Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MAY 19, 2020

Angiography showed normal coronaries. 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. Troponin I rose to 44.1

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. His ECG was repeated at this point: This shows a well developed anterior STEMI. The peak troponin I was over 100.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

DECEMBER 29, 2015

Case history A middle-aged woman with a history of HTN, but no prior CAD, presented to the ED with chest pain. 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."

STEMI 40

STEMI Coronary ALS CAD 40

Dr. Smith's ECG Blog

APRIL 24, 2015

He had a history of CAD with CABG. Ventricular fibrillation is not only caused by acute coronary syndrome. We found that 38% of out of hospital ventricular fibrillation was due to STEMI. A middle-aged male had a V Fib arrest. He had not complained of any premonitory symptoms (which is very common). Learning Points: 1.

Defibrillator 52

Defibrillator ACS CAD STEMI 52

ACEP Now

APRIL 4, 2024

This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries. Figure 1: EKG for Dextrocardia showing STEMI. The second EKG was concerning for STEMI in the precordial leads (see figure 1). Click to enlarge.) 1 It has a prevalence of 0.01

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

STEMI 52

STEMI ACS Coronary CAD 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Just because you don't see hemodynamically significant CAD on angiogram does not mean it is not OMI. It can only be seen by IVUS.

Emergency Department 52

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

Dr. Smith's ECG Blog

MARCH 19, 2023

Concerning history, known CAD" Recorded 2 hours after pain onset: What do you think? The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. This was my response: "This looks like a worrisome EKG. But by now you must have a repeat ECG.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JUNE 19, 2024

The ED provider ordered a coronary CT scan to assess the patient for CAD. His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”. The patient started receiving medications for “STEMI” (including heparin!!!)

STEMI 61

STEMI Coronary CAD ED 61

Dr. Smith's ECG Blog

JUNE 12, 2017

This is diagnostic of inferior MI, though does not meet millimeter criteria for "STEMI." He had a family history of early CAD and occasional drug and tobacco use. He was worried for inferior MI and ordered another, which was recorded 15 minutes later: Now clearly and obviously diagnostic of inferior STEMI.

STEMI 52

STEMI CAD Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JULY 31, 2018

She had zero CAD risk factors. It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. The lesion was stented.

Coronary 52

Coronary ACS STEMI OR 52

Emergency Medicine Ireland

DECEMBER 7, 2020

As the pregnant population continues to age and with RF and smoking and DM still common we can expect to see pregnant woman with CAD. Some unique features to consider in pregnancy is spontaneous coronary artery dissections. Valve disease provides the most interesting part of obstetric care.

Critical Care 40

Critical Care CAD Plasma ACS 40

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. 2009;95:1701–1706.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Is this due to coronary occlusion? The medic activated the cath lab but was refused by the interventionalist, who did not believe that this ECG represented acute coronary occlusion. 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.

E-9-1-1 40

E-9-1-1 STEMI Coronary CAD 40

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve. Look at the aortic outflow tract.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. Despite ongoing chest discomfort and an uptrending troponin, he never meets STEMI criteria.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 20, 2020

A 75 yo with h/o CAD, CABG, and HFrEF presented after a syncopal episode. The medics were worried about STEMI, as it meets STEMI criteria. Discussion Thus, no further ECGs were recorded and there was no angiogram or stress test or CT coronary angiogram. There was no prodrome and no associated symptoms such as SOB or CP.

STEMI 52

STEMI CAD OR Coronary 52

Dr. Smith's ECG Blog

JULY 11, 2019

These findings are very subtle but suspicious for LAD occlusion, as we have seen in many similar (but less difficult) cases on this blog: A man in his sixties with chest pain at midnight with undetectable troponin How long would you like to wait for your Occlusion MI to show a STEMI? He also had non-acute CAD of the RCA (50%) and LCX (50%).

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

They found non-obstructive CAD, with only a 20% stenosis of OM2 and 10% RCA. normal variant, not pericarditis) A Young Man with Sharp Chest pain (normal variant, not pericarditis) 24 yo woman with chest pain: Is this STEMI? A repeat ECG was performed and cardiology was re-consulted: Roughly unchanged. No acute culprit. Pericarditis?

