Plaque, STEMI and Ultrasound - Cardiovascular Update

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. Bedside cardiac ultrasound with no obvious wall motion abnormalities. Conversely, pathological evaluation, as shown in Fig 2, will correctly identify the percentage of cross-sectional area occupied by plaque.

Ischemia

Ischemia Plaque Stenosis Myocardial Infarction

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

MINOCA may be due to: coronary spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis/emboli , and coronary dissection; myocardial disorders, including myocarditis, takotsubo cardiomyopathy, and other cardiomyopathies. Thus, intracoronary imaging modalities are crucial in this setting. From Gue at al.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

Cardiac arrest, LBBB with STEMI on the ECG, but no Acute Coronary Syndrome!

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

We did a bedside cardiac ultrasound. This is as clear a STEMI as you can get. So this is classic inferoposterior STEMI on the ECG but is NOT acute coronary syndrome! The ECG and ultrasound could not have been differentiated from acute plaque rupture with occlusion of the RCA. 3 points gets you an MI by Sgarbossa.

Cardiac Arrest

Cardiac Arrest STEMI Ultrasound Chest Pain

Webinars

Bridging Innovation & Patient Care: The Growing Role of AI

MORE WEBINARS

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Dr. Smith's ECG Blog

MAY 20, 2024

The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand). Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing?

Chest Pain

Chest Pain Blood Pressure Ischemia STEMI

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Dr. Smith's ECG Blog

APRIL 22, 2024

Bedside ultrasound with no apparent wall motion abnormalities, no pericardial effusion, no right heart strain. 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). Labs ordered but not yet drawn.

Chest Pain

Chest Pain Myocardial Infarction Anatomy Angina

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. It is not rare.

Plaque

Plaque Angina Blog Stents

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

Although it is statistically unlikely, multiple plaque ruptures are possible. On intravascular ultrasound (IVUS), the mid RCA plaque was described as "cratered, inflamed, and bulky," and the OM plaque was described as "bulky with evidence of inflammation and probably ulceration." Heitner et al.

Angina

Angina Plaque Document Stents

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

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. An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!!

Plaque

Plaque Chest Pain Thrombosis Stenosis

1 hour of CPR, then ECMO circulation, then successful defibrillation.

Dr. Smith's ECG Blog

MAY 19, 2020

This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest was caused by acute MI due to plaque rupture, then the diagnosis is MINOCA. I believe the latter (type II STEMI) is most likely. Troponin I rose to 44.1 What is Type 2 MI?

Defibrillator

Defibrillator Circulation Plaque Cardiac Arrest

A 40-something woman with acute pulmonary edema -- see the Speckle Tracking echocardiogram.

Dr. Smith's ECG Blog

APRIL 12, 2023

Prehospital Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI Transformed ECG by PM Cardio: PM Cardio AI Bot interpretation: OMI with High Confidence What do you think? On arrival, lung ultrasound confirmed pulmonary edema (B lines). Mild Plaque no angiographically significant obstructive coronary artery disease.

Echocardiogram

Echocardiogram Pulmonary Cardiomyopathy Coronary Artery Disease

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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

Ischemia STEMI Stenosis Chest Pain

ECG with Aslanger's Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory.

Dr. Smith's ECG Blog

JANUARY 4, 2021

Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), In Septal STEMI , transmural ischemia of the septum is recorded by the overlying lead V1 as ST Elevation. Lead III is also on the right and might manifest ST Elevation in Septal STEMI. with ADDED STE in III?

Ischemia

Ischemia Pulmonary STEMI Chest Pain

Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.

Dr. Smith's ECG Blog

MARCH 28, 2017

EMS recorded these ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 Here are a couple shots with strain, or "speckle tracking" on ED Echo: To, me these look like anterior wall motion abnormality, but I showed them to one of our ultrasound fellows who is very interested in this. She called 911.

STEMI

STEMI Risk Factors Bicuspid/Mitral Ultrasound

A young peripartum woman with Chest Pain

Dr. Smith's ECG Blog

OCTOBER 24, 2019

Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA. A recent study found that SCAD causes almost 20% of STEMI in young women. A study by Hassan et al. Lobo et al.

Chest Pain

Chest Pain SCAD STEMI Cardiogenic Shock

30 yo woman with trapezius pain. HEART Pathway = 0. Computer "Normal" ECG. Reality: ECG is Diagnostic of LAD Occlusion.

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 To, me these look like anterior wall motion abnormality, but I showed them to one of our ultrasound fellows who is very interested in this. She was having a transient STEMI, briefly. She called 911.

STEMI

STEMI Chest Pain Hospital Risk Factors

Is this a STEMI? No, not by definition! Why not? Why is this Important?

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. As there was ruptured plaque, this is NOT Prinzmetal's angina. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF.

STEMI

STEMI Angina Myocardial Infarction Plaque

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

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

Bradycardia STEMI Cardiogenic Shock Ischemia

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

As in all ischemia interpretations with OMI findings, the findings can be due to type 1 AMI (example: acute coronary plaque rupture and thrombosis) or type 2 AMI (with or without fixed CAD, with severe regional supply/demand mismatch essentially equaling zero blood flow). Now another, with ultrasound. What is the Diagnosis?

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

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? Beware a negative Bedside ultrasound. Diagnostic of Massive OMI.

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Which patient needs a CT scan?

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. This was ruptured plaque with thrombus. She was a walk-in at triage.

Chest Pain

Chest Pain STEMI Aortic Ultrasound

Chest pain and this ECG. Angiogram totally normal. Is this myocarditis?

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? Provocative testing is very helpful for this Coronary Thrombus with lysis (one must do optical coherence tomography or at least intravascular ultrasound to find thes non-obstructive plaques that ruptured. He called 911. Medics recorded a BP of 79/52 with pulse of 47.

Chest Pain

Chest Pain Embolism STEMI Plaque

Normal ACS care, everything by the book! But normal ACS care could be much better. This post explains everything.

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. Does anyone think that this is a "false positive" STEMI because the vessel was open?

STEMI

STEMI Chest Pain Myocardial Infarction Document

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Cardiac arrest, LBBB with STEMI on the ECG, but no Acute Coronary Syndrome!

Webinars

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Concerning EKG with a Non-obstructive angiogram. What happened?

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

1 hour of CPR, then ECMO circulation, then successful defibrillation.

A 40-something woman with acute pulmonary edema -- see the Speckle Tracking echocardiogram.

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

ECG with Aslanger's Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory.

Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.

A young peripartum woman with Chest Pain

30 yo woman with trapezius pain. HEART Pathway = 0. Computer "Normal" ECG. Reality: ECG is Diagnostic of LAD Occlusion.

Is this a STEMI? No, not by definition! Why not? Why is this Important?

A 40-Something male with a "Seizure," Hypotension, and Bradycardia

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Which patient needs a CT scan?

Chest pain and this ECG. Angiogram totally normal. Is this myocarditis?

Normal ACS care, everything by the book! But normal ACS care could be much better. This post explains everything.

Stay Connected