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Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).
I received the following text message with these 3 EKGs (providers text me ECGs all day every day; most are false positives; many are subtle true positives):" Hi Steve, here are 3 EKGs for you (my colleague ' s case). A 67 yo f developed chest pain this morning. "EKG #1Followed 15 minutes by this #2 EKG:Then the patient received aspirin andDilaudid (hydromorphone, same effect as morphine) and the pain went away and there was this 3rd ECG:Smith comment: hydromorphone will make any pain go away (or improve) without any improvement in the underlying pathology. Do NOT give it unless you are committed to t...
Source: Dr. Smith's ECG Blog - May 31, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 50s with chest pain
Sent by anonymous, written by Pendell MeyersA man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. He denied any lightheadedness, shortness of breath, vomiting, or abdominal pain. Vitals were within normal limits.Here is his triage ECG at 0343:What do you think?Meyers interpretation: Diagnostic of LAD OMI, with hyperacute T waves in a large LAD distribution including precord...
Source: Dr. Smith's ECG Blog - March 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, RBBB but “STEMI Negative”: Is this a false cath lab activation, or a false cancellation?
A 90 year old with a history of atrial fibrillation presented with two weeks of intermittent retrosternal chest pain lasting minutes. An hour prior to presentation it became constant and more severe, accompanied by nausea and general weakness, and the paramedics brought them to the ED as a code STEMI. Heart rate was in the 50s and other vitals normal. What do you think? There ’s atrial fibrillation, a right bundle branch block, normal axis and normal voltages. RBBB should produce secondary ST depression and T wave inversion in the anterior leads with the RsR’ (as it does in V1). But here in...
Source: Dr. Smith's ECG Blog - July 18, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Quiz post - which of these, if any, are OMI? What is the South African Flag Sign? Will you activate the cath lab? Can you tell the difference on ECG?
Written by Pendell Meyers, additions and edits by Grauer, Smith, McLarenBelow we have 5 cases of adults (ranging from 40-70 years old) who all presented to the ED with acute nontraumatic chest pain that sounded at least somewhat like potential ACS to the provider. You should look at each ECG and decide if it is OMI, not OMI, or something else.Our goal in this post is to compare and contrast OMIs with false positives that mimic them. In this post we will examine the anterolateral distribution that has been described as the " South African Flag Sign. " (SAFS)It is very hard to describe why an ECG expert can easily...
Source: Dr. Smith's ECG Blog - May 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 60s with chest pain. Cardiologist refuses to take to the lab. Obvious STEMI, even with criteria. Yet final diagnosis " NSTEMI " . This happens far too often.
Submitted by Anonymous MD, edits by MeyersA man in his 60s with past medical history of multiple sclerosis and hypertension was brought in by EMS from home for chest pain thatstarted acutely just prior to arrival. He rated the pain at 9/10, describes as pressure, radiates towards the left arm with associated shortness of breath, diaphoresis and had one episode of emesis. He did not have a prior history of CAD or other cardiac disease. His pain improved to 6/10 after EMS gave him 3 sprays of sublingual nitroglycerin and 324 mg of aspirin. Prehospital ECGs:What do you think?Both ECGs are diagnostic of acute LAD OMI...
Source: Dr. Smith's ECG Blog - April 15, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 50s with acute chest pain and history of prior MI
Written by Pendell MeyersA man in his 50s with prior history of anterior MI with LAD stent presented with acute chest pain similar but more intense than his last MI. He presented around midnight with pain that had started around 9pm the night before. He had taken NTG at home with no improvement, and immediately received morphine on arrival at the ED for severe chest pain (a very bad idea if your accuracy for finding OMI on ECG is low, since ongoing pain will be your last chance to identify those with ongoing untreated OMI).Here is his triage ECG at 0012:What do you think? What is the differential of this ECG?There is sinus...
Source: Dr. Smith's ECG Blog - April 13, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
False cath lab activation or false cancellation?
Written by Jesse McLarenA 40 year old developed sudden chest pain radiating to the jaw, with diaphoresis and vomiting. What do you think?What do you think? There ’s normal sinus rhythm with normal conduction, normal axis, normal R wave progression and normal voltages. There are hyperacute T wave in I/aVL and possibly V5-6, with reciprocal change in III. There’s also ST depression in V1-3. The computer interpretation labeled this ECG as “nonspecific”, and it does not meet STEMI criteria. But there are ischemic abnormalities in the majority of leads that add up to an ECG diagnostic of posterolateral Occlusion MI...
Source: Dr. Smith's ECG Blog - March 16, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Did the posterior leads help here? Why not just get good at STDmaxV1-V4?
Written by Pendell MeyersA middle aged woman presented with chest pain and dyspnea. Her exam and vitals were within normal limits. Here is her triage ECG:What do you think?There is sinus rhythm with a relatively normal QRS (except for the substantial positive QRS component in V2). There is STD in V2-V4, with no QRS explanation, and downsloping ST morphology in V2 and horizontal morphology in V3-4. Thus, there is posterior OMI until proven otherwise, because of STD maximal in V1-V4. There is also subtle evidence of inferior OMI, with slight STD and TWI in aVL with suspiciously full upright T waves in the III and ...
Source: Dr. Smith's ECG Blog - December 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
A man his 50s with chest pain. What happens when you treat with morphine rather than with reperfusion?
Written by Pendell MeyersA man in his late 50s presented to the ED with 3 days of left chest pain radiating into the jaw and neck. He described it as " heartburn. " The pain radiates into his left arm and causes numbness and tingling from time to time. The history does not state what changed on day 3 that made him finally present to the ED; the history has no details as to whether the pain was off and on, or fluctuating, or whether the pain become persistent soon before arrival (these are key details and would help with many important questions we will have below!). Vitals were normal, and his triage ECG is below, at...
Source: Dr. Smith's ECG Blog - December 17, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Even when the story is obvious, with intractable pain, the STEMI paradigm can cause preventable delays
Written by Pendell MeyersA man in his early 60s presented with acute chest pain rated 10/10 with associated nausea and vomiting with known history of multivessel CAD. He presented at 2300 with onset of symptoms at 2230. He was awoken from sleep by the symptoms, which were identical to prior MI for which he received a stent years ago. On arrival his heart rate was 43 bpm and blood pressure 91/62. Atropine and IV fluid was given.Here was his triage ECG:What do you think? Baseline below for comparison, but try first without it.His baseline ECG was available on file:The presentation ECG shows diagnostic evidence of poste...
Source: Dr. Smith's ECG Blog - December 1, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 60s woken from sleep by epigastric pain. Would you have been able to correctly diagnose him?
Written by Pendell MeyersA 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. He called EMS who brought him to the ED. He had active chest pain at the time of triage at 0137 at night, with this triage ECG:I sent this ECG, without any text at all, to Dr. Smith, and he replied: " LAD OMI with low certainty. V3 is the one that is convincing. " After his response I sent him the baseline ECG (below), still with no context at all except that this was his prior ECG:Dr. Smith replied: " Now high certainty. By the way,...
Source: Dr. Smith's ECG Blog - October 5, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
A 52 year old female with chest pain
Written by Pendell Meyers, edits by Steve SmithA 52 year old female with history of hypothyroidism and smoking presented to the ED with an episode of chest pain that began suddenly around 1500 while sitting down at work. She states it felt like a central chest pressure that radiated to her jaw. The pain had been persistently present since since 1500 (seen at 1615 in the ED), but had waxed and waned in severity, with the initial onset of pain being the worst. She had dyspnea and diaphoresis when the pain began. Coworkers called EMS who administered aspirin and NTG, which the patient says did not relieve her pain. During ini...
Source: Dr. Smith's ECG Blog - August 16, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)
Conclusion: Among high-risk ACS patients, the specificity for OMI of suspected ischemic STDmaxV1-4 was 97%. STEMI criteria missed half of OMIs detected by STDmaxV1-4. These data support that any ischemic STD maximal in V1-V4 in ACS is due to OMI until proven otherwise.
Source: Dr. Smith's ECG Blog - June 27, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
32 yo with right sided chest pain. Zero ST Elevation, but that does not matter.
DiscussionIn hindsight I feel there are very few alternative causes for an ECG like this other than an acute LAD occlusion. I believe this is one of those ' subtle STEMI ' cases where neither the ECG nor the symptoms are very obvious or severe and the usual evolution is not seen.I think of these cases as ' insidious infarcts ' and I have seen this in all infarct territories and I do not think they are particularly rare. Essentially the patient is fairly comfortable and the ECG is not obvious but the patient ended up with Q waves, huge troponins and we missed the opportunity to reperfuse the artery when it counts. These pat...
Source: Dr. Smith's ECG Blog - February 17, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
The delay between OMI and STEMI claims yet another patient ' s anterior wall
Written by Pendell Meyers with edits by Steve SmithAn elderly woman with HTN presented with L sided chest pain, intermittent over the past week but worse over the past hour, associated with shortness of breath. She had no known history of CAD.Here is her presenting EKG at 2210:What do you think?This is quite an obvious anterior OMI, with STE in V2 with hyperacute T-waves in V2-V3, however it unfortunately does not meet STEMI criteria as there is insufficient STE in either lead V1 or V2 to have two consecutive leads. There is a small amount of coved, convex STE in aVL with a terminal T-wave inversion. There is also the begi...
Source: Dr. Smith's ECG Blog - April 11, 2019 Category: Cardiology Authors: Pendell Source Type: blogs
