Dr. Smith's ECG Blog

JULY 18, 2014

Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. the presence of such well developed, wide, anterior Q-wave suggests completed transmural STEMI. Could it be acute (vs.

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

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? Is this an acute STEMI? -- Unlikely!

STEMI 52

STEMI Pulmonary Stents Stent 52

Dr. Smith's ECG Blog

MAY 10, 2014

The following ECG was recorded: There is an obvious acute inferior STEMI. Whenever there is inferior STEMI, one should think about Right Ventricular STEMI (RVMI). As 85% of inferior STEMI are due to RCA occlusion [the rest due to occlusion of a "dominant" circumflex (i.e., and STE in lead III > STE in lead II.

STEMI 40

STEMI Chest Pain Pulmonary Ultrasound 40

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. Answer : Bedside ultrasound! Smith : RV infarct may also have this appearance on ultrasound. So hypoxia without B lines on lung ultrasound strongly weights toward PE. So hypoxia without B lines on lung ultrasound strongly weights toward PE.

Cardiogenic Shock 128

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

Chest Pain 119

Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

APRIL 8, 2016

Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 Learning Points: 1.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

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 which is concerning for LAD occlusion.

Chest Pain 120

Chest Pain STEMI Ultrasound Heart Attack 120

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 126

Chest Pain Blood Pressure Ischemia STEMI 126

Dr. Smith's ECG Blog

OCTOBER 1, 2023

She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. Gallbladder ultrasound was negative for stones. Chest x-ray was normal.

Stent 127

Stent Stents STEMI Physiology 127

Dr. Smith's ECG Blog

MARCH 15, 2021

The computer read Anterior STEMI along with RBBB. I would activate the cath lab based on this and the clinical presentation, but I do NOT see any evidence of anterior STEMI The patient arrived in the ED and had this ECG: The T-waves are now less hyperacute, but ST Elevation remains. Here is his prehospital ECG: What do you think?

Chest Pain 40

Chest Pain Ultrasound Pericarditis STEMI 40

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

The problem is difficult to study because angiographic visualization of arteries is not perfect, and not all angiograms employ intravascular ultrasound (IVUS) to assess for unseen plaque or for plaque whose rupture and ulceration cannot be seen on angiogram. Thus, intracoronary imaging modalities are crucial in this setting. From Gue at al.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

DECEMBER 20, 2010

This case was posted on the [link] ultrasound site, of which this ECG blog is a part. I refer you to the video case presentation by one of my colleagues, Dr. Rob Reardon (who has, by the way, a fantastic collection of ED ultrasound cases). In this case, the ECG never mimicked a STEMI.

Echocardiogram 52

Echocardiogram Cardiomyopathy Ultrasound STEMI 52

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 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. Bedside cardiac ultrasound with no obvious wall motion abnormalities. . — He had a previous ECG on file: Proving the findings are new The cath lab was activated. He was given aspirin and sublingual nitro and the pain resolved.

Ischemia 122

Ischemia Plaque Stenosis Myocardial Infarction 122

Dr. Smith's ECG Blog

DECEMBER 15, 2015

A bedside cardiac ultrasound was recorded: Here is a still image of the echo: The red arrows outline the right ventricle and the yellow arrows outline the left ventricle chamber. Although most cardiac arrest from MI is due to ventricular fibrillation, some is due to high grade AV block, and so this could indeed be due to large acute STEMI.

STEMI 40

STEMI Embolism Pulmonary Ultrasound 40

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. 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, There was good flow.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

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 135

Chest Pain Defibrillator STEMI Coronary Artery Disease 135

Dr. Smith's ECG Blog

OCTOBER 22, 2017

This was sent by a recent ultrasound fellow, asking for my ECG diagnosis. However, there are morphologies of Takotsubo that cannot be distinguished from STEMI. Takotsubo This looks like and infero-posterior STEMI, but the QT is bizarrely long. There is ST elevation in I, II, III, aVF, V2, V3, V4, V5, and V6.

Chest Pain 52

Chest Pain STEMI Cardiomyopathy Ultrasound 52

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 118

Chest Pain Myocardial Infarction Anatomy Angina 118

Dr. Smith's ECG Blog

APRIL 26, 2017

This meets "STEMI criteria" However, there is very high voltage, with a very deep S-wave in V2 and tall R-wave in V4. The morphology is not right for STEMI. My interpretation: LVH with secondary ST-T abnormalities, exaggerated by stress, not a STEMI. This is very good evidence that the ST elevation is not due to STEMI.

