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.

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STEMI Chest Pain Myocardial Infarction Blog 121

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 110

Chest Pain STEMI Ischemia Myocardial Infarction 110

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 116

Chest Pain STEMI Pericarditis Stents 116

The British Journal of Cardiology

NOVEMBER 10, 2023

The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug-eluting stent, drug-coated balloon, or both in different combinations and permutations.

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Stents Stent Coronary Artery Disease Myocardial Infarction 40

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

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STEMI Chest Pain Ultrasound Blood Pressure 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.

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EKG Technician Chest Pain Blog STEMI 124

Nature Reviews - Cardiology

APRIL 1, 2024

Nature Reviews Cardiology, Published online: 02 April 2024; doi:10.1038/s41569-024-01020-2 In ST-segment elevation myocardial infarction, the role of interventional modification of thrombi in the coronary arteries before stenting is controversial.

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STEMI Myocardial Infarction Embolism Stents 40

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.

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Chest Pain STEMI Bradycardia Article 100

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 Stents Stent 121

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.

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STEMI Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

OCTOBER 26, 2011

Echo on the day after admission showed EF of 30-35% and antero-apical wall akinesis with an LV thrombus [these frequently form in complete or near complete (no early reperfusion) anterior STEMI because of akinesis/stasis] 2 more days later, this was recorded: ST elevation is still present. An open 90% LAD was stented.

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STEMI Chest Pain Myocardial Infarction Angioplasty 52

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.

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Chest Pain STEMI Stents Stent 98

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

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STEMI Chest Pain Risk Factors Anatomy 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 STEMI 59

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.

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Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 122

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.

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Chest Pain Blood Pressure Ischemia STEMI 125

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 116

Chest Pain STEMI Echocardiogram Stents 116

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.

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Chest Pain Myocardial Infarction Anatomy Angina 117

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.)

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Chest Pain STEMI Physiology Research 96

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.

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Chest Pain STEMI Blog Exercise 113

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.

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Chest Pain STEMI Blog Stents 98

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.

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AFIB Stents Stent Chest Pain 105

Ken Grauer, MD

AUGUST 26, 2023

These tall T waves are associated with flattening ( straightening ) of the ST segment in the inferior leads — with slight S T elevation in leads V2-thru-V6 ( albeit not enough to qualify as a "STEMI" — Akbar et al, StatPearls, 2023 ). ECG Blog #185 — Reviews the P s, Q s, 3 R Approach to Rhythm Interpretation.

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Blog Chest Pain STEMI Ischemia 145

Dr. Smith's ECG Blog

JANUARY 20, 2017

Validation of the Modified Sgarbossa Rule for Diagnosis of STEMI in the Presence of Left Bundle Branch Block. There is no ST depression in lead I, which suggests a circumflex lesion The cath lab was activated and a circumflex occlusion was opened and stented, with a door to balloon time of 3 hours. Limkakeng AT. Theiling BJ.

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STEMI Chest Pain Stents Stent 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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STEMI Chest Pain Blog Pericarditis 125

Dr. Smith's ECG Blog

MARCH 2, 2009

reports MI in 2001 with a stent placed in the "marginal" artery. First, this patient had a known stent in the "marginal" artery and thought he was having a heart attack. By definition, this is a non-STEMI because there is not 1 mm of ST elevation in 2 consecutive leads. Pain is similar, but associated with less SOB.

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Heart Attack Heart attacks STEMI Echocardiogram 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.

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Chest Pain STEMI Bradycardia Ischemia 114

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.

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STEMI Myocardial Infarction Chest Pain Aneurysm 40

Dr. Smith's ECG Blog

JANUARY 5, 2024

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.

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Angina Plaque Document Stents 120

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,

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Outcomes Cardiogenic Shock Angina STEMI 40

Dr. Smith's ECG Blog

FEBRUARY 18, 2012

This is typical for subendocardial ischemia, not STEMI, and often means left main ischemia or 3 vessel ischemia. Right sided ECGs are best recorded in the context of inferior STEMI. Because of precordial ST depression, clinicians were also worried about posterior STEMI. A right sided ECG was recorded 3 minutes later.

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STEMI Ischemia Chest Pain Stents 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. So there was 3-vessel disease, but with an acute posterior STEMI. There is no ST elevation. See the list below.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

JULY 23, 2024

Another ECG was recorded while awaiting the cath team: Now there is STEMI Let's look at that first (prehospital ECG) again: Very subtle! It was opened and stented. I wondered the next day what the Queen would have said: OMI with high confidence!! Peak trop was 7000 ng/L (since the intervention was so fast)!!

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Chest Pain Critical Care STEMI Stents 115

Dr. Smith's ECG Blog

MAY 6, 2018

They do not study whether this wave differentiates between MI and non-MI, between STEMI and NonSTEMI, or between OMI and NOMI. Another ECG was recorded: Obvious inferior, posterior, lateral STEMI What is the infarct artery? Of all inferior STEMI, 85% are due to RCA. This is hard to tell. The cath lab was activated.

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STEMI Chest Pain Myocardial Infarction Article 52

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. Despite ongoing chest discomfort and an uptrending troponin, he never meets STEMI criteria.

Pericarditis 52

Pericarditis Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). While this may be change that is reciprocal to an Acute/Subacute Inferior STEMI, the problem is that LV aneurysm may also manifest with this reciprocal change. In STEMI, they are generally upright and large in proportion to the QRS. This case is tough.

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Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

JUNE 12, 2016

Just as hyperacute T-waves can be reciprocal to T-wave inversion ( last case ),T-wave inversion can be reciprocal to STEMI of opposite wall! An 80% thrombotic RCA was stented. This case was sent by Arthur Lee. Case : A 50 yr old woman presented after a syncopal episode, with sweating and left arm numbness.

Chest Pain 52

Chest Pain Ischemia STEMI Stents 52