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. Below is the ECG. What do you think? There’s sinus bradycardia, first degree AV block, normal axis, delayed R wave progression, and normal voltages. There’s minimal concave ST elevation in III which does not meet STEMI criteria, so this ECG is "STEMI negative". But there are multiple other abnormalities that when combined are diagnostic of OMI and predictive of RCA occlusion: sinus bradycardia ..read more

 Submitted by Dr. Caio Aguiar from Brazil, written by Pendell Meyers It is immensely rewarding to receive these emails, like I received from Dr. Aguiar last week: "Last year I had a couple of lessons with you while on my internship. I finished my residency of Emergency Medicine and I’m working at a great Emergency Department here in Brazil. Since then, I started looking for OMI EKG findings and not just STEMI. So, I'm a follower of your blog, and I think I have a interesting case that I attended yesterday." Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Risk Fact ..read more

This ECG was texted to me in real time, but I did not notice the message until about an hour after it came.  "50 + yo. Concerning history, known CAD" Recorded 2 hours after pain onset: What do you think? This was my response: "This looks like a worrisome EKG. It looks like an Occlusion MI (OMI), but I am not 100% certain. But by now you must have a repeat ECG.  Can I see it?" Pendell Meyers had an identical response when I sent it to him. PM Cardio AI algorithm said "OMI with high confidence" Explanation: There is subtle ST Elevation in inferior leads, with a hyperacute T-w ..read more

Submitted by anonymous, written by Pendell Meyers A woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. She had a prior history of "NSTEMI" one month ago, during which she had a coronary angiogram reportedly showing no stenosis in any coronary artery. Her vitals were within normal limits. Here is her triage ECG: PM Cardio Version (see original screenshot I received below) Original image. What do you think? Here is the prior ECG on file (from 1 month ago, when she was having "NSTEMI ..read more

This middle-aged patient has a remote history of cardiac surgery as a young child for a "heart murmur".  Her Apple Watch suddenly told her that she is in atrial fibrillation.  She did notice something slightly wrong subjectively, but had no palpitations, chest pain, or SOB, or any other symptom. Exam was completely normal except for an irregular heart rate. She was on no medications. Potassium was normal.  Troponin was negative. Here is her EKG: What is unusual about this? Patients with healthy AV nodes who are not on AV nodal blockers and who are not hyperkalemic sho ..read more

A 40-something woman called 911 in the middle of the night for Chest pain that was intermittent.    On arrival, she complained of severe pain. The medics had recorded this ECG and were uncertain whether it was recorded during chest pain: Let's get a better image with use of the PM Cardio app: What do you think? There is deep T-wave inversion in proximal LAD territory (V2-V4, I, aVL) that is all but diagnostic of Wellens'. This is acute ACS, but it almost always seen in a pain free state.  Since the patient has active pain now, if this is indeed Wellens,' she m ..read more

 Sent by anonymous, written by Pendell Meyers A 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 hyp ..read more

If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation? This is a trick question, as you will see below.  But you can make a diagnosis here, and Pendell and I do this all the time when reading ECGs from databases.  I sent this to Pendell without any information at all, and he replied "Postero-lateral Reperfusion." The T-waves in V2-V4 appear hyperacute, suggesting LAD occlusion, BUT there is also T-wave inversion that is typical morphology for reperfusion in V5 and V6. Thus, one must think of reperfusion.  When there ..read more

 A 30-something with h/o DM and HTN presents with CP and SOB and cough. The ECG is rather classic for pulmonary embolism, and indeed this was a large acute PE. This is a classic S1Q3T3.  Most S1Q3T3 is not due to PE.  This one is far more specific, as it is combined with sinus tachycardia and some T-wave inversion in V1-V3.  So this entire ECG is very high probability for PE in a patient with acute dyspnea. T-wave inversion in anterior leads can be Wellens.  This is NOT Wellens because the T-wave inversion is DURING the pain (not after -- Wellens' is a syndro ..read more

We are happy to announce that our "OMI Toolbox" application has just released and ready for your use.  As myocardial infarction (MI) and many other diagnoses (for example left ventricular hypertrophy, prior MI etc.) can cause ST-segment elevation (STE) on electrocardiogram (ECG), the distinction between them may be hard and complicated. Furthermore, some ECGs may not meet the STEMI criteria but may still be diagnostic for acute coronary occlusion (ACO). For this purpose, only one set of diagnostic or differentiating criteria (STEMI criteria) is not enough, therefore a bunch of different t ..read more