Dr. Smith's ECG Blog

AUGUST 24, 2012

This ECG is diagnostic of anterior STEMI. But there was some doubt as to whether it might be pericarditis because of the ST elevation in I and II, without ST depression in III. Add that to "sharp" pain and a 33 year old, and it is easy to convince yourself that this is, indeed, pericarditis. However, look closely!

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Dr. Smith's ECG Blog

JUNE 19, 2024

His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The undergraduate continues: This new EKG pattern is more suggestive of acute pericarditis. Usually with pericarditis, some degree of PR segment depression is expected. This is typical of pericarditis. This EKG seems to lack it.

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ECG Cases

MAY 10, 2023

In this ECG Cases blog we look at 10 cases of patients with chest pain, including false positive STEMI, false negative STEMI, and other causes to help hone your ECG interpretation skills in time-sensitive cases where those very ECG skills might save a life.

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Dr. Smith's ECG Blog

JUNE 20, 2018

Clinician and EKG machine read of acute pericarditis. While it is true that inferior MI has ST depression in aVL 99% of the time (Bischof and Smith), and that inferolateral ST elevation is the most common distribution for pericarditis, the ST elevation in V3 has "terminal QRS distortion (TQRSD)," (diagnostic of LAD occlusion).

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Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. J waves can also be induced by Occlusion MI (5), STEMI mimics including takotsubo and myocarditis complicated by ventricular arrhythmias (6, 7), and subarachnoid hemorrhage with VF (8). Take home : Not all STEs are STEMIs or OMIs. What do you think?

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Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

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Dr. Smith's ECG Blog

MAY 29, 2024

Triage ECG: It was interpreted as lateral STEMI, and he was sent to the cath lab, where the angiogram showed unchanged CAD from known prior, with no acute culprit. Patient 2 A man in his 50s with history of CAD and prior PCI, diabetes, presented with acute constant chest pain for the past few hours. Described as a dull ache, 6/10 in severity.

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ECG Cases

OCTOBER 17, 2023

Jesse McLaren guides us through 10 cases, driving home the points that sepsis is a common cause of rapid Afib and diffuse ST depression with reciprocal ST elevation in aVR, myo/pericarditis is a diagnosis of exclusion, endocarditis or lyme carditis can cause AV block, PE can cause low grade fever and ECG signs of acute RV strain and that fever can (..)

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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.

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Dr. Smith's ECG Blog

DECEMBER 20, 2013

Here is his initial ED ECG: The R-wave in V4 extends to 33 mm, the computerized QTc is 372 ms The only available previous ECG is from one year ago, during the admission when he was diagnosed with pericarditis: 1 year ago ECG, with clinician and computer interpretatioin of pericarditis Normal 0 false false false EN-US X-NONE X-NONE What do you think?

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Dr. Smith's ECG Blog

JUNE 18, 2011

This is a 45 yo male who had an inferior STEMI 6 months prior, was found to have severe LAD and left main disease, and was supposed to be set up for CABG a few weeks later, but did not follow up. But it could be anterior STEMI. 40% of anterior STEMI has upward concavity in all of leads V2-V6. is likely anterior STEMI).

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Dr. Smith's ECG Blog

OCTOBER 17, 2022

If you were thinking that this is not anterior OMI because there is no reciprocal ST depression , it is important to remember that half of anterior STEMI do NOT have any reciprocal ST depression. Pericarditis? If you were thinking that this is pericarditis, that would be possible in the absence of any clinical information.

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Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." St depression in lead AVL differentiates inferior st-elevation myocardial infarction from pericarditis. The case continues.

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Dr. Smith's ECG Blog

APRIL 25, 2023

First, many on Twitter said "Pericarditis". This is NOT pericarditis, which virtually NEVER has ST depression any where except aVR. 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.

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Chest Pain Pericarditis Blog Cardiomyopathy 52

Dr. Smith's ECG Blog

JUNE 17, 2018

PR depression, which suggests pericarditis 4. We also showed that, of 47 cases of pericarditis with ST elevation, none had ST depression in aVL. ) Exclusion criteria were age less than 18, SBP less than 100 mmHg, echocardiogram with EF less than 50%, STEMI, pregnancy, and trauma. Absence of any ST depression in aVL. (

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Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

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Dr. Smith's ECG Blog

JANUARY 10, 2020

It could also be due to pericarditis or myocarditis, but I always say that "you diagnose pericarditis at your peril." The clinical presentation is very suggestive of myo-pericarditis. But one should always remember that acute MI is a far more common pathology than myo- or pericarditis. Pericarditis? 13, 2019 Dr.

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Dr. Smith's ECG Blog

FEBRUARY 16, 2020

So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution. So this is STEMI, right? Well, don't we see diffuse ST Elevation in Myo-pericarditis (with STD in aVR)? It is often confused with a wide QRS due to conditions such as hyperkalemia. Which artery? Could this be myopericarditis?

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Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Transient STEMI has been studied and many of these patients will re-occlude in the middle of the night. Is it normal STE? The computer thinks so, and the physician thinks that is quite possible. However , there is terminal QRS distortion in lead V3.

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Dr. Smith's ECG Blog

MARCH 3, 2023

Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO).

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Dr. Smith's ECG Blog

JANUARY 28, 2018

The STD in V2-V4 is almost certainly reciprocal STD, reciprocal to STEMI in the posterior wall; this is evident because it is maximal in V2-V4, not in V4-V6. In patients with suspicion of acute MI who have any ST elevation, aVL is also a very useful lead to differentiate between pericarditis and MI. mm ST depression in aVL.

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Dr. Smith's ECG Blog

MARCH 11, 2016

cm diameter in the apex The presence of thrombus led the clinicians to state that this was a "late presentation STEMI." It does take some time for thrombus to form, but the EKG and the troponin profile show that this was NOT a late presentation STEMI. of AMI patients and is often preceded by postinfarction regional pericarditis (PIRP).

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Dr. Smith's ECG Blog

JANUARY 17, 2024

The limb leads have been removed because there was no ST elevation in those leads, the QRS complexes have been obscured because this is irrelevant to STEMI criteria, and red lines have been added to measure ST segment elevation. But STEMI criteria ignore all this and look at ST segments in isolation.

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Dr. Smith's ECG Blog

JULY 19, 2019

This morphology can be cause by or associated with cocaine: A Patient with Cocaine Chest Pain and Prehospital Computer interpretation of STEMI This is OMI of the anterior, lateral, and inferior walls until proven otherwise. But it does not meet STEMI criteria and it was not initially recognized. The cath lab was now activated.

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Dr. Smith's ECG Blog

MAY 16, 2023

There is a reasonable chance of pericarditis in this case, or this could be a baseline." Here is the Queen of Heart's interpretation: The cath lab had been activated for concern of STEMI. Sadly, I did not receive enough information to adjudicate whether this patient has pericarditis or not. I immediately responded: "cool fake!

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Dr. Smith's ECG Blog

OCTOBER 5, 2011

T-wave to ST ratio is greater than 4 in lead V6, making pericarditis unlikely (also there were no symptoms of pericarditis). If there are no changes in aVL, it is highly unlikely to be inferior STEMI. Would you be certain that it is not STEMI? There is ST elevation diffusely: 2 mm in V2, 3.5 mm in V3, 2.5 mm in V4, 1.5

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Dr. Smith's ECG Blog

NOVEMBER 13, 2022

This is a bad ST vector orientation, because it causes widespread STE and one of the most important mistakes that needs to be avoided here is thinking of the diagnosis of pericarditis. Such an out-of-proportion STE is virtually never seen in pericarditis. Look at the STE in lead II, aVF.

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Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. 24 yo woman with chest pain: Is this STEMI? Pericarditis? Beware a negative Bedside ultrasound.

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Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." Dyspnea, Chest pain, Tachypneic, Ill appearing: Bedside Cardiac Echo gives the Diagnosis 31 Year Old Male with RUQ Pain and a History of Pericarditis. What is the Diagnosis?

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Dr. Smith's ECG Blog

FEBRUARY 29, 2016

It is uncommon in the age of reperfusion therapy, as most STEMI get treated reasonably early, before transmural infarct. Patients with completed, transmural infarct are also at risk for post-infarction regional pericarditis and myocardial rupture. Most STEMI peak at over 10 ng/mL; most NonSTEMI at less than 10 ng/mL.

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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." All very very subtle. So the patient was placed back in the waiting room like many others. Aspirin was given. History and more info?" (I What is the South African Flag Sign?

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Dr. Smith's ECG Blog

NOVEMBER 1, 2022

Discharge Diagnosis was STEMI (The STE did not meet "criteria," so "OMI" would be better, but "STEMI" is far better than what this could have been called: NonSTEMI) Quotes from a note written by a really fine and knowledgable physician: "12-lead EKG was obtained initial 1 at time zero. Initial troponin came back negative."

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Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. Haven't you been taught that this favors pericarditis? Weren't you taught that concave morphology favors pericarditis? This is a high troponin (most STEMI are above 10 ng/mL for troponin I). There is no STE or STD in III an aVF.

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Dr. Smith's ECG Blog

OCTOBER 11, 2020

As always, takotsubo cardiomyopathy and focal pericarditis can mimic OMI, but takotsubo almost never mimics posterior MI, and both are diagnoses of exclusion after a negative cath. The provider contacted cardiology to discuss the case, but cardiology "didn't think it was a STEMI, didn't think he needed emergent cath." Canto et al.

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Dr. Smith's ECG Blog

JANUARY 17, 2018

Let's look at the ED ECG more closely: Sinus rhythm There is ST Elevation in anterior leads: V2-V6 There is ST elevation in I, II, aVL Why is this not STEMI? I am reluctant to reverse a diagnosis of STEMI because I would rather there be a false positive cath lab activation than a false negative. No active chest pain 2.

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Dr. Smith's ECG Blog

AUGUST 6, 2024

These latter findings are typical of pericarditis, but pericarditis never has reciprocal ST depression. It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. Usually with pericarditis and myocarditis — hyperacute T waves (HATW) are not present.

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Dr. Smith's ECG Blog

MARCH 11, 2019

You do NOT see this in normal variant STE, nor in pericarditis. Here is the computer interpretation: (Veritas algorithm) This is what I said: "This is diagnostic of an acute inferior MI. There is upsloping ST elevation in III, with reciprocal ST depression in aVL.

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