STEMI, Stenosis 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. Because the pathologist determines the degree of stenosis by dividing the lumen area by the total area, the degree of stenosis will be overestimated.

Ischemia

Ischemia Plaque Stenosis Myocardial Infarction

Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04 ng/ml)

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).

STEMI

STEMI Pericarditis Hospital Aneurysm

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

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event. However, one can certainly imagine that many thromboses of non-obstructive lesions completely lyse and do not leave a stenosis on same day or next day angiogram.

Coronary Angiogram

Coronary Angiogram Plaque Thrombosis STEMI

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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 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

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 Angina Anatomy

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. Takotsubo is a sudden event, not one with crescendo angina. Learning Points: 1.

Plaque

Plaque Chest Pain Thrombosis Stenosis

A 60-something with Syncope, LVH, and convex ST Elevation

Dr. Smith's ECG Blog

APRIL 26, 2017

This meets "STEMI criteria" However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4. The morphology is not right for STEMI. My interpretation: LVH with secondary ST-T abnormalities, exaggerated by stress, not a STEMI. This is very good evidence that the ST elevation is not due to STEMI.

Chest Pain

Chest Pain STEMI Ultrasound Pulmonary

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? His response: “subendocardial ischemia.

Ischemia

Ischemia STEMI Stenosis Chest Pain

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

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. What should be done? Should the cath lab be activated?

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

Guess the culprit with ST Elevation in posterior leads

Dr. Smith's ECG Blog

APRIL 24, 2020

When the ST vector is primarily posterior, the diagnosis is usually posterior STEMI. ST depression maximal in V5 and V6 cannot be reciprocal to subepicardial, transmural ischemia under aVR because, as stated above, there is no ventricular myocardium beneath that lead, no STEMI under aVR. I just read Ken's comments before publishing.

Ischemia

Ischemia Chest Pain Stenosis STEMI

40-something with severe CP. True + vs. False + high lateral MI. ST depression does not localize.

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

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. Some are STEMI-equivalents. RCA: dominant.

Ischemia

Ischemia Chest Pain STEMI Stenosis

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 Ultrasound Bicuspid/Mitral

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 had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI. I believe the latter (type II STEMI) is most likely.

Defibrillator

Defibrillator Circulation Plaque Cardiac Arrest

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

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 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."

Angina

Angina Plaque Document Stents

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

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. Left main: no significant stenosis. LAD: proximal 60% eccentric stenosis the hemodynamic significance of which is indeterminate. RCA: Dominant: Mid 50-60% stenosis. It supplies a small diagonal branch.

Chest Pain

Chest Pain STEMI Stenosis Blog

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

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

Chest Pain STEMI Bradycardia Stenosis

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

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. This is written by Willy Frick, an amazing cardiology fellow in St. He described it as "10/10" intensity, radiating across his chest from right to left.

Plaque

Plaque Angina Blog Stents

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

Chest pain, and Cardiology didn't take the hint from the ICD

Dr. Smith's ECG Blog

JANUARY 23, 2023

PMID: 34775811; PMCID: PMC9075358 A bedside ultrasound was performed, shown here: Parasternal short axis view demonstrating inferior LV wall motion akinesis Apical 2 chamber view again demonstrating inferior LV wall akinesis The cath lab was not activated based on the ECG and bedside echo. J Am Heart Assoc. 2021 Dec 7;10(23):e022866.

Chest Pain

Chest Pain Blog Stenosis Myocardial Infarction

"Pericarditis" strikes again

Dr. Smith's ECG Blog

DECEMBER 13, 2019

They found non-obstructive CAD, with only a 20% stenosis of OM2 and 10% RCA. normal variant, not pericarditis) A Young Man with Sharp Chest pain (normal variant, not pericarditis) 24 yo woman with chest pain: Is this STEMI? Beware a negative Bedside ultrasound. No acute culprit. He was admitted to cardiology. Pericarditis?

Pericarditis

Pericarditis Chest Pain Aortic Blog

Early repol or anterior OMI?

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

Chest Pain STEMI Ultrasound Heart Attack

What are treatment options for this rhythm, when all else fails?

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. Angiography : LMCA — 90-99% osteal stenosis. LCx — 50-69% stenosis of the 1st marginal branch; with 100% distal LCx occlusion. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain.

Arrhythmia

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

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

PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don't miss case 4 at the bottom.

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

STEMI Chest Pain Cardiac Arrest Stents

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Dr. Smith's ECG Blog

MARCH 3, 2025

I suspect pulmonary edema, but we are not given information on presence of B-lines on bedside ultrasound, or CXR findings. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. Truly, the Marquette 12 SL algorithm correctly identifies this STEMI. Management?

Tachycardia

Tachycardia Pulmonary Chest Pain Stenosis

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

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

Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04 ng/ml)

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

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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.

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

A 60-something with Syncope, LVH, and convex ST Elevation

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

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Guess the culprit with ST Elevation in posterior leads

40-something with severe CP. True + vs. False + high lateral MI. ST depression does not localize.

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.

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

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

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

12 Example Cases of Use of 3- and 4-variable formulas, plus Simplified Formula, to differentiate normal STE from subtle LAD occlusion

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

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

Chest pain, and Cardiology didn't take the hint from the ICD

"Pericarditis" strikes again

Early repol or anterior OMI?

What are treatment options for this rhythm, when all else fails?

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

PseudoSTEMI and True ST elevation in Right Bundle Branch Block (RBBB). Don't miss case 4 at the bottom.

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

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

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