Look what happens when you advocate for your patient with a skeptical cardiologist.

While at ACC, I received this text message from a former resident:

Good morning Steve! Hope you’re doing well.

Just curious what you think of this?

He writes: "To me, the downsloping ST in V2/V3 is always OMI until proven otherwise. Also looks hyperacute inferior." 

"I activated cath lab, cardiologist is not impressed. Trop pending." 

Smith: "It is diagnostic of OMI!  Cardiologists are rarely impressed because they do not understand OMI ECG findings.  Always advocate for the patient even if the cardiologist disagrees."

The inferior T waves are inflated. They are hyperacute. There is a reciprocally inverted hyperacute T wave and lead AVL.  The slight ST depression in right precordial leads is diagnostic of posterior OMI. Inferior and posterior OMI go together.  It all fits together as an inferior and posterior OMI.

He then provided some history: "Classic story for angina, few hours of crushing chest pain."

The cardiologist said to me: “those aren’t hyperacute T waves and this isn’t a posterior MI, but I’ll come in anyway.”

"He’s here now, and think he’s about to take the patient to the lab, even though he doesn’t believe me." 

"He tried to teach me about the EKG and I just said that you were my mentor and taught me to treat it as an OMI, he still didn’t get impressed but took him to cath anyway." 

"I was using this post (below) to educate my scribe, maybe I’ll send to the cardiologist, if I’m feeling brave" 

7 steps to missing posterior Occlusion MI, and how to avoid them.  

Here is the Queen of Hearts interpretation:

Here is the cardiologist's impression: "EKG does not show a STEMI."

Here is the cath report (TIMI-2 flow in the circumflex -- stented):

Learning Point:

Just because the cardiologist says it is "not a STEMI" and "wants to teach you about the ECG", it does not mean you should back down.

They do not recognize these patterns.

Use the Queen of Hearts!!

Here is another nice example of a posterior OMI:

Occlusion/reperfusion through 6 ‘normal’ ECGs

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MY Comment, by KEN GRAUER, MD (4/11/2025):

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Today's case raises the question of, "What to do when you know you are right — and, you know that your consultant (in this case, the On-Call cardiolgoist) is wrong?"

• The Answer: The patient comes first — which means that when you know you are right (ie, in this case, when you know the patient is having an acute OMI) — that you should continue to tactfully (but firmly) convey what you know is correct until appropriate management is undertaken (which in today's case was timely cath with PCI ).
• The "good news" — is that results of a timely cath will almost always reveal the answer (which in today's case confirmed what Dr. Smith's former resident predicted, namely acute posterior OMI).

NOTE: Significant delay in performing cardiac cath may sometimes result in a false negative result (ie, If some time has passed and there has been spontaneous reperfusion — and/or if intra-vascular imaging is not done in cases in which standard cath is equivocal) — in which case, the "proof' may reside with Troponin rise and serial ECGs that show evolution of acute changes, ultimately with reperfusion T waves in the affected area(s).

• For an example of how it can happen that potential false negative cardiac caths occur — Check out the March 17, 2025 post.

What Else To Do When You KNOW You Are Right?

I submit that the "other things" you can do when you know you are right (but your consultant remains unconvinced) — include the following:

• Show your consultant how QOH (Queen Of Hearts) may be of assistance! As per Dr. Smith — there was no hesitation by QOH calling today's initial ECG a STEMI Equivalent that merits an "immediate invasive strategy".
• Tactfully (but firmly) convey to your doubting consultant that in a case such as today's, in which this patient presents with a "classic story for angina, with a few hours of crushing CP" (Chest Pain) — You see ECG abormalities in no less than 10/12 leads, that when put together, tell a story. Hopefully — it will be hard for your doubting consultant to negate your story when cardiac cath proves your prediction to be completely correct.

What are the ECG Findings?

For clarity in Figure-1 — I've reproduced and labeled today's initial ECG. The rhythm is sinus bradycardia at ~55-60/minute.

• My "eye" was immediately captured in this patient with new crushing CP — by the ST-T wave appearance in lead V3, supported by the abnormal ST-T wave in neighboring lead V2 (the leads within the RED rectangle). As per Dr. Smith's former resident — in this patient with new crushing CP, the diagnosis of acute posterior OMI can be made within less than 5 seconds — unless and until proven otherwise by cardiac cath.
• The Mirror Test in lead V3 is clearly positive (See My Comment at the bottom of the page in the September 21, 2022 post). But regardless of whether or not you are a "fan" of the Mirror Test — Dr. Smith's "mantra" is all that is needed = maximal ST depression in one or more of the leads V2,V3,V4 in a patient with new CP = posterior OMI until proven otherwise.
• Abnormal ST-T wave appearance continues in neighboring chest leads V5,V6 (both of which show ST straightening with slight depression and disproportionate terminal T wave positivity).
• As always — whenever we see evidence of acute posterior OMI — we should look closely for associated acute inferior OMI (ie, While we'll occasionally see isolated posterior OMI — the common blood supply to inferior and posterior LV walls most often results in simultaneous acute inferior and posterior lead changes).
• Each of the inferior leads in today's initial ECG manifest ST segment straightening, with disproportionately taller and "bulkier"-than-expected upright T waves that we know are hyperacute because: i) These T waves are very large considering small QRS amplitude in these same leads; ii) These inferior lead T waves are seen in association with acute posterior OMI in the chest leads; and, iii) There is reciprocal ST depression in lead aVL (and to a lesser extent — in the form of abnormal ST segment flattening in lead I, which is the other high-lateral lead).

BOTTOM Line: Credit to Dr. Smith's former resident for immediately recognizing today's acute infero-postero OMI, with need for prompt cath. Credit to this clinician for importantly advocating for his patient — who as a result, received timely PCI that was needed. 

Figure-1: I've labeled the initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio).