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 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 110

Chest Pain Myocardial Infarction Stent Stents 110

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.

Stent 126

Stent Stents STEMI Physiology 126

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 115

Chest Pain STEMI Pericarditis Stent 115

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 99

Chest Pain STEMI Bradycardia Stents 99

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

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 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.

STEMI 52

STEMI Chest Pain Myocardial Infarction Angioplasty 52

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.

STEMI 40

STEMI Myocardial Infarction Embolism Stent 40

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 123

EKG Technician Chest Pain Blog STEMI 123

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 120

Chest Pain STEMI Stent Stents 120

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

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 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 122

Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 122

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 98

Chest Pain STEMI Stent Stents 98

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.

STEMI 52

STEMI Chest Pain Stent Stents 52

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 40

STEMI Myocardial Infarction Chest Pain Aneurysm 40

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 115

Chest Pain STEMI Echocardiogram Stent 115

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.

Blog 145

Blog Chest Pain STEMI Ischemia 145

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

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 96

Chest Pain STEMI Physiology Stent 96

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 98

Chest Pain STEMI Blog Stent 98

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.

Stents 40

Stents Stent Coronary Artery Disease Myocardial Infarction 40

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.

STEMI 124

STEMI Chest Pain Blog Pericarditis 124

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 113

Chest Pain STEMI Bradycardia Ischemia 113

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

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.

Heart Attack 52

Heart Attack Heart attacks STEMI Echocardiogram 52

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.

STEMI 52

STEMI Ischemia Chest Pain Stent 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

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.

Chest Pain 52

Chest Pain Aneurysm STEMI Document 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

STEMI 52

STEMI Myocardial Infarction Chest Pain Ischemia 52

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 104

AFIB Stent Stents Chest Pain 104

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

Chest Pain 69

Chest Pain STEMI Myocardial Infarction Electrocardiogram 69

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.

STEMI 52

STEMI Chest Pain Myocardial Infarction Stent 52

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 40

Outcomes Cardiogenic Shock Angina STEMI 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.

Angina 119

Angina Plaque Document Stent 119

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)!!

Chest Pain 114

Chest Pain Critical Care STEMI Stent 114