Do these Serial Prehospital ECGs show OMI?

A 50-something male with a history of hypertension called 911 after sudden onset chest pain in the middle of his chest radiating up to his neck. He reports that earlier in the day he had some chest pain that came on while he was teaching that subsequently resolved with rest.  + Diaphoresis and SOB, no radiation to the shoulders. He had 3 prehospital ECGs recorded:What do you think?The 1st ECG is may appear normal, but is ischemic.  There is a very tiny amount of ST depression in V2, but there is definitely a bit of STD in V3 and V4.  The 2nd ECG has clear STD in V2-V4 and slightly larger inferior T-waves.  The 3rd has still larger T-waves in inferior leads.  There is now RBBB (but QRS is only 120 ms), with rSR in V1, but no R'beyond V1.  Without an R'-wave in V2, there is no reason to have ST depression other than posterior OMI (RBBB with rSR'usually is followed by some STD that is discordant to that preceding large R'wave).So this is highly suspicious, if not diagnostic, of inferior-posterior OMI.For reasons I can't explain to myself, I was skeptical when I saw these prehospital ECGs.  I should know without doubt that in the context of acute chest pain,ANY ST depression maximal in V1-V4 is highly specific for OMI.  After all, Pendell and I wrote the paper.  This shows that even I am biased by the STEMI paradigm.He arrived at the ED and had normal VS and normal exam.On arrival, he had an ED ECG recorded:What do you t...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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A middle aged male presented after onset, approximately 50 minutes prior, of constant crushing 10/10 substernal chest pain, radiating into right arm associated with shortness of breath. He had never felt this way before. There was a history of HTN but he was not taking any medicines.Prehospital ECG was recorded approximately 20 minutes after pain onset and 20 minutes prior to ED arrival:There are somewhat large T-waves in II and aVF and a sagging ST segment in aVL, suggestive of inferior OMI.  There is some minimal downsloping ST depression in V2 and V3, which is suggestive of posterior OMI. The ECG isnot di...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A 40-something male called 911 for 2 hours of crushing, non-radiating, chest pain at about 11 AM.  He reported a similar episode last year when his blood pressure was very out of control and that again he has not taken his BP meds for 2 months.  He stated he had drunk 12 cans of Mountain Dew (high caffeine content) overnight. On exam, he was very anxious,  holding his chest, breathing normally.  Chest pain was worse with palpation.  His BP was 250/150 with a heart rate of 150.Here are 2 prehospital ECGs, 6 minutes apart:Heart rate 156.  ST Elevation. Large T-wavesThe computer re...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Submitted and written by Kaley El-Arab MDPeer reviewed by Pendell Meyers, Alex Bracey, Stephen Smith A 64-year-old male with past medical history of coronary artery disease with prior MI s/p stent to RCA (2008), hypertension, dyslipidemia, and diabetes presented with acute onset of chest pain.  Around 15:00 while at work he developed left-sided chest tightness that lasted for a few hours, then eventually went away, but returned the same evening around 22:00 when it woke him from sleep. He reportedly tried to “walk it off” which relieved the pain transiently. When the pain returned it was more severe a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This is a case from many years ago that I discovered recently.  The patient has heart failure as a result of this event.A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away.  There was SOB at the start and increased work of breathing.  He had been drinking 5 beers.  He does not seek medical attention often.  He called 911.  Medics recorded this ECG:There is a lot of artifact, but you can clearly see ST depression in V2 and V3....
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Written by Pendell Meyers, submitted by George KonstantinouA man in his early 40s with history of smoking and hypertension presented to the ED with substernal and right sided chest pain of 8 hours duration. The pain had first started after a stressful event and had waxed and waned several times over the 8 hours. The pain was reproducible with palpation on the right side of the chest.Here is his initial ECG:Notice the leads configuration (this ECG comes to us from Greece).There is sinus rhythm with very small STE in V2-V3. The T waves in V2-V5 are very concerning for hyperacute T waves with increased area under the curve. C...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This case is from one of our fantastic 3rd year residents, Aaron Robinson.A woman in her 60s with SyncopeA woman in her 60s presented to a facility with syncope. She had a history of CHF, pulmonary hypertension,CAD s/pCABG, and ESRD on hemodialysis. She had a dialysis run the day prior. Prehospital VS were: BP 115/70, HR 65, RR 12. The patient did not have a 12 lead completed pre-hospital.She arrived at the ED awake, alert, and complaining only ofmild chest discomfort. A 12 lead ECG was immediately completed:Aaron showed this to me and this is what I said:Suggestive of inferior posterior MI, but not dia...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Wrapping up this year and looking back on the particularly interesting developments in medical technology, we at Medgadget are impressed and very excited about the future. We’re lucky to cover one of the most innovative fields of research and o...
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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
Written by Meyers, edits by SmithA 50-ish year old man was working construction when he suddenly collapsed. Coworkers started CPR within 1 minute of collapse. EMS arrived within 10 minutes and continued CPR and ACLS, noting alternating asystole and sinus bradycardia during rhythm checks. He received various ACLS medications and arrived at the ED with a perfusing rhythm.Initial vitals included heart rate around 100 bpm and BP 174/96. Here is his initial ECG, very soon after ROSC:What do you think?Sinus tachycardia.  There is incomplete RBBB (QRS duration less than 120 ms).  There is diffuse STD, maximal in V4-V5 a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
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