Dueling OMI: does this 30 year old with chest pain have any signs of occlusion or reperfusion?
Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. Below is ECG #1 at triage. Are there any signs of occlusion or reperfusion?There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages. There’s mild inferior ST elevation in III that doesn’t meet STEMI criteria, but it’s associated with ST depression in aVL and V2 that makes itdiagnostic of infero-posterior Occlusion MI (from either RCA or circumflex) – accomp...
Source: Dr. Smith's ECG Blog - January 29, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)
Submitted by anonymous, written by Pendell Meyers.  Additional case by Smith.Case 1A middle aged woman presented with acute chest pain and shortness of breath, unclear time since onset, and likely with episodic symptoms off and on throughout the day. Her vitals were within normal limits.ED1 @1512What do you think?Meyers: Very clear and specific for acute LAD OMI, with hyperacute T waves in the LAD distribution including leads V2-V6, II, III and aVF. Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of suf...
Source: Dr. Smith's ECG Blog - January 28, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

What is this Rhythm?
==================================My Comment by KEN GRAUER, MD (1/26/2023):==================================While reading ECGs — Dr. Smith came across the intriguing tracing shown in Figure-1. No history was available. However, the rhythm is indeed challenging  — and illustrates a number of important principles in rhythm interpretation of interest to all emergency care providers.How would YOU interpret the ECG in Figure-1? Can you come up with a definitive rhythm diagnosis?Figure-1: 12-lead ECG and simultaneously-recorded 3-lead rhyth...
Source: Dr. Smith's ECG Blog - January 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain, and Cardiology didn't take the hint from the ICD
Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and GrauerA 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG:What do you think?Triage physician interpretation: -sinus bradycardia-lateral ST depressionsWhile there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. Additionally, lead V3 has ST depressions, which are always abnormal (recall that lead V3 will haveST elevation under nor...
Source: Dr. Smith's ECG Blog - January 23, 2023 Category: Cardiology Authors: Bracey Source Type: blogs

Unconscious + STEMI criteria: activate the cath lab?
Case submitted and written by Dr. Mazen El-Baba and Dr. Evelyn Dell, with edits from Jesse McLarenEMS brought a John Doe, in his 30s, who was found in an urban forest near a homeless encampment on a cool fall day. There were no signs of trauma on scene or on the patient. EMS reported an initial GCS of 8 with pupils equal and reactive. The patient had a witnessed generalized tonic-clonic seizure leading to GCS 4.Vitals: HR 45; systolic BP was 110-120; irregular respiratory rate; oxygen saturation was normal; tympanic temperature 30; glucose was 6. In the resuscitation room, the patient had another seizure that stopped after...
Source: Dr. Smith's ECG Blog - January 21, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

A 60 year old with chest pain
CONCLUSION:Take another LOOK at Figure-1. It was after Dr. Smith suggested repeating the initial ECG after repositioning the LL electrode — that ECG #2 was recorded.In your mind ' s eye — Wouldn ' t ECG #1 look like ECG #2 if we took away the artifactual deflections highlighted in RED, BLUE and GREEN?That said — there is nonspecific ST-T wave flattening in multiple leads of ECG #2, as well as T wave inversion in lead V2. There are also fairly large U waves in leads V3 and V4. Finally — significant baseline artifact persists in leads II and III of ECG #2, s...
Source: Dr. Smith's ECG Blog - January 17, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

OMI can be very subtle and easy to miss, but be a very large infarction.
I was reading ECGs on the system and came across this one.  There is minimal STE in II, III, with an inverted T-wave in aVL.There is a very flat ST segment in V2, with 0.5 mm of STD, highly suspicious for posterior OMI.We showedin this paper that ANY amount of STD maximal in V1-V4 (especially in V2) in a patient with chest symptoms is posterior OMI until proven otherwiseI knew that if this is a patient with chest discomfort, that it is an infero-posterior OMI.So I went to the chart and found that it was from a 50-something woman with CP of a couple hours duration.Unfortunately, the OMI was not seen.When the ...
Source: Dr. Smith's ECG Blog - January 15, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

Quiz post: do either or both of these patients have high lateral OMI / South African flag sign?
 Written by Pendell Meyers, edits by SmithTwo patients presented with acute chest pain/pressure. Here are their ECGs:Patient 1:Patient 2:See below for " answers " , and below that for both cases." Answers " : Patient 1 shows very subtle high lateral OMI, South African flag sign. She had an acute LAD OMI in the process of reperfusion, see case below.Patient 2 has a normal variant ECG which mimics high lateral OMI, and ruled out for MI, see case below.Here is theSouth African Flag sign (Figure by Ken Grauer — with the original 12-lead from Patient 1 attached below — See his Comment from theApril 8, 2022 post in...
Source: Dr. Smith's ECG Blog - January 12, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

A teenager with chest pain, a troponin below the limit of detection, and " benign early repolarization "
Sent by anonymous, written by Pendell MeyersA male in his teens presented with complaints of chest discomfort and dyspnea beginning while exercising but without obvious injury. He immediately stopped exercising and symptoms started to improve. Later that evening he felt recurrent central chest discomfort, shortness of breath, and vomited. Symptoms have been constant since this second episode, and are still present on arrival, which seems to have been less than 1 to 2 hours from onset of symptoms. No similar symptoms in the past. No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of...
Source: Dr. Smith's ECG Blog - January 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

A woman in her 50s with acute chest pain
Submitted and written by Anonymous, edits by Meyers and SmithA 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache.Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 FTriage ECG:ECG Interpretation:Sinus rhythm with normal QRS. There is slight STE in V1, V2, and aVR, with STD in V3-V6, I, aVL, and II. There are T waves in lead III which are suspicious for hyperacute T waves, with reciprocal negative large T wave inversions in aVL. I do not think this ECG is by itself diagnostico...
Source: Dr. Smith's ECG Blog - January 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs

An ECG which is obviously diagnostic of OMI can appear wholly non-specific to most interpreters. A comment on AI.
 This was texted to me by a former resident, with no information:What do you think?Here Ken Grauer has used the PM Cardio app to improve the image:This was my immediate response:" Acute proximal LAD OMI "  To me it is obvious and diagnostic.There are hyperacute T-waves in I, aVL, V2-V6.  These are wide, bulky, with large area under the curve relative to the QRS size.Furthermore, there is a QS-wave in V3 and qrS in V4, both diagnostic of MI at some time (past or present).  We have shownhere and validatedhere that old MI has relatively small T-wave (by amplitude).  In this situation (QS-waves), ...
Source: Dr. Smith's ECG Blog - January 1, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs

30-something woman with a HEART score of zero, EDACS of 2, computer " Normal " ECG, and initial troponin < Limit of Detection
I was working in triage very late when a 30 yo previously completely healthy woman walked in with 30 minutes of central chest pressure.This ECG was recorded:The computer called it " Normal " except for " Possible right ventricular conduction delay "What do you think?I immediately recognized an inferior-posterior-lateral OMI.  There are hyperacute T-waves in II, III, and aVF.  They are too large, wide, fat, and bulky in comparison to the size of the QRS to be normal.  The degree of upward concavity is less than normal.  There is a downsloping ST segment in V2.  There are relatively large T-waves in ...
Source: Dr. Smith's ECG Blog - December 23, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

See OMI vs. STEMI philosophy in action
by Emre AslangerDr. Aslanger is our newest editorial member.  He is an interventional cardiologist in Turkey. Dr. Aslanger is also the author of the DIFFOCULT study:Emre K. Aslanger,a,⁎ Özlem Yıldırımtürk,b Bar ış Şimşek,c Emrah Bozbeyo ğlu,c Mustafa Aytek Şimşek,a Can Y ücel Karabay,b Stephen W. Smith,d and Muzaffer De ğertekina  DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction.  International Journal of Cardiology Heart& VasculatureCaseA 40-year-old man presents with...
Source: Dr. Smith's ECG Blog - December 22, 2022 Category: Cardiology Authors: Emre Aslanger Source Type: blogs

A young patient with diminishing pain with a subtle but diagnostic ECG.
Written by Emre Aslanger(Emre is our newest editor.  He is an interventionalist in Turkey and one of 3 originators of the OMI/NOMI paradigm, along with Pendell and Smith. Here are his publications.)CaseA 39-year-old male without prior medical history presents with chest pain that started 2 hours prior to presentation. He says that the pain intensity was 10/10 at home but now about 4/10. His medical exam is unremarkable. He has no cardiovascular risk factors except smoking for 10 pack-years. He denies any illicit drug use. His ECG is shown below. What do you think ?Although not striking, this is clearly a dia...
Source: Dr. Smith's ECG Blog - December 18, 2022 Category: Cardiology Authors: Emre Aslanger Source Type: blogs

A woman in her 70s with chest pain
 Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, SmithA woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. She felt nauseous and lightheaded with no neurologic deficits. EMS noted prehospital vitals for heart rates in the 60s, SPO2 of 98% on room air, initially hypotensive to 66/34 with improvement to 100/70 after 800 mL of IV fluids by EMS.  Here is her ECG on arrival to the ED: What is your differential? What are your next steps?The ECG is quickly reviewed and shows si...
Source: Dr. Smith's ECG Blog - December 18, 2022 Category: Cardiology Authors: Pendell Source Type: blogs