Written by Bobby Nicholson What do you think of this “STEMI”? A man in his 90s with a history of HTN, CKD, COPD, and OSA presented to the emergency department after being found unresponsive at home. With EMS, patient had a GCS of 3 and was saturating 60% on room air. He improved to 100% with the addition of non-rebreather, however remained altered and was intubated by EMS with ketamine and succinylcholine. Vital signs were within normal limits on arrival to the Emergency Department. Blood glucose was not low at 162 mg/dL. CTA head and neck were obtained and showed no evidence of intracranial ..read more

Written by Pendell Meyers A man in his early sixties with no significant medical history (including a "negative cardiac workup a few years ago" for unclear indication) called 911 for acute chest pain constantly for the past 5 hours.  EMS arrived and recorded vital signs within normal limits and the following ECG during active pain: EMS1 @ 0157: What do you think? Smith: There are hyperacute T-waves in inferior leads, with a reciprocally inverted hyperacute T-wave in aVL.  There is a negative T-wave in V2, suggesting posterior OMI, and minimal ST depression in V3 wit ..read more

This was sent to me by a reader who wishes to remain anonymous. A lady in her 60s came to the ER with chest discomfort and shortness of breath. She had a history of previous anterior MI treated by primary PCI to the proximal LAD. The first EKG is from 2:30 PM on the day of presentation to the ER. Smith: To me this is a blatantly obvious acute anterior OMI.  There are massive hyperacute T-waves in V2 and V3.  There is ST Elevation that does not meet criteria in V2 and V3.  My eyes would bulge within a second of viewing this ECG. I texted this to our group "EK ..read more

This patient had the onset of chest pain 24 hours before arrival to the ED.  An ECG was recorded immediately at triage and, at this hospital, the Queen of Hearts is routinely used to determine cath lab activation. Here is that ECG: Original ECG What do you think? There is ST depression maximal in V1-V4, which is diagnostic of posterior OMI.  There is some ST Elevation and slightly hyperacute T-wave in V6.  This is a common finding in posterior OMI because V6 is "almost" around to the back, near where posterior leads would be placed. These are NOT de Winte ..read more

=================================== MY Comment, by KEN GRAUER, MD (8/30/2024):   =================================== I was sent the ECG shown in Figure-1 — knowing only that the patient was being seen in the ED (Emergency Department). How would you interpret this tracing?  Figure-1: The initial ECG in today's case. MY Initial Thoughts: In my experience — all-too-many emergency providers fail to appreciate the potential contribution that a brief (1-to-2 line) history may conve ..read more

A 50 yo was resuscitated from ventricular fibrillation.   He had a prehospital ECG recorded after ROSC:  What do you think? This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL.  Although one may have all kinds of ischemic findings as a result of cardiac arrest (rather than cause of cardiac arrest), this degree of ST elevation and HATW is all but diagnostic of acute proximal LAD occlusion. This prompted cath lab activation. On arrival to the ED, this ECG was recorded: What do you think ..read more

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. A healthy 45-year-old female presented with chest pain, with normal vitals. The computer interpretation was “ST elevation, consider early repolarization, pericarditis or injury.” What do you think? Only one of these options is concerning, so should the patient stay in the waiting room until a bed becomes available, or do they need to be seen immediately? There’s normal sinus rhythm, normal conduction, borderlin ..read more

This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech.  The undergraduate is now willing to identify himself: Hans Helseth. A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. He was admitted to the hospital for evaluation of these symptoms — but no ECG was done at that time.  On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast.&nb ..read more

 Abstract of QOH Retrospective Data by Willy Frick MD et al ..read more

Written by Willy Frick with edits by Ken Grauer A woman in her 70s with a history of hypertension presented with acute onset shortness of breath. She was out walking her dog when she developed sudden dizziness and light-headedness. When EMS found her, she was dyspneic and diaphoretic. Her ECG is shown below: What do you think? The conventional machine algorithm interpreted this ECG as STEMI. It shows sinus tachycardia with right bundle branch block. In addition, there is concordant STE in V1. New RBBB and concordant STE in V1 can be seen in LAD OMI. Additionally, with STE in V1 ..read more