Dr. Smith's ECG Blog

OCTOBER 18, 2023

If you were working in a busy emergency department, would you like to be interrupted to interpret these ECGs or can these patients safely wait to be seen because of the normal computer interpretation? have published a number of warnings about the previous reassuring studies.[4,5] minutes).

STEMI 125

STEMI Emergency Department Coronary OR 125

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

STEMI 98

STEMI OR Coronary Emergency Department 98

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.

STEMI 128

STEMI Coronary ALS CAD 128

Dr. Smith's ECG Blog

MARCH 14, 2024

This is obviously unreliable data, as Dr. Smith’s Blog has published 51 cases of OMI with ECGs labeled ‘normal’ , 35 of which were identified by the Queen of Hearts – with 10 examples here. This was just published in print in this month's Academic Emergency Medicine: McLaren, Meyers, Smith and Chartier.

STEMI 126

STEMI ACS Coronary Emergency Department 126

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 123

STEMI Coronary ACS ED 123

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? A man in his 90s with a history of HTN, CKD, COPD, and OSA presented to the emergency department after being found unresponsive at home. Vital signs were within normal limits on arrival to the Emergency Department. Blood glucose was not low at 162 mg/dL.

STEMI 122

STEMI Coronary Emergency Department ACS 122

Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

STEMI 130

STEMI Coronary ALS Emergency Department 130

ECG Medical Training

SEPTEMBER 4, 2016

He is transported to the Emergency Department where care is transferred to a nurse. At the hospital a 12-lead ECG is recorded within 10 minutes and read by the attending physician, who activates the “Code STEMI” protocol. Is this a STEMI? So technically it is a STEMI equivalent. The answer is yes!

STEMI 52

STEMI Paramedic Coronary Emergency Department 52

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." Learning Points: You cannot trust conventional algorithms even to find STEMI(+) OMI, even when they say "normal ECG." We have shown many examples of this on this blog.

STEMI 119

STEMI Coronary Emergency Department OR 119

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Diagnosis of Type I vs. Type II Myocardial Infarction in Emergency Department patients with Ischemic Symptoms (abstract 102).

CAD 132

CAD STEMI Coronary ACS 132

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.

STEMI 98

STEMI Coronary Paramedic ED 98

Dr. Smith's ECG Blog

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Context: a man in his 40s presented to the emergency department with 1 day of sudden onset chest pain. I sent this to our group without information and Dr. Smith responded: "Not OMI.

STEMI 123

STEMI OR Emergency Department 123

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation.

OR 136

OR STEMI Coronary Emergency Department 136

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

STEMI 98

STEMI Defibrillator Coronary EMS 98

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He presented to the Emergency Department with a blood pressure of 111/66 and a pulse of 117. He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. He had this ECG recorded.

ACS 52

ACS STEMI OR Critical Care 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high).

Coronary 127

Coronary STEMI Emergency Department OR 127

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. From Gue at al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

EMS 12-Lead

APRIL 14, 2022

There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI). Western Journal of Emergency Medicine, 18 (4), 752-760. [2] link] [1] Zachary et al. 2] Costanzo, L.

ACS 130

ACS Coronary Paramedic ALS 130

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. As per Dr. Aslanger — a number of medical providers were initial confused by what initially appears as marked ST elevation with reciprocal ST depression, indicative of an acute STEMI.

Coronary 118

Coronary EMR STEMI Emergency Department 118

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

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. I would expect TIMI-3 flow (normal flow, no persistent ischemia) with a culprit in the RCA (or possibly Circumflex). Jesse McLaren et al.

STEMI 98

STEMI Emergency Department OR ALS 98

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

20% of cases that everyone would call a STEMI have a competely open artery by the time of angiogram 60-90 minutes later. PEARL #2: = Aslanger's Pattern: Examples of Aslanger's Pattern appear in a number of cases in Dr. Smith's ECG Blog ( This pattern is very nicely described by Dr. Smith in the January 4, 2021 post).

ED 125

ED Coronary CAD STEMI 125

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. The emergency physician was called to see the patient 90 minutes later after the troponin I returned at 1100 ng/L. What do you think? Take home 1.

STEMI 76

STEMI Coronary OR ALS 76

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. Barely any STE, and thus not meeting STEMI criteria. Only now that the patient has STEMI criteria is he allowed to go to the cath lab, at around 0530.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 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?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He arrived in the emergency department hemodynamically stable. Thus, this patient had increased ST elevation (current of injury) superimposed on the ST elevation of LVH and simulating STEMI. He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. His initial ECG is shown here.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

Dr. Smith's ECG Blog

MARCH 20, 2023

I finished my residency of Emergency Medicine and I’m working at a great Emergency Department here in Brazil. Since then, I started looking for OMI EKG findings and not just STEMI. So, I'm a follower of your blog, and I think I have a interesting case that I attended yesterday."

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

JUNE 18, 2013

His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI. It is not a missed STEMI, but it is a missed coronary occlusion. Ann Emerg Med 1998;31(1):3-11.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). In STEMI, they are generally upright and large in proportion to the QRS. So this argues against acute STEMI. This case is tough.

STEMI 52

STEMI ACS Emergency Department OR 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

I am going to code this as an acute STEMI as he had transient ST elevation which started to evolve in the emergency department but I think this is most appropriately termed STEMI." When is it anterior STEMI? Next day ECG: 2 Very instructive posts on LVH and OMI and Pseudo-OMI 1. Is this Acute Ischemia?

STEMI 52

STEMI EMS ED Emergency Department 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

Is this inferor STEMI? 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). The EM provider asked if the cardiologist thought it was a "STEMI."

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. 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)? Physician interpretation: "No STEMI." Physician: "No STEMI." He had no symptoms of ACS.

OR 52

OR STEMI ACS ALS 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. New ST elevation diagnostic of STEMI [equation value = 25.3

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Here is the repeat ECG at 52 minutes after arrival to triage: Obvious posterolateral STEMI Angiographic findings: 1. 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: A report of the American college of cardiology solution set oversight committee. •

OR 52

OR STEMI ED Critical Care 52

Dr. Smith's ECG Blog

JULY 3, 2018

While in the emergency department, he undergoes an additional ECG: 00:49 - Not much change Second ECG with measurements and calculations Magnified view of second ECGs measurements and calculation It is still "negative" for LAD occlusion (less than 23.4) Despite having acute coronary occlusion by cath, his ECGs never met STEMI criteria.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2022

Not seeing any changes on the initial 12 lead ECG, the emergency physician got a 15 lead ECG (below, where V4-6 are actually V4R and V7-8): There’s no posterior ST elevation but the anterior ST depression has resolved between the first and second ECG. Smith : this proves my impression that the inferior T-waves on the first ECG are hyperacute.

STEMI 40

STEMI ALS Emergency Department OR 40

Dr. Smith's ECG Blog

MAY 1, 2023

edits by Meyers A woman in her 60s with a history of chronic atrial fibrillation on Eliquis, ESRD on hemodialysis, type-II diabetes mellitus, prior CVA, hypertension, and hyperlipidemia presented to the emergency department with multiple complaints after missing dialysis. Is this inferor STEMI? Christmas Eve Special Gift!!

OR 52

OR STEMI Emergency Department 52

Dr. Smith's ECG Blog

APRIL 22, 2022

The HEART and EDACS scores are helpful to risk stratify patients with chest pain, but they hinge on accurate ECG interpretation: a low score doesn’t apply if the ECG shows STEMI(+)OMI, and shouldn’t be used for STEMI(-)OMI or OMI reperfusion either 2. Am J Emerg Med 2020 3. Backus BE, Six AJ, Kelder JC, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52