischemia STEMI 123

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. Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. No further troponins were drawn.

STEMI 52

STEMI Angina Myocardial Infarction Plaque 52

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. An open 90% LAD was stented.

STEMI 52

STEMI Myocardial Infarction Chest Pain Angioplasty 52

EMS 12-Lead

MARCH 19, 2023

He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myocardial infarction, or any prior PCI/stent. It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. No appreciable skin pallor.

Myocardial Infarction 52

Myocardial Infarction STEMI Coronary Angiogram Coronary Artery Disease 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.’

STEMI 40

STEMI Myocardial Infarction Chest Pain Angina 40

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

Chest Pain 90

Chest Pain STEMI Blog Stents 90

Dr. Smith's ECG Blog

AUGUST 9, 2019

When total LM occlusion does present with STE in aVR, there is ALWAYS ST Elevation elsewhere which makes STEMI obvious; in other words, STE is never limited to only aVR but instead it is part of a massive and usually obvious STEMI. All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery?

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 8, 2024

The CAG showed a 99% thrombotic lesion of the proximal RCA, which was stented. This OMI went unrecognized and, had the artery not re-perfused by itself, the patient could have suffered a very large myocardial infarction. Due to rapid spontaneous reperfusion, high sensitivity troponin I peaked at just under 5000 ng/L.

Chest Pain 79

Chest Pain Myocardial Infarction Hypertension Hospital 79

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. This confirms these Q waves are caused by an acute infarct. But the ECG still doesn’t meet STEMI criteria. Smith : Normal ST Elevation in V2-V4 never has an associated Q-wave! the computer interpretation 2.

Chest Pain 70

Chest Pain STEMI Myocardial Infarction Electrocardiogram 70

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Angiogram: Culprit Lesion (s): Thrombotic occlusion of the proximal RCA -- stented. Literature cited In inferior myocardial infarction, neither ST elevation in lead V1 nor ST depression in lead I are reliable findings for the diagnosis of right ventricular infarction Johanna E.

Chest Pain 82

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 82

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. A New ST-segment elevation myocardial infarction equivalent pattern? An Impella was placed for cardiac output augmentation.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

MARCH 19, 2023

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. It was opened and stented. The patient was diagnosed with a"Non-STEMI." They have large infarcts and high mortality. To me, that is a meaningless diagnosis.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Document 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

It is diagnostic of OMI, but this is SUBACUTE OMI I sent this ECG to my "EKG Nerdz" friends, without any clinical info at all and they answered "OMI" The Queen said: "STEMI-Equivalent with High Confidence:" Notice she sees findings in both normal beats and PVCs. It was opened and stented. This is then a large MI, but it is subacute.

Blog 58

Blog Chest Pain Myocardial Infarction Critical Care 58

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

A very large myocardial infarction. The next day the ECG not unexpectedly shows a completed transmural inferior and posterior wall infarction. The patient, albeit very delayed was referred for angiography where a 99% stenosed pRCA was stented. No further episodes of atrial fibrillation occurred during monitoring.

Chest Pain 86

Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 86

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

Aslanger's pattern (Smith was co-author on this): A new electrocardiographic pattern indicating inferior myocardial infarction The next troponin returned at 8822 ng/L. 20% of cases that everyone would call a STEMI have a competely open artery by the time of angiogram 60-90 minutes later.

Chest Pain 103

Chest Pain Ischemia Echocardiogram Myocardial Infarction 103

Dr. Smith's ECG Blog

MAY 6, 2018

One of our fine interns, Daniel Lee, who is also an ECG whiz, found this paper from 2013 and brought it to my attention: The delayed activation wave in non-ST-elevation myocardial infarction. When present, the infarct artery is more likely to be the circumflex. Of all inferior STEMI, 85% are due to RCA.

STEMI 52

STEMI Chest Pain Myocardial Infarction Article 52

Dr. Smith's ECG Blog

JUNE 12, 2017

This is diagnostic of inferior MI, though does not meet millimeter criteria for "STEMI." He was worried for inferior MI and ordered another, which was recorded 15 minutes later: Now clearly and obviously diagnostic of inferior STEMI. He was found to have a 100% circumflex lesion for which a bare metal stent was placed.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. So there was 3-vessel disease, but with an acute posterior STEMI. There is no ST elevation. See the list below.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

The ECG is diagnostic of occlusion myocardial infarction (OMI). It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. The overall read is OMI with HIGH confidence. == Below is the ECG of Patient #2 — as interpreted by the QOH.

Chest Pain 85

Chest Pain Ischemia Pericarditis Tachycardia 85

Dr. Smith's ECG Blog

JUNE 17, 2017

Because of the high troponin, echocardiography was done and showed a wall motion abnormality in the anterior, anterolateral, and apical walls, consistent with LAD myocardial infarction. It was stented. The possibility of anterior STEMI was not noticed during patient care.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Stents 52

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.) On the combined basis of angiography and IVUS, this patient received stents to his mid RCA, proximal PDA, and OM. RCA and PDA before and after, arrows indicating stented regions.

Angina 107

Angina Plaque Document Stents 107