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

EMS 12-Lead

APRIL 8, 2022

Furthermore, there was no family history of early CAD, MI, or sudden cardiac death. BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI.

STEMI 130

STEMI ALS Coronary CAD 130

EMS 12-Lead

AUGUST 14, 2022

Otherwise, no admission of CAD, HLD, or family history of sudden cardiac death. A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. it has been subsequently deemed a STEMI-equivalent. But the lesion is still active!

MICU 130

MICU STEMI CAD Coronary 130

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" All are, however, clearly massive STEMI. This is her ECG: An obvious STEMI, but which artery? Widimsky P et al.

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

APRIL 8, 2016

He had significant history of CAD with CABG x5, and repeat CABG x 2 as well as a subsequent PCI of the graft to the RCA (twice) and of the graft to the Diagonal. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? Most recent echo showed EF of 60%. Learning Points: 1.

STEMI 52

STEMI Plasma Defibrillator OR 52

Dr. Smith's ECG Blog

MARCH 24, 2023

Written by Jesse McLaren, with comments from Smith An 85 year old with a history of CAD presented with 3 hours of chest pain that feels like heartburn but that radiates to the left arm. There’s minimal concave ST elevation in III which does not meet STEMI criteria, so this ECG is "STEMI negative". Below is the ECG. Take home 1.

STEMI 52

STEMI Coronary CAD OR 52

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e STEMI , ST-segment elevation acute myocardial infarction ). I B Ambulance personnel must be trained and equipped to identify STEMI and administer fibrinolysis if necessary.

STEMI 40

STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality.

E-9-1-1 90

E-9-1-1 CAD OR STEMI 90

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 40

STEMI CPR CAD Coronary 40

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. Is that an obvious STEMI underneath that rhythm? In this case, there is diffuse ischemic ST depression of subendocardial ischemia, of course with accompanying reciprocal STE in aVR.

STEMI 52

STEMI ACS CAD OR 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

No family history of sudden cardiac death, cardiomyopathy, premature CAD, or other cardiac issues. 50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI 52

STEMI ALS ACS ICU 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

As in all ischemia interpretations with OMI findings, the findings can be due to type 1 AMI (example: acute coronary plaque rupture and thrombosis) or type 2 AMI (with or without fixed CAD, with severe regional supply/demand mismatch essentially equaling zero blood flow). He had multiple cardiac arrests with ROSC regained each time.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

In this study of dialysis patients with severe CAD, 77% had an abnormal resting EKG and the most common abnormality was LVH. Another reason may be that the EKG is more difficult to interpret in patients with dialysis due to baseline abnormalities, including LVH. Herzog et al.

CAD 52

CAD OR ED ALS 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

No prior similar symptoms or known CAD. The Queen of Hearts Diagnosed "STEMI/STEMI equivalent" on that first ECG (she now uses "STEMI Equivalent" rather than OMI). The fact that she states "STEMI-Equivalent" here means that she does not think it is reperfused, but she does not know that the patient is pain free now.

OR 111

OR STEMI Coronary CAD 111

Dr. Smith's ECG Blog

JANUARY 24, 2025

Written by Willy Frick A 52 year old man with hypertension, dyslipidemia, and seropositive rheumatoid arthritis (a risk factor for CAD) presented with acute substernal chest pressure with diaphoresis which woke him from sleep just after midnight. He said it felt like "someone ripped [his] heart out." But that is not what happened.

STEMI 125

STEMI CAD Coronary ED 125

Dr. Smith's ECG Blog

JANUARY 21, 2025

A 70-something dialysis patient presented and coronary disease had missed dialysis and then presented with acute onset of shortness of breath. Negative trops and negative angiogram does not rule out coronary ischemia or ACS. This is extremely elevated for a type 2 MI and totally consistent with STEMI. He denied chest pain.

OR 62

OR Coronary STEMI ACS 62