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". First obtuse marginal also had an 80% stenosis and was stented. Pt received 324 ASA and 2 sprays of nitro with improvement. Cath lab was activated by EMS and transported emergent." Pain was decreased to 2/10.

STEMI 118

STEMI Chest Pain Myocardial Infarction Aneurysm 118

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 91

Chest Pain Myocardial Infarction Stents Stent 91

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. Is this acute STEMI? Is this an acute STEMI? -- Unlikely! He had no chest pain. Medications were aspirin, clopidogrel, metoprolol, and simvastatin.

STEMI 52

STEMI Pulmonary Stents Stent 52

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 105

Chest Pain STEMI Aneurysm Stent 105

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Two stents were placed with resultant TIMI 3 flow. What do you think? Of course not.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Ischemia 52

Frontiers in Cardiovascular Medicine

MARCH 10, 2024

Background Hyperglycemia, characterized by elevated blood glucose levels, is frequently observed in patients with acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). There are conflicting sources regarding the relationship between hyperglycemia and outcomes in STEMI patients. 3.45) and 4.47 (95% CI: 2.54–7.87),

Myocardial Infarction 59

Myocardial Infarction Cardiogenic Shock Article Outcomes 59

Dr. Smith's ECG Blog

DECEMBER 22, 2022

The lesion was successfully stented. Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later. Turk Kardiyol Dern Ars.

STEMI 52

STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MARCH 31, 2024

The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). I advised that perhaps posterior leads would help to persuade the interventionalist, since the 2022 ACC recommendations include posterior STEMI as a formal STEMI equivalent, but only officially by 0.5

Chest Pain 95

Chest Pain STEMI Ischemia Myocardial Infarction 95

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI 52

STEMI Chest Pain Stent Stents 52

Dr. Smith's ECG Blog

OCTOBER 1, 2023

A man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. It is stented with good angiographic result.

Stents 126

Stents Stent STEMI Physiology 126

Circulation

NOVEMBER 11, 2024

A random-effects model was used for outcomes with high heterogeneity.Results:We included 4 RCTs with 3173 patients comparing FFR-guided CR with culprit-only PCI in patients with STEMI and multivessel coronary artery diseases. vs 13.6%), any stent thrombosis (RR=1.42; 95% CI [0.35, 5.72]; p=0.62; 2.2%

Coronary Artery Disease 40

Coronary Artery Disease Myocardial Infarction STEMI Thrombosis 40

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.

STEMI 119

STEMI Chest Pain Myocardial Infarction Stent 119

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. His disease included 70% prox LAD, 80% distal LAD, 10% in-stent stenosis in the distal LCX, 70% OM1, 70% OM2, and 60% prox RCA. Described as a dull ache, 6/10 in severity.

Chest Pain 104

Chest Pain STEMI Pericarditis Stent 104

The British Journal of Cardiology

APRIL 16, 2024

Intra-procedural data included access route, coronary anatomy, lesion complexity, number of stents deployed, door-to-balloon time for primary PCI, and any intra-procedural complications. and the average number of stents 2.6. The radial approach was used in 544/567 (95.94%), the average SYNTAX score was 34.8 ± 9.6,

Outcomes 52

Outcomes Cardiogenic Shock Angina STEMI 52

Circulation

NOVEMBER 11, 2024

Types of ACS include stable angina 5.3% (n=8), unstable angina 24% (n=36), NSTEMI 28.7% (n=43), and STEMI 24% (n=36). All patients had interventional PCI with balloon and stent insertion. The mean age of patients was 57.68 (SD= 11.19) years. The mean of SIRI was 24.45 (SD=25.49) and the mean of SII was 663.30 (SD= 403.75).

Angina 40

Angina Coronary Artery Disease Biomarkers Atherosclerosis 40

Frontiers in Cardiovascular Medicine

JANUARY 15, 2024

with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. Approximately 48.5% and 1.3%, respectively.

SCAD 75

SCAD Coronary Artery Bypass Graft Outcomes Myocardial Infarction 75

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. Cath lab was activated, and found a 95% proximal LAD occlusion which was stented. It’s unclear if the paramedic ECGs were seen or missed in the ED.

Chest Pain 76

Chest Pain STEMI Bradycardia Article 76

Dr. Smith's ECG Blog

AUGUST 15, 2019

Over the next few hours, four other general cardiologists "signed off on the initial ECG without recognizing STEMI." They found 100% acute mid-LAD Occlusion MI, stented with excellent angiographic result. Learning Points: STEMI criteria misses 25-40% of OMI, like this case for example. mm of the "required" 1.0

STEMI 52

STEMI Chest Pain Risk Factors Anatomy 52

Dr. Smith's ECG Blog

MAY 5, 2024

There was a 100% proximal LAD occlusion that was opened and stented. Therefore, the provider had appropriately recorded another ECG (but unfortunately unnecessarily delayed by 45 minutes at 0615): Now it is obvious to everyone, not only to an expert. The cath lab was activated. But 45 minutes later than it should have been.

EKG Technician 117

EKG Technician Chest Pain Blog STEMI 117

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. This was a large OMI.