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. However the patient continued to have chest pain and bedside ultrasound showed hypokinesis of the septum with significantly reduced LVEF. Is there STEMI? The patient continued having chest pain. What is the rhythm?

Chest Pain 107

Chest Pain Arrhythmia Myocardial Infarction STEMI 107

Dr. Smith's ECG Blog

JUNE 27, 2021

A bedside ultrasound was done, with dozens of clips, and was even done with Speckle Tracking. Because we are hypnotized the STEMI paradigm. "If If there is no STEMI, there is no emergent problem and the patient can wait." It was not a STEMI) 1. To me, this looks like pulmonary edema. Here are a few clips.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis Answer: pulmonary embolism. Now another, with ultrasound. What is the Diagnosis? This is a quiz.

Chest Pain 139

Chest Pain Embolism Pulmonary Tachycardia 139

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. Results Of 149 patients with inferior STEMI , 43 (29%) had RVMI and 106 (71%) did not. What is the atrial activity? Is it sinus arrest with junctional escape? How would one tell?

Chest Pain 97

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

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

SEPTEMBER 16, 2015

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. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think? The ECG is consistent with high lateral STEMI. Called 911.

STEMI 40

STEMI Chest Pain Cardiac Arrest Stents 40

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. Another approach is sympathetic chain (stellate ganglion) blockade if you have the skills to do it: it requires some expertise and ultrasound guidance. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Takotsubo is a sudden event, not one with crescendo angina.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

Could this be Septal STEMI (STE in V1 and aVR, with reciprocal ST depression in V4-V6?), In Septal STEMI , transmural ischemia of the septum is recorded by the overlying lead V1 as ST Elevation. Lead III is also on the right and might manifest ST Elevation in Septal STEMI. with ADDED STE in III?

Ischemia 40

Ischemia Pulmonary STEMI Chest Pain 40

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. She called 911.

STEMI 40

STEMI Risk Factors Bicuspid/Mitral Ultrasound 40

Dr. Smith's ECG Blog

APRIL 12, 2023

Prehospital Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI Transformed ECG by PM Cardio: PM Cardio AI Bot interpretation: OMI with High Confidence What do you think? On arrival, lung ultrasound confirmed pulmonary edema (B lines). This is proximal LAD Occlusion until proven otherwise.

Echocardiogram 52

Echocardiogram Pulmonary Cardiomyopathy Coronary Artery Disease 52

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. In equivocal cases, point-of-care ultrasound may be the difference between taking the patient to the lab or not. 1] Wereski, R., Chapman, A. Gray, A., &

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

FEBRUARY 14, 2009

A bedside ultrasound revealed a possible anterior wall motion abnormality. They may be the only remaining clue to a reperfused LAD occlusion. Today the discomfort is associated with multiple episodes of vomiting and it is unremittant. The following EKG was obtained and hyperkalemia was diagnosed. The K returned at 2.9

Chest Pain 52

Chest Pain Ultrasound STEMI Stent 52

Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio greater than 0.36, then it is STEMI, not LV aneurysm. These ultrasounds confirm LAD occlusion. How do I know?

STEMI 40

STEMI Chest Pain Ischemia Aneurysm 40

Dr. Smith's ECG Blog

MAY 19, 2020

This is a troponin I level that is almost exclusively seen in STEMI. So this is either a case of MINOCA, or a case of Type II STEMI. If the arrest had another etiology (such as old scar), and the ST elevation is due to severe shock, then it is a type II STEMI. I believe the latter (type II STEMI) is most likely.

Defibrillator 52

Defibrillator Circulation Plaque Cardiac Arrest 52

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. EKG is pictured below: What do you think?

Bradycardia 40

Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

APRIL 20, 2018

Given her risk factors (HTN, HLD, ESRD from diabetes) I decided to obtain a broad cardiac workup for the patient: serial ECGs, labs, serial troponins, CXR and bedside cardiac ultrasound. Ultrasounds can be very helpful in guiding your diagnostic pathway: location of WMA on US led to obtaining posterior leads.

Chest Pain 40

Chest Pain Ultrasound Risk Factors STEMI 40