Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. 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 97

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

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. Learning Points: 1.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

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 52

Ischemia STEMI Stenosis Chest Pain 52

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 52

Defibrillator Circulation Plaque Cardiac Arrest 52

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 40

Ischemia Pulmonary STEMI Chest Pain 40

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.) HsTnI drawn at that time was 9 ng/L (ref. 80%) and definitely too much for hour to hour. From angiography, it is not clear what the culprit is. The ECG changes were inferior, posterior, and lateral.

Angina 121

Angina Plaque Document Stents 121

Dr. Smith's ECG Blog

JUNE 17, 2018

Smith, MD – Department of Emergency Medicine, Hennepin County Medical Center, Professor, University of Minnesota School of Medicine, Minneapolis, MN ABSTRACT: Background: Patients with type 1 myocardial infarction with normal left ventricular function that are hemodynamically stable do not usually manifest with sinus tachycardia.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 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." This was a point of care ultrasound, not a bubble contrast echo. Cath lab activated Dual antiplatelet therapy and heparin given. NTG drip started. Pain better still.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

APRIL 20, 2018

Given her risk factors (HTN, HLD, ESRD from diabetes) I decided to obtain a broad cardiac workup for the patient: serial ECGs, labs, serial troponins, CXR and bedside cardiac ultrasound. Ultrasounds can be very helpful in guiding your diagnostic pathway: location of WMA on US led to obtaining posterior leads.

Chest Pain 40

Chest Pain Ultrasound Risk Factors STEMI 40

Dr. Smith's ECG Blog

APRIL 25, 2023

No pericardial effusion on ultrasound." See our publication: ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis There is STE in inferior leads, high lateral leads, and V4-V6. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI. What do you think?

Chest Pain 52

Chest Pain Pericarditis Blog Cardiomyopathy 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Here is the repeat ECG at 52 minutes after arrival to triage: Obvious posterolateral STEMI Angiographic findings: 1. Regional wall motion abnormality-inferolateral (this is the formal ultrasound location of a posterior wall motion abnormality). After return from CT, the patient's pain was severe again. 2022.08.750 Section 5.2.2,

Chest Pain 52

Chest Pain STEMI Stenosis Blog 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Electrocardiographic Differentiation of Early Repolarization FromSubtle Anterior ST-Segment Elevation Myocardial Infarction. 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)? 100% LAD occlusion.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

A recent study found that SCAD causes almost 20% of STEMI in young women. Often, intravascular ultrasound or intravascular optical coherence tomography is requeried to make the diagnosis. examined SCAD presenting as STEMI (unlike Hassan et al. Type 2 is more difficult to appreciate on angiography than type 1. Lobo et al.

Chest Pain 52

Chest Pain SCAD STEMI Cardiogenic Shock 52

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. In fact, bedside ultrasound might even find severe aortic stenosis.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Association between opioid analgesia and delays to cardiac catheterization of patients with occlusion Myocardial Infarctions. Unfortunately, they follow their own guidelines only 6% of the time!! Lupu L, et al. mg/dL, K 3.5

Chest Pain 52

Chest Pain Ischemia Myocardial Infarction ICU 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

APRIL 8, 2016

Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 Learning Points: 1.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

JULY 7, 2013

Thus, this is both an anterior and inferior STEMI. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Armstrong et al.)], the presence of such well developed anterior Q-wave suggests completed transmural STEMI. Could it be acute (vs.

STEMI 52

STEMI Myocardial Infarction Pericarditis Ultrasound 52

Dr. Smith's ECG Blog

JULY 18, 2014

Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. the presence of such well developed, wide, anterior Q-wave suggests completed transmural STEMI. Could it be acute (vs.

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 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. Do not treat AIVR.

Chest Pain 107

Chest Pain Arrhythmia Myocardial Infarction STEMI 107

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. First, the name (Myocardial Infarction or Not) is not important. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

A bedside cardiac ultrasound was normal, with no effusion. Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 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 40

Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. Troponin T peaked at 38,398 ng/L ( = a very large myocardial infarction, but not massive-- thanks to the pre-PCI spontaneous reperfusion, and rapid internvention!! ). The below ECG was recorded. Inotropic medication was continued.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

OCTOBER 2, 2021

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. In equivocal cases, point-of-care ultrasound may be the difference between taking the patient to the lab or not. 1] Wereski, R., Chapman, A. Gray, A., &

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

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. Occlusion Myocardial Infarction (OMI) often does not present with diagnostic ST elevation, or even any STE, especially in dialysis patients.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 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 40

STEMI Chest Pain Ischemia Aneurysm 40

Dr. Smith's ECG Blog

JANUARY 28, 2012

A middle aged patient who was 3 weeks s/p STEMI came from cardiac rehab where he developed some chest pain, dyspnea and weakness on the treadmill. There is no acute STEMI. This is diagnostic of recent, reperfused STEMI. This is diagnostic of recent, reperfused STEMI. Acute STEMI would have upright T-waves.

Chest Pain 40

Chest Pain STEMI Pericarditis Ultrasound 40

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. And almost all of them could be detected by bedside ultrasound.

Chest Pain 105

Chest Pain Aortic STEMI Ultrasound 105

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 81

STEMI Chest Pain Myocardial Infarction Document 81

Dr. Smith's ECG Blog

APRIL 9, 2025

The paramedics diagnosis was "Possible Anterolateral STEMI." On arrival in the ED, a bedside ultrasound showed poor LV function (as predicted by the Queen of Hearts) with diffuse B-lines. More proof that a huge STEMI may have normal or near normal initial troponin. I don't know what the device algorithm interpretation stated.

Defibrillator 63

Defibrillator Cardiac Arrest Myocardial Infarction STEMI 63