tag:blogger.com,1999:blog-549949223388475481.post3846323811364244753..comments2024-03-29T11:45:03.667-05:00Comments on Dr. Smith's ECG Blog: Our patients deserve better than the "STEMI criteria"Unknownnoreply@blogger.comBlogger10125tag:blogger.com,1999:blog-549949223388475481.post-30497288502274974292020-02-25T07:55:52.978-06:002020-02-25T07:55:52.978-06:00Drs,
When reading this post over morning coffee (...Drs, <br />When reading this post over morning coffee (daily routine for past 6 years), I’m reminded of a case posted here involving an 80 something year old female with chest pain and a paced rhythm. This ecg presented with concordant depression in the inferior leads an concordant elevation in aVR. It was not recognized by the intensivist and she eventually arrested expired. <br /><br />With regards to this post, would it still have been considered wrong considering occlusion within a paced rhythm (abnormal qrs) in the inferior leads even though there were hints of reciprocal changes between III and aVL? Does a paced rhythm/abnormal qrs exclude cath lab consideration?Brian Imdiekehttps://www.blogger.com/profile/12094550299651836241noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-87786429357475276522018-02-04T12:15:35.836-06:002018-02-04T12:15:35.836-06:00Compleatly agree with Matt. MI is a much wider con...Compleatly agree with Matt. MI is a much wider concept than STEMI. But for most common ED Docs and cardiologists, STEMI concept provides a framework which is handy and easily available. Nevertheless, I do agree bigger efforts can be made by most of us to widen our scope of this potentially mortal disease. But unfortunately, our efforts and energy have to focus on many other issues and most of us cannot embrace them all strong enough.Fernandohttps://www.blogger.com/profile/11496808512836930126noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-86644083131092782612018-01-29T07:29:30.709-06:002018-01-29T07:29:30.709-06:00Matt, I can only speak for my very short experienc...Matt, I can only speak for my very short experience at my own institution. When we have a patient with clear ACO which manifests with obvious ST elevation (a classic, clear cut STEMI), we activate the cath lab and the cardiologists come down immediately to evaluate the patient. When we have anything less than that, but we're worried that the patient might still need emergent cath, we generally don't activate the cath lab outright but instead call the cardiology fellow or attending directly, to explain our concerns and have them look at the ECG. If the cardiologist doesn't agree, the conversation doesn't usually make a difference. They decide whether and when the patient goes to the lab. We try to get a stat echo done on these patients. Subtle findings such as in EKG #2 are generally not accepted at my institution (except by the emergency medicine providers who keep up with this blog and other similar resources) - I imagine this is the situation for at least 90% of all institutions worldwide. <br /><br />I'll let Dr. Smith explain the details of how the process works at his institution, but overall it sounds a little different. They have a formal "pathway B" for their patients with high suspicion and/or subtle findings, including immediate formal contrast echos, low threshold to take the patient for immediate diagnostic cath, and the benefit of having spent 30 years working with Dr. Smith. So you can imagine how they might be more receptive to subtle findings!Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-14611289110703360362018-01-29T06:52:32.664-06:002018-01-29T06:52:32.664-06:00Thanks!Thanks!Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-12117702613944515182018-01-27T12:13:19.484-06:002018-01-27T12:13:19.484-06:00Drs. Smith and Meyers,
My suspicion is that the t...Drs. Smith and Meyers,<br /><br />My suspicion is that the two of you are more expert at identifying acute coronary occlusion on the EKG than many of the cardiologists at your respective institutions. So what happens when you are presented with an EKG such as #2? Do you handle it in the same manner as an EKG meeting traditional STEMI criteria? And what is the conversation like if/when the cardiologist does not agree with this interpretation?Matthttps://www.blogger.com/profile/04515801225821387686noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-362253796139479222018-01-27T09:34:22.127-06:002018-01-27T09:34:22.127-06:00"...when the clinicians struggle to reconcile..."...when the clinicians struggle to reconcile normal results with the intense mobilization of resources used and an ECG that they cannot bring themselves to consider a possible normal variant: The clinicians concluded that the patient has "viral myocarditis." "<br /><br />The name given to this phenomenon is "cognitive dissonance".<br /><br />Excellent post.Shivahttps://www.blogger.com/profile/01672927832443674944noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-8362507215828954032018-01-27T08:03:18.473-06:002018-01-27T08:03:18.473-06:00They are fine to help diagnose some MIs and avoid ...They are fine to help diagnose some MIs and avoid some false negatives. But they miss many. Better to have a false positive cath lab activation than a false negative!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-86635655537003542692018-01-27T08:02:26.572-06:002018-01-27T08:02:26.572-06:00Thanks, Ken!Thanks, Ken!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-51827878073405946042018-01-27T01:20:33.705-06:002018-01-27T01:20:33.705-06:00I identied the case 2 by lead 2 and aVL changes by...I identied the case 2 by lead 2 and aVL changes by IRBBB and is its concordant changes ... But case 1 was offcourse STEMI for me if the patient was symptomatic.<br />In my opinion the STEMI criteria is required to help us in courtrooms, otherwise doctors will be sued more times than ever because reaching to such an expertise level will be problematic for the majority for the lack of mentors/cases/time etc etc..<br />So guidelines need to be there and for better patient management yes we need to be aware of what you have been tryin to teach us.. 🙂 MGhttps://www.blogger.com/profile/06233522417024317416noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-78553415538939767942018-01-26T21:38:07.553-06:002018-01-26T21:38:07.553-06:00Superb presentation by Pendell Meyers! The feature...Superb presentation by Pendell Meyers! The feature that for me is most against the 1st ECG being an acute stemi is the diffuseness of the abnormal findings. Virtually all leads show either abnormal T wave peaking (the inferior leads with ST elevation) or T wave inversion — and, large Q waves are seen in no less than 6 leads. The width and fragmentation of the Q waves in leads III and aVF is beyond that seen with “septal q waves” — with unusual loss of R wave from V3-to-V4 and uncharacteristically deep Q waves in V5,V6. What surprised me most about this case is that the Echo was completely normal. I think use of the term, “normal” variant to describe these findings is potentially problematic. By exclusion, the follow-up in this case confirms that the ST-T wave findings constitute a repolarization variant. I find it hard to describe these Q waves as “normal”. What the insightful follow-up to this case proves is that an “MI Mimic” tracing such