Chest Pain 109

Chest Pain STEMI Echocardiogram Stent 109

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

She was treated for NonSTEMI with antiplatelet and antithrombotic agents and went to cath the next day, where an where multiple LAD thrombi were found and the lesion will be stented. Waiting to cath a transient STEMI can be hazardous. See this case in which I made that mistake. Learning Points: 1.

Chest Pain 121

Chest Pain STEMI Stent Stents 121

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? It too is "normal" and you decide that this is not OMI or STEMI and you just decide to get troponins.

Chest Pain 87

Chest Pain STEMI Stent Stents 87

Circulation

FEBRUARY 26, 2024

The primary efficacy objective was to demonstrate superiority of PPA to reduce the primary efficacy end point of all-cause death, nonfatal myocardial infarction, nonfatal stroke, stent thrombosis (definite), or urgent revascularization (any vessel) within 30 days.

Myocardial Infarction 40

Myocardial Infarction Academic Thrombosis STEMI 40

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., She was taken to the cath lab, where she was found to have 100% in-stent restenosis of the proximal LAD. In our study, there were 20/53 complete LAD OMI (TIMI-0 flow) which did not meet STEMI criteria. None of the 20 ever evolved to STEMI criteria. This one is easy for the Queen.

Cardiac Arrest 111

Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 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

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." Successful drug-eluting stent placement opening up 95% mid RCA stenosis to 0% residual Nonobstructive left system disease. At this point — a STEMI was diagnosed, and cardiac cath with PCI was performed.

Chest Pain 112

Chest Pain STEMI Blog Exercise 112

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”. Troponin was elevated and no “STEMI” was seen on the EKG, so if it is acute MI, then “NSTEMI” is the diagnosis (however flawed), not a pathology on the differential.

Chest Pain 124

Chest Pain Blood Pressure Ischemia STEMI 124

Dr. Smith's ECG Blog

OCTOBER 22, 2024

Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." Successful primary angioplasty of the mid-circumflex artery towards the main marginal branch with the implantation of a drug-eluting stent. Good angiographic result.

Chest Pain 66

Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

Chest Pain 92

Chest Pain STEMI Blog Stent 92

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%. It must have re-occluded between the ED and the cath lab) --Lesion was stented. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.)

Chest Pain 82

Chest Pain STEMI Physiology Research 82

Dr. Smith's ECG Blog

DECEMBER 6, 2010

This is all suggestive of posterior STEMI, but not definitely diagnostic. mm in only one posterior lead is highly sensitive and specific for posterior STEMI). Two stents were placed. ST depression in V1-V4, isolated, may be either posterior STEMI or NSTEMI. The ECG normalized overnight. Maximum troponin was 2.1

STEMI 52

STEMI Chest Pain Ultrasound Blood Pressure 52

Dr. Smith's ECG Blog

MARCH 22, 2024

This is documented as a STEMI in the clinical notes and in the cath report, but certainly does not meet STEMI criteria and is therefore an NSTEMI by definition. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0. Large STEMI are approximately 30-80.

Chest Pain 112

Chest Pain STEMI Bradycardia Ischemia 112

Dr. Smith's ECG Blog

JULY 14, 2024

The cath lab was activated, and then not cancelled, and the angiogram showed 99% TIMI 2 flow proximal LAD culprit lesion, stented in less than 90 minutes of arrival. Cath days later showed complete occlusion of the LAD, stented. Another missed OMI by the False STEMI-NonSTEMI Dichotomy Don't miss them!!! Normal vitals.

AFIB 72

AFIB Stent Stents Chest Pain 72

EMS 12-Lead

AUGUST 14, 2022

One stent was deployed with restorative TIMI-0 flow. link] deWinter first reported his unique characteristics of LAD occlusion in 2008, and since the respective ECG changes do not fit the conventional STEMI paradigm (as he even stated – “instead of signature ST-segment elevation” ….) it has been subsequently deemed a STEMI-equivalent.

STEMI 52

STEMI Sudden Cardiac Death Thrombosis Thrombolysis 52

Dr. S. Venkatesan MD

JUNE 26, 2024

Final message Coronary arterial anomaly is a less discussed topic nowadays, unless & until, it intrudes an interventional cardiologist in his daily routine life, of delivering stents. We know, how adverse is the outcome of Left main STEMI. In reality, there could be thousands of asymptomatic ones in the public domain.

Coronary Angiogram 52

Coronary Angiogram Cardiothoracic Anatomy Atherosclerosis 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

The report describes heavy plaque in the proximal RCA by IVUS, but no lesions in the previously occluded RPL branch and no stent was deployed. Her ECG afterward is shown below: ECG from five days prior Smith : this shows an old inferior MI with persistent ST elevation. It is consistent with an inferior LV aneurysm.

Chest Pain 66

Chest Pain Hospital Anatomy Aneurysm 66

Dr. Smith's ECG Blog

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." Can you diagnose an ACO (STEMI) when you also have LVH? The criteria of Armstrong et al. References 1.

STEMI 52

STEMI Myocardial Infarction Chest Pain Aneurysm 52