STEMI, Stents and Ultrasound - Cardiovascular Update

Brachial artery approach for managing retroperitoneal bleed following coronary intervention for STEMI

The British Journal of Cardiology

NOVEMBER 29, 2023

Primary percutaneous coronary intervention (PPCI) remains the gold-standard treatment for ST-elevation myocardial infarction (STEMI). We present the case of a man in his 50s, admitted with cardiac arrest secondary to inferolateral STEMI.

STEMI

STEMI Cardiac Arrest Myocardial Infarction Ultrasound

Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI

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. He had diffuse crackles on exam and B-lines on chest ultrasound, and chest x-ray also confirmed pulmonary edema. Is this acute STEMI? He had no chest pain.

STEMI

STEMI Pulmonary Stent Stents

Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall

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

Stent Stents STEMI Physiology

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”. 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

Chest Pain Blood Pressure Ischemia STEMI

ST depression V2-V4: Posterior leads, resolution of pain, and absence of posterior wall motion abnormality ruled out posterior STEMI

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). I performed a bedside cardiac ultrasound and the posterior wall appeared to be contracting and shortening normally. Two stents were placed.

STEMI

STEMI Chest Pain Ultrasound Blood Pressure

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 The culprit mid LAD lesion was stented.

Chest Pain

Chest Pain STEMI Ultrasound Heart Attack

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 Anatomy Angina

Is this a STEMI? No, not by definition! Why not? Why is this Important?

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. It was stented. A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. Values: STE60V3 = 2.0,

STEMI

STEMI Angina Myocardial Infarction Plaque

A 50-something with chest pain.

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

He reports that this chest pain feels different than prior chest pain when he had his STEMI/OMI, but is unable to further describe chest pain. Arrival at time 0 ECG 7 min Roomed in hallway at 17 min Moved to room with monitor at 37 min The patient was seen briefly by the physician, who then went to get an ultrasound machine.

Chest Pain

Chest Pain Defibrillator STEMI Coronary Artery Disease

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

Dr. Smith's ECG Blog

JANUARY 5, 2024

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." On the combined basis of angiography and IVUS, this patient received stents to his mid RCA, proximal PDA, and OM.

Angina

Angina Plaque Document Stent

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So the RCA was stented. Vitals were HR 58 BP 167/70 R20 sat 96%.

Chest Pain

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Dr. Smith's ECG Blog

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. He was successfully treated with one drug eluting stent. A second troponin had been drawn 3 hours after arrival and was again less than 0.30ng/mL. 1] Wereski, R.,

Chest Pain

Chest Pain Ultrasound STEMI Myocardial Infarction

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

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

STEMI Chest Pain Cardiac Arrest Stent

What do you think the echocardiogram shows in this case?

Dr. Smith's ECG Blog

MAY 13, 2020

This was a point of care ultrasound, not a bubble contrast echo. One would not expect wall motion to recover so quickly after stenting, so this is good evidence that the POCUS echo was indeed accurate. What do you think the echocardiogram shows? First trop I returns at 1.5. Is this OMI?

Echocardiogram

Echocardiogram Ischemia Chest Pain Blog

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Case continued A bedside ultrasound showed diminished LV EF and of course bradycardia. Angiogram: Culprit Lesion (s): Thrombotic occlusion of the proximal RCA -- stented. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not.

Chest Pain

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock

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. It was stented.

STEMI

STEMI Risk Factors Bicuspid/Mitral Ultrasound

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

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

Ischemia Chest Pain Stenosis STEMI

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. He was successfully stented.

Bradycardia

Bradycardia Cardiogenic Shock STEMI Ischemia

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

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Two thirds of MINOCA cases are due to atherosclerotic causes One way to prove the diagnosis in this case would have been with intravascular imaging such as optical coherence tomography (OCT) or intravascular ultrasound (IVUS). Fortunately, that is exactly what happened. The patient did well afterward without any recurrence of symptoms.

Plaque

Plaque Angina Blog Stent

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. It was stented.

STEMI

STEMI Chest Pain Hospital Risk Factors

Missed myocardial infarction with subsequent cardiac arrest

Dr. Smith's ECG Blog

OCTOBER 24, 2013

He underwent coronary stenting (uncertain which artery). An emergency cardiac ultrasound could be very useful. He underwent immediate CPR, was found to be in ventricular fibrillation, and was successfully resuscitated. I do not have the post-resuscitation ECG. Could this have been avoided?

Cardiac Arrest

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia

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. QTc is the computer measurement. 100% LAD occlusion.

Chest Pain

Chest Pain STEMI Bradycardia Stenosis

Hyperacute T waves

Dr. Smith's ECG Blog

FEBRUARY 14, 2009

A bedside ultrasound revealed a possible anterior wall motion abnormality. There was an LAD occlusion that was opened and stented. They may be the only remaining clue to a reperfused LAD occlusion. The patient was treated with Calcium, Insulin, D50, and bicarbonate, with no change in the ECG. The K returned at 2.9

Chest Pain

Chest Pain Ultrasound STEMI Stent

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

His ED cardiac ultrasound (which is not at all ideal for detecting wall motion abnormalities, and is also very operator dependent for this finding) was significant for depressed global EF. It was thought to be an in stent restenosis and thrombosis from a DES placed in the same region 6 months prior. There was initially TIMI 0 flow.

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

A woman in her 50s with acute chest pain

Dr. Smith's ECG Blog

JANUARY 6, 2023

Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. Smith comment: Point of Care ultrasound is not adequate to rule out wall motion abnormality; moreover, diffuse subendocardial ischemia often has no wall motion abnormality because the epicardium is still contracting. mg/dL, K 3.5

Chest Pain

Chest Pain Ischemia Myocardial Infarction ICU

Brachial artery approach for managing retroperitoneal bleed following coronary intervention for STEMI

Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI

Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

ST depression V2-V4: Posterior leads, resolution of pain, and absence of posterior wall motion abnormality ruled out posterior STEMI

Early repol or anterior OMI?

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Is this a STEMI? No, not by definition! Why not? Why is this Important?

A 50-something with chest pain.

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

LBBB: Using the (Smith) Modified Sgarbossa Criteria would have saved this man's life

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

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

What do you think the echocardiogram shows in this case?

Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?

Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.

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

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

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.

Missed myocardial infarction with subsequent cardiac arrest

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

Hyperacute T waves

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

A woman in her 50s with acute chest pain

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