Coronary Disease and Chest pain: Is it acute inferior OMI or old inferior MI?

An elderly woman with a h/o myocardial infarction presented with 2 hours of burning substernal chest pain.Here is her ECG:Is there an OMI?What is the best next strategy to assess for OMI?ECG description:There is sinus rhythm.  There are well-formed Q-waves in inferior leads, with some minimal ST Elevation, and reciprocal ST depression in aVL.  The STE with STD in aVL is typical of inferior OMI, right?Exceptfor the well-formed Q-waves, which suggest anold inferior MI.There is also anearly R/S transition in precordial leads, with alarge R-wave in V2.  This suggestsprevious posterior MI as well.  (Bayes de Luna would say " lateral MI " )There are also Q-waves (qR-waves) in V3-V6 of old anterior MI.This ECG is classic for old inferior MI with persistent ST elevation.  Why? Because of very well formed Q-waves, and h/o MI.Differentiate acute inferior MI from old inferior MIThere is no very good way to differentiate inferior acute OMI with Q-waves from old inferior MI with persistent ST Elevation.  They can look remarkably similar, and so looking for old ECGs and other historical information is key.On the other hand, anterior aneurysm (persistent STE after old MI) can be fairly reliably distinguished by the T/QRS ratio.See this case: Subtle Anterior STEMI Superimposed on Anterior LV Aneurysm MorphologyAnd many more: https://hqmeded-ecg.blogspot.com/search?q=T%2FQRS+ratio+aneurysmSo what is the Plan?? Look for an old ECG and prev...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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Written by Pendell Meyers, submitted by Siva Vittozzi-WongA man in his 30s with history of hypertension, hyperlipidemia, and diabetes presented with chest pain which started 12 hours prior to presentation. The pain was described as pressure, constant for 12 hours, radiating to the jaw, with left arm numbness. Initial vitals were significant for bradycardia at 45 beats per minute.Here is his presenting ECG with active pain:What do you think?Here was the prior EKG on file:The emergency medicine resident (who has received lectures from me on hyperacute T-waves, suble OMI, etc) documented the following interpretation:" In...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
In this study, approximately 10% of Transient STEMI had no culprit found:Early or late intervention in patients with transient ST ‐segment elevation acute coronary syndrome: Subgroup analysis of the ELISA‐3 trialOne must use all available data, including the ECG, to determine what happened.Final Diagnosis?If the troponin remained under the 99% reference, then it would be unstable angina.  If it rose above that level before falling, it would be acute myocardial injury due to ischemia, which is, by definition, acute MI.  If that is a result of plaque rupture, then it is a type I MI.  The clinical presentat...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A 57-year-old man with a personal history of arterial hypertension and overweight was referred from his primary care medical centre to our tertiary hospital reporting refractory typical chest pain lasting 3  h with persistent electrocardiogram (ECG) changes. The initial ECG (Panel A) showed: (i) atrial fibrillation with marked upsloping ST-segment depression; (ii) hyperacute T waves from leads V2 through V5, with a millimetric J point rise at lead aVR (De Winter sign, which was recently recognized as a ST-segment elevation equivalent). TheST ‐segment-elevation myocardial infarction network was activated and the pa...
Source: European Heart Journal - Category: Cardiology Source Type: research
A middle-aged woman with history of hypertension presented to another hospital approximately 2 hours after onset of chest pain and shortness of breath.This ECG was recorded on arrival:What do you think?This is technically a STEMI, with 1.5 mm STE in V1 and 1.5-2.0 mm in V2. The current criteria only require 1mm in V1 and 1.5mm in V2 for a female. However, I think many practitioners might not see this as a clear STEMI, and would instead call this " borderline. " The normal QRS complex with STE and large volume underneath the T-waves in V1-V3 confirm Occlusion MI (OMI). There is not technically STD in V6 and I, how...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell Meyers, few edits by SmithA man in his 60s with history of stroke and hypertension but no known heart disease presented with chest pain that started on the morning of presentation at around 8am.Here is his triage ECG when he presented at 1657:What do you think?There is sinus rhythm with normal QRS complex and ST depression in V2-V5, maximal in V3-V4. There is no ST depression in V6, II, III, or aVF, and no significant ST elevation in aVR, all confirming that the ST vector is not consistent with diffuse subendocardial ischemia, but rather a focal ST vector pointed at the posterior wall. It is posterior OM...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
An elderly man, with history of hypertension and obstructive sleep apnea, woke up with severe chest pain, nausea, and sweating. Upon arrival of the emergency medical team, he had low blood pressure (85/40  mm Hg), with no significant difference between upper limbs, no signs of congestion, and palpable bilateral upper and lower limb pulses. An electrocardiogram (ECG; Figure 1A) was performed, revealing ST-segment elevation in aVR and aVL and diffuse ST-segment depression, which was interpreted as an ST-segment elevation myocardial infarction (STEMI) equivalent.
Source: The Journal of Emergency Medicine - Category: Emergency Medicine Authors: Tags: Visual Diagnosis in Emergency Medicine Source Type: research
A 60-something presented with hypotension, bradycardia, chest pain and back pain.She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension.  She had a mechanical aortic valve.  She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing.  BP was 70/49, pulse 60.A bedside echo showed good ejection fraction and normal right ventricle and no pericardial fluid. Here is the initial ECG:What do you think?This ECG actually looks like a left main occlusion (which rarely presents to the ED alive):  ST Elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell MeyersWe walked in to an overnight shift with approximately 70 patients in the waiting room and a room full of sign-outs at midnight. At 3:55 AM during that kind of a night shift, this ECG (among many others) was brought from triage for review by my team.We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. No prior available.Here is the computer interpretation:So we have a triage-computer-normal ECG.Don't bother me with this, right?I'm sure you can imagine the cognitive burden we had during this type of night. On first review from triage, my attending and I waffled ab...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This study from Herzog et al (from our own Hennepin County Medical Center) included patients from a national registry and compared 3049 patients on dialysis admitted and eventually found to have acute MI compared with 534,395 patients not on dialysis admitted with an eventual diagnosis of acute MI. Of these groups, only 22% of dialysis patients had an admission diagnosis consistent with acute MI while 43.8% of nondialysis patients had the correct admission diagnosis of acute MI.  Dialysis patients had double the rate of cardiac arrest (11% vs 5%), were less likely to receive reperfusion therapy when eligible (47% vs. ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Case submitted and written by Alex Bracey, with edits by Pendell Meyers and Steve SmithThis ECG was tossed onto my desk on my first day of a new rotation at a community site. The technician was nowhere to be found by the time I turned to ask what the story is or where the patient is located.Initial ECG at 1350 - are you concerned? - There is 0.5 mm STE in aVL, no clear STE in lead I. - There is ST depression in II, III, and aVF. - Nicely demonstrated here, leads III and aVL are reciprocal: STD in III is reciprocal ST depression to STE in aVL.This is diagnostic of occlusion (OMI). - There is also some slight STD in V4-...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
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