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 94

Chest Pain STEMI Ischemia Myocardial Infarction 94

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 121

STEMI Chest Pain Myocardial Infarction Stents 121

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.

Stent 40

Stent Stents 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 120

Chest Pain Myocardial Infarction Anatomy Angina 120

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

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 126

Chest Pain Blood Pressure Ischemia STEMI 126

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 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

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

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 74

Chest Pain STEMI Myocardial Infarction Electrocardiogram 74

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

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. Here is his most recent previous ECG: This was recorded after intervention for inferior STEMI (with massive ST Elevation, see below), and shows inferior Q-waves with T-wave inversion typical of completed inferior OMI.

STEMI 115

STEMI Heart Failure Stents Stent 115

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 88

Chest Pain STEMI Blog Stents 88

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 87

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 87

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 81

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 81

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

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 90

Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 90

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 Stents 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

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 109

Angina Plaque Document Stents 109

Dr. Smith's ECG Blog

MARCH 11, 2016

Appearance of abnormal Q waves early in the course of acute myocardial infarction: implications for efficacy of thrombolytic therapy. It was treated with and dual "kissing balloons" and drug eluting stents. cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI."

Myocardial Infarction 52

Myocardial Infarction Pericarditis Angina STEMI 52

EMS 12-Lead

APRIL 21, 2022

His father and brother both died of myocardial infarction at ages 61 and 45, respectively. STEMI was activated and the patient went to Cath on arrival. Advanced multi-vessel disease was found with stents deployed to the mid-LCx (80% stenosis), D1 (90% stensosis), and the pLAD (95% stenosis). 2] Aslanger, E.,

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 52

Dr. Smith's ECG Blog

NOVEMBER 13, 2022

The ECG in ER is shown below: ECG is still diagnostic but we are watching the natural course of myocardial infarction here. The lesion was successfully stented, but it was unfortunately done after a significant myocardial loss. Considerations on the naming of myocardial infarctions. J Electrocardiol.

Chest Pain 52

Chest Pain Myocardial Infarction Blog Pericarditis 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. As the conversation progressed, another ECG spontaneously printed. The pathology is now painfully evident.

STEMI 52

STEMI Stents Stent Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2014

A male in late middle age with a history of RCA stent 8 years prior complained of chest pain. Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died. EMS recorded the following ECG: What do you see?

Chest Pain 52

Chest Pain Cardiac Arrest Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main." One would not expect wall motion to recover so quickly after stenting, so this is good evidence that the POCUS echo was indeed accurate. NTG drip started. Is this OMI?

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

DECEMBER 14, 2016

ng/mL (ULN = 0.030 ng/mL) , diagnostic of myocardial injury. The "criteria" for posterior STEMI are 0.5 Acute myocardial injury: Is it myocardial infarction, or perhaps myocarditis? Is it STEMI or NonSTEMI? The troponin I returned at 4.1 mm STE in one lead. There is zero ST Elevation. This includes: 1.

Chest Pain 52

Chest Pain STEMI Aortic Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 28, 2018

Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. See these posts for Wellens' mimics: Pseudo-Wellens' Syndrome due to Left Ventricular Hypertrophy (LVH) Anterior STEMI? Am Heart J.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. A mid-LAD culprit lesion was identified and stented. Smith comment : V5 and V6 are excessively discordant!!!! Pacing Clin Electrophysiol.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

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. High-Sensitivity Cardiac Troponin Concentrations at Presentation in Patients With ST-Segment Elevation Myocardial Infarction.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 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. He was successfully stented.

Bradycardia 52

Bradycardia Cardiogenic Shock STEMI Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

They were stented. Available from: [link] Excerpt: "To illustrate the limitations imposed by sample size, recent data from our institution reveal that we identify approximately 225 type I myocardial infarctions (MI) in a typical year. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion.

Chest Pain 52

Chest Pain STEMI Article Myocardial Infarction 52