Dr. Smith's ECG Blog

JANUARY 27, 2024

So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. The patient was admitted as ‘NSTEMI’ which is supposed to represent a non-occlusive MI, but the underlying pathophysiology is analogous to a transient STEMI. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

Chest Pain 117

Chest Pain STEMI Aneurysm Stents 117

Dr. Smith's ECG Blog

AUGUST 13, 2020

His previous echo one month prior shows the same thing: “consistent with old infarct in LAD vascular territory, with EF 45%” "I think there is something else causing his tachycardia which is exaggerating his EKG findings and mimicking an acute myocardial infarction." The patient spontaneously converted back to sinus tachycardia.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? This is the response he got: Interventionist: "No STEMI, no cath. After stabilizing the patient and recording more ECGs, he tried again: Interventionalist: "It isn't a STEMI." It is a STEMI equivalent. We don't know how many though.

STEMI 52

STEMI Hospital Blog Defibrillator 52

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. It shows sinus tachycardia with right bundle branch block. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). When EMS found her, she was dyspneic and diaphoretic. Both were wrong.

Cardiogenic Shock 127

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 127

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Sinus tachycardia has many potential causes. This is especially true for the elderly patient with sinus tachycardia. What is the cause of the sudden tachycardia? It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI.

Cardiogenic Shock 109

Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

Tachycardia 40

Tachycardia STEMI Chest Pain Ischemia 40

Ken Grauer, MD

MAY 28, 2024

KEY Point: Look for additional simultaneously-recorded leads = “12 Leads are Better than One!” ( ie, For example with tachycardias — the QRS may look narrow if all you have is 1 or 2 leads — whereas if part of the QRS lies on the baseline in the single lead you are looking at, this might be VT! ). 19:50 — Not appreciating statistical odds! (

Blog 143

Blog Arrhythmia Tachycardia CME 143

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 Stents Stent 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later? This caused a type 2 anterior STEMI. This prompted cath lab activation.

Cardiac Arrest 109

Cardiac Arrest STEMI Ischemia SCAD 109

Dr. Smith's ECG Blog

OCTOBER 17, 2024

The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Vitals were normal except for oxygen saturation of 94%. Vitals were normal.

Chest Pain 73

Chest Pain STEMI Pulmonary Embolism 73

Dr. Smith's ECG Blog

SEPTEMBER 3, 2010

One might think this represents acute STEMI, or Bundle branch block with discordant ST segments and suspicously concordant T-waves. Upon arrival to the ED, he had the following 12-lead ECG: There is striking ST segment elevation in V1 and V2, with ST depression in V3-V6 as well as I, II, and aVF. There is also a wide QRS.

Tachycardia 52

Tachycardia Atrial Fibrillation STEMI Ablation 52

Dr. Smith's ECG Blog

MARCH 9, 2024

The cardiologist agreed that the ECG was suggestive of STEMI, but the facility's cath lab was apparently not available and he therefore recommended emergent transfer to a cath capable facility. Due to the chest pain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection.

Chest Pain 117

Chest Pain Pericarditis Aortic Echocardiogram 117

Dr. Smith's ECG Blog

DECEMBER 20, 2010

This is the ECG of a 50 yo old woman who collapsed, was found to have a pulse, but then found to be in ventricular tachycardia. The cath lab was activated for STEMI, but the patient had clean coronaries. This is highly suspicious for acute anterior STEMI. She was shocked into sinus rhythm. She presented to the ED comatose.

Cardiomyopathy 52

Cardiomyopathy STEMI Hemorrhage Echocardiogram 52

Frontiers in Cardiovascular Medicine

MARCH 3, 2024

Background Early ventricular tachycardia/fibrillation (VT/VF) in patients with ST-elevation myocardial infarction (STEMI) has higher morbidity and mortality. This study examines gender-differentiated risk factors and underlying mechanisms for early onset VT/VF in STEMI. vs. 61.0 ± 13.0 vs. n  = 46, L5: 4.3 ± 9.9%, P  = 0.016).

Myocardial Infarction 59

Myocardial Infarction STEMI Defibrillator Diet 59

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)]. Notice there is tachycardia. So there was 3-vessel disease, but with an acute posterior STEMI.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

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”. He wrote most of it and I (Smith) edited. It was stented.

Chest Pain 116

Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

JANUARY 1, 2024

While the initial impression might not immediately suggest ventricular tachycardia (VT), a closer examination raises suspicion. Additionally, the qR morphology, particularly in a patient with right bundle branch block (RBBB) type wide QRS complex tachycardia (WQCT), lends further support for VT. What is the rhythm?

Tachycardia 112

Tachycardia Blog Heart Failure Ischemia 112

Dr. Smith's ECG Blog

DECEMBER 26, 2020

Is this inferor STEMI? Tachycardia and ST Elevation. Atrial Flutter with Inferior STEMI? Inferolateral ST elevation, vomiting, and elevated troponin The treating team did not identify the flutter waves and they became worried about possible "STEMI" (despite the unusual clinical scenario). Long-term outcome is unknown.

Atrial Flutter 52

Atrial Flutter Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

MAY 30, 2024

Does the ECG represent STEMI-negative OMI findings? Putting all the findings together; dyspnea, slight tachycardia, delayed R-wave progression, prominent lateral S waves and ST depression maximal where the P waves are largest all point toward pulmonary disease as the cause of the ECG findings. How would you mange this patient?

Ischemia 88

Ischemia Coronary Angiogram Pulmonary STEMI 88

Dr. Smith's ECG Blog

JANUARY 8, 2024

She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. Medics recorded the above ECG and called a STEMI alert. Her symptoms at the time ECG #1 was obtained were CP and SOB — yet interpretation of this initial tracing prompted a STEMI alert. Junctional tachycardia? ).

Chest Pain 71

Chest Pain Pulmonary Embolism STEMI 71

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

This is ischemic ST depression, and could be due to increasing tachycardia, with a heart rate over 130, but that is unlikely given that the patient is now complaining of crushing chest pain and that there was tachycardia all along. There is widespread ST depression. Figure-1: Comparison of the first 2 ECGs in today's case.

Chest Pain 118

Chest Pain Ischemia Echocardiogram Myocardial Infarction 118

Dr. Smith's ECG Blog

JUNE 11, 2011

Is this an anterior STEMI with LBBB? Explanation : The patient had a worrisome history: 59 yo with significant substernal chest pressure, so his pretest probability of MI (and even of STEMI) is reasonably high. Additionally, appropriate discordance is common in NonSTEMI, but very unusual in coronary occlusion (STEMI).

Chest Pain 52

Chest Pain Ischemia STEMI Tachycardia 52

Dr. Smith's ECG Blog

MAY 16, 2023

Sent by Dan Singer MD, written by Meyers, edits by Smith A man in his late 30s presented with acute chest pain and normal vitals except tachycardia at about 115 bpm. Here is the Queen of Heart's interpretation: The cath lab had been activated for concern of STEMI. Here is his triage ECG: What do you think? Do you have a prior?

Chest Pain 52

Chest Pain Pericarditis Tachycardia STEMI 52

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? aVR ST Segment Elevation: Acute STEMI or Not?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

AUGUST 6, 2024

It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. NOTE #1: Sinus tachycardia is not usually seen in an uncomplicated acute MI. . == Below is the ECG of Patient #2 — as interpreted by the QOH. The ECG is diagnostic of occlusion myocardial infarction (OMI).

Chest Pain 104

Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

JUNE 17, 2018

There is sinus tachycardia. Sinus tachycardia, which exaggerates ST segments and implies that there is another pathology. I have always said that tachycardia should argue against acute MI unless there is cardiogenic shock or 2 simultaneous pathologies. Here is that ECG: What do you think? See Table for diagnostic utility.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Ken Grauer, MD

FEBRUARY 18, 2023

The finding of a fairly regular, wide tachycardia without clear sign of atrial activity ( especially when seen in an acutely symptomatic patient ) — should immediately prompt a diagnosis of VT until proven otherwise. The rhythm looks fairly regular — and atrial activity is absent. What is S hark F in M orphology ?

Blog 78

Blog AFIB Chest Pain STEMI 78

Dr. Smith's ECG Blog

DECEMBER 14, 2016

The "criteria" for posterior STEMI are 0.5 Is it STEMI or NonSTEMI? The patient had no hypertension, no tachycardia, a normal hemoglobin, no drug use, no hypotension/shock, no murmur of aortic stenosis. The troponin I returned at 4.1 ng/mL (ULN = 0.030 ng/mL) , diagnostic of myocardial injury. mm STE in one lead.

Chest Pain 52

Chest Pain STEMI Aortic Pulmonary 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

Here was the ECG: There is sinus tachycardia. So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution. So this is STEMI, right? This was sent by a reader. A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock. and K was normal. Which artery?

Cardiogenic Shock 52

Cardiogenic Shock STEMI Pericarditis Blog 52

Dr. Smith's ECG Blog

JUNE 17, 2017

There is sinus tachycardia. The possibility of anterior STEMI was not noticed during patient care. I saw this as I was reading a large a stack of ECGs: What do you think? The T-waves are slightly peaked, suggesting hyperkalemia. But what is atypical is that the T-wave in V3 towers over the R-wave. The QTc is 462 ms. It was stented.

Chest Pain 52

Chest Pain Myocardial Infarction STEMI Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). The conventional computer algorithm called “ sinus tachycardia, otherwise normal EKG ”. The patient received a diagnosis of “NSTEMI” and angiography was scheduled for the next day.

Chest Pain 120

Chest Pain Blog Hospital Tachycardia 120

Ken Grauer, MD

AUGUST 22, 2024

But for those wanting a "simpler" approach" — Consider the following ( which I review below in my ADDENDUM ): This patient is in a wide, "ugly-looking" and seemingly regular tachycardia without P waves. BOTTOM Line: The ECG in Figure-4 shows an extensive infero-postero-lateral STEMI.

Blog 100

Blog STEMI Tachycardia Cardiomyopathy 100

Dr. Smith's ECG Blog

MAY 1, 2023

First, we have a narrow-complex, regular tachycardia, with a rate of about 135-140. This narrows our differential for the rhythm down to sinus tachycardia, paroxysmal supraventricular tachycardia (PSVT, or SVT), and atrial flutter. Is this inferor STEMI? Tachycardia and ST Elevation. Christmas Eve Special Gift!!

Atrial Flutter 52

Atrial Flutter Tachycardia Arrhythmia Blog 52

EMS 12-Lead

JULY 21, 2022

If this was a tachycardia at a rate of 150, it might appear to be a narrow complex tachycardia, when in fact, it would be a wide complex tachycardia! Generally speaking, right bundle branch block does not mimic, or obscure, the ECG diagnosis of acute STEMI the way left bundle branch block does. An ECG is captured.

Bradycardia 52

Bradycardia Tachycardia STEMI Chest Pain 52

Dr. Smith's ECG Blog

MAY 27, 2012

In other words, after reperfusion therapy for STEMI, the appearance of AIVR is usually a good sign, meaning that the artery is reperfused. Our electrophysiologist, Rehan Karim, states he has ablated AVNR"T" ("T" because it is not tachycardia) in a 90 year old, and that he has seen rate-related BBB at very slow rates.

Chest Pain 52

Chest Pain Ischemia Dysrhythmia STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life. But the rate is ~130/minute — which is a bit fast for sinus tachycardia. The patient was treated.

Tachycardia 52

Tachycardia Document Blog Bradycardia 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? In addition to sinus tachycardia, the only abnormalities listed by the computer were "low voltage, precordial leads" and "anteroseptal infarct, old.Q Physician: "No STEMI."

Chest Pain 52

Chest Pain STEMI Document Ischemia 52