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? His response: “subendocardial ischemia.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

1-4 Surprisingly, serial angiographic studies have revealed that the plaque at the site of the culprit lesion of a future acute myocardial infarction often does not cause stenosis that, as seen on the antecedent angiogram, is sufficiently severe to limit flow. Learning Points: 1.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Barely any STE, and thus not meeting STEMI criteria. Annals of Emergency Medicine Cardiology was called to evaluate the patient immediately for emergent cath, but they stated that the ECG did not meet STEMI criteria and elected to wait for further information before proceeding with cath. He was given 6mg IV morphine for ongoing pain.

Chest Pain 52

Chest Pain STEMI Myocardial Infarction Blog 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Jason asked me if I thought it is due to occlusion (without either of us knowing the outcome), and this was my answer: This is a posterolateral MI. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. Some are STEMI-equivalents.

Ischemia 40

Ischemia Chest Pain STEMI Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

COPD, Idiopathic PAH, acute or chronic PE, pulmonary valve stenosis, etc) 3) Conditions affecting RV myocardial contractility, such as ARVD or RV infarction The ECGs does not really show any signs of chronic RV dilation or hypertrophy. Troponin T peaked at 2074 ng/L (very high, typical of OMI/STEMI). The LV EF was 57% at formal echo.

Pulmonary 115

Pulmonary Chest Pain Tricuspid Cardiogenic Shock 115

Dr. Smith's ECG Blog

APRIL 8, 2022

There is clearly sufficient STE for STEMI criteria in leads V2 and aVL, but lead I has less than 1.0 mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI. This ECG was immediatel y discussed with the on-call cardiologist who said the ECG was "concerning but not a STEMI."

Chest Pain 52

Chest Pain SCAD STEMI Blog 52

Dr. Smith's ECG Blog

JULY 31, 2013

We have found in our study comparing inferior STEMI (manuscript in preparation) to inferior early repol several distinguishing characteristics. It showed a 99% stenosis in the RCA, and proximal to a posterolateral branch. Is this inferior ST elevation due to "early repolarization"? There is reciprocal ST depression in aVL.

Chest Pain 52

Chest Pain Aneurysm STEMI Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." See far below for data on 24 troponin T in STEMI and NSTEMI, and correlation with infarct size. This difficulty results in high lateral OMI being the most commonly missed OMIs by the misguided STEMI criteria. Pride et al.

Chest Pain 40

Chest Pain STEMI Myocardial Infarction Coronary Artery Disease 40

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. Angiogram showed a critical LAD thrombotic stenosis.

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

OCTOBER 28, 2013

The last section is a detailed discussion of the research on aVR in both STEMI and NonSTEMI. The additional ST Elevation in V1 is not usually seen with diffuse subendocardial ischemia, and suggests that something else, like STEMI from LAD occlusion, could be present. Here is an article I wrote: Updates on the ECG in ACS. see below).

Cardiac Arrest 52

Cardiac Arrest Ischemia Defibrillator Electrocardiogram 52

Dr. Smith's ECG Blog

APRIL 17, 2023

Full case details and outcomes are below. The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Physician interpretation: "No STEMI." Physician: "No STEMI." Case 1: Case 2: Case 1: What do you think?

Chest Pain 52

Chest Pain STEMI Document Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). The red arrow points to a 90% stenosis in the proximal segment of the LAD. Nevertheless, cases like the one presented today — illustrate the continued need for review of these points that are KEY to attaining a good outcome.

Chest Pain 119

Chest Pain Blog Hospital Tachycardia 119

Dr. Smith's ECG Blog

MARCH 9, 2013

Here is the prehospital ECG, with pain:  Hyperacute anterolateral STEMI  The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. Type B waves are deeper and symmetric. When the patient had chest pain, prior to nitroglycerine, what do you think the ECG showed ? A stent was placed.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

JULY 3, 2018

Despite ongoing chest discomfort and an uptrending troponin, he never meets STEMI criteria. As has been mentioned numerous times on this site and is redemonstrated here: expert, subjective ECG interpretation is superior to STEMI criteria. Despite having acute coronary occlusion by cath, his ECGs never met STEMI criteria.

Pericarditis 52

Pericarditis Chest Pain Stent Stents 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. Am J Cardiol.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Article 52

Dr. Smith's ECG Blog

JANUARY 12, 2023

ECG read as: "Shows T wave inversions in the inferior leads and less than 1mm STE in V2, without STEMI criteria." Cath was done at around 9AM: Culprit lesion mid-LAD, 99% stenosis, pre-intervention TIMI flow not listed, PCI performed with TIMI 3 flow and 0% stenosis resulting. All very very subtle. Aspirin was given.

Chest Pain 52

Chest Pain STEMI Blog Stenosis 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

90% stenosis of the proximal ramus intermedius, pre procedure TIMI II flow The ramus intermedius is a normal variant on coronary anatomy that arises between the LAD and LCX. 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

AUGUST 28, 2020

This can only be due to STEMI. Here I annotate it: This shows 100% occluded circumflex (red arrow) and a 90% stenosis of the LAD (Yellow arrow). The LAD was thought to be not thrombotic, but a chronic tight stenosis. The LAD was thought to be not thrombotic, but a chronic tight stenosis. I said "activate the cath lab."

Cardiogenic Shock 40

Cardiogenic Shock Chest Pain Ischemia Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. Long term outcome is unavailable. So the cath lab was activated.

Chest Pain 120

Chest Pain STEMI Cardiogenic Shock Heart Failure 120

Dr. Smith's ECG Blog

JUNE 15, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. High sensitivity troponin I was 23 ng/L.

STEMI 98

STEMI Chest Pain Stenosis Outcomes 98

Dr. Smith's ECG Blog

JUNE 27, 2024

A reliable study would keep track of all patients with shockable arrest and analyze the ones who were not enrolled to see their outcomes. COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab.

Defibrillator 112

Defibrillator Cardiac Arrest STEMI Chest Pain 112

Dr. Smith's ECG Blog

MAY 13, 2024

This ECG is highly concerning for LAD occlusion despite it not showing a STEMI criteria. You can find the variables used to calculate the value on MD calc here: [link] Utilizing Dr. Smith’s Subtle Anterior STEMI Calculator (4-Variable), the value is greater than 18.2 which is concerning for LAD occlusion.

Chest Pain 119

Chest Pain STEMI Ultrasound Heart attacks 119

Dr. Smith's ECG Blog

FEBRUARY 25, 2009

RBBB in acute STEMI has a very high mortality. Angiography revealed a very tight LAD stenosis with some flow (confirming the reperfusion that we see on the ECG). A stent was placed, and the patient had an excellent outcome with no wall motion abnormality. But here there is a large degree of ST elevation in V2-V6, I, and aVL.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Defibrillator STEMI 52

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. Limkakeng AT.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Pacemaker 52

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

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 40

STEMI Chest Pain Cardiac Arrest Stent 40

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. 33% of STEMI are reperfused by the time of angiography. Very frustrating.

STEMI 80

STEMI Chest Pain Echocardiogram Stent 80

Dr. Smith's ECG Blog

MARCH 3, 2025

Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. An EKG from a year prior was available for comparison: The ED physician noted Initial EKG here read by the computer as a STEMI, however, there is a very poor baseline and a lot of artifact. See reference and discussion below.

Tachycardia 73

Tachycardia Pulmonary Chest Pain Stenosis 73

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". A paradox in the literature: All trials of very early intervention for NSTEMI which do not exclude patients with persistent chest pain show that intervention in < 2 hours results in a better outcome. Pain was decreased to 2/10.

STEMI 120

STEMI Chest Pain Myocardial Infarction Aneurysm 120