Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. The patient had a history of ‘NSTEMI’ a decade prior, with an RCA stent. So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion.

Chest Pain 101

Chest Pain STEMI Aneurysm Stent 101

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. Most large STEMI have peak troponin I in the 20.0 This was stented with a 2.25 Next trop in AM.

Chest Pain 88

Chest Pain Myocardial Infarction Stent Stents 88

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. The two cases were considered: Patient 1 was recognized by the ED provider and the cardiologist as having resolved “STEMI”. It was stented.

Chest Pain 106

Chest Pain STEMI Echocardiogram Stent 106

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”. Or is it a very tight stenosis that does not allow enough flow to perfuse myocardium that has a high oxygen demand from severely elevated BP?

Chest Pain 122

Chest Pain Blood Pressure Ischemia STEMI 122

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Angiogram findings included: 95% mid RCA stenosis with occluded distal right PDA secondary to thrombus (peristent OMI). At this point — a STEMI was diagnosed, and cardiac cath with PCI was performed.

Chest Pain 111

Chest Pain STEMI Blog Exercise 111

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). As far as I can tell, there is only one randomized trial of immediate vs. delayed intervention for transient STEMI. Labs ordered but not yet drawn.

Chest Pain 117

Chest Pain Myocardial Infarction Anatomy Angina 117

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

I would expect that a stent would be placed. The angiogram showed an open artery with 95% stenosis and thrombosis and it was stented. Quiz : What percent of full blown STEMI have an open artery with normal flow at angiogram? In the meantime, a lot of myocardium is lost. They were interpreted as completely NORMAL!!

Chest Pain 83

Chest Pain STEMI Stent Stents 83

Dr. Smith's ECG Blog

JUNE 5, 2023

Here it is: Obvious Inferior Posterior STEMI (+) OMI. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%. Here is the angiogram: --Culprit is 100% stenosis in the proximal RCA. Here is the angiogram: --Culprit is 100% stenosis in the proximal RCA. (It

Chest Pain 78

Chest Pain STEMI Physiology Research 78

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 The culprit mid LAD lesion was stented.

Chest Pain 107

Chest Pain STEMI Ultrasound Heart attacks 107

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

MAY 10, 2023

LAD plaque with 0-25 percent stenosis. Later, she developed chest pain again, and had this ECG recorded: Obvious Anterior OMI that is also a STEMI Coronary angiogram- --Right dominant coronary artery system --The left main artery was normal in appearance and free of obstructive disease. --The A CT Coronary angiogram was ordered.

Coronary Angiogram 52

Coronary Angiogram Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

It was opened and stented. 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. But what we truly care about is coronary occlusion, for which STEMI is just a surrogate that is only about 75% sensitive for occlusion. RCA: dominant.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

JANUARY 5, 2024

The LAD has diffuse disease with a few areas of moderate stenosis but no flow-limiting lesions. 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. OM before and after, arrow indicating stented region.

Angina 106

Angina Plaque Document Stent 106

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

Chest Pain 52

Chest Pain STEMI Stent Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. 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. So there is pathologic ST elevation here, consistent with anterolateral STEMI. Called 911.

STEMI 52

STEMI Chest Pain Cardiac Arrest Stent 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

DECEMBER 14, 2016

The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI? The patient had no hypertension, no tachycardia, a normal hemoglobin, no drug use, no hypotension/shock, no murmur of aortic stenosis. The troponin I returned at 4.1 ng/mL (ULN = 0.030 ng/mL) , diagnostic of myocardial injury. mm STE in one lead.

Chest Pain 52

Chest Pain STEMI Aortic Myocardial Infarction 52

EMS 12-Lead

MAY 20, 2022

There is ventricular hypertrophy in the absence of abnormal loading conditions, such as aortic stenosis, or hypertension, for example – of which the most common variant is Asymmetric Septal Hypertrophy. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital.

Cardiomyopathy 52

Cardiomyopathy Ischemia STEMI Coronary Angiogram 52

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 She was having a transient STEMI, briefly. It did not progress to full STEMI with loss of the anterior wall, as in this case. It was stented. She called 911. mm at the J-point, relative to the PQ junction.

STEMI 52

STEMI Risk Factors Bicuspid/Mitral Ultrasound 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. RAO Caudal View Post PCI This is the RAO Caudal view after thrombectomy and stent placement. At 1605, another repeat troponin resulted at 5.271 ng/mL.

Chest Pain 107

Chest Pain Blog Hospital Tachycardia 107

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

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, This alone could be due to LVH, but V4 could NOT be due to LVH.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. The image on the left shows the LAD before intervention, and the red circled portion on the right indicates the stented region.

Plaque 118

Plaque Angina Blog Stent 118

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. There is evidence that de Winter's T-waves really represent a tiny trickle of blood through the thrombotic stenosis. Both were stented. mm ST depression in aVL.

Pericarditis 52

Pericarditis Ischemia STEMI Chest Pain 52

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

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 She was having a transient STEMI, briefly. It did not progress to full STEMI with loss of the anterior wall, as in this case. It was stented. She called 911. Learning Points : 1. See this case.

STEMI 52

STEMI Chest Pain Hospital Risk Factors 52

Dr. Smith's ECG Blog

JANUARY 16, 2020

It was opened and stented with resulting TIMI-3 (normal) flow. The stent to LCX is patent. OM1 is occluded and OM2 has 60% stenosis. Her RCA is a medium caliber vessel with tandem, at least moderate stenosis in the mid segment. Marked acute STEMI changes in no less than 4 lateral leads. A balloon pump was placed.

Aneurysm 52

Aneurysm Heart Disease Stent Stents 52

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

EMS 12-Lead

APRIL 21, 2022

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). Of these, the pLAD was determined to be the acute culprit.

Ischemia 52

Ischemia Myocardial Infarction Blog Coronary Angiogram 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

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. A stent was placed. When the patient had chest pain, prior to nitroglycerine, what do you think the ECG showed ? de Zwaan C., Wellens H.J.J.,

Myocardial Infarction 52

Myocardial Infarction Chest Pain Ischemia Angina 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 52

Cardiogenic Shock Chest Pain Ischemia Stenosis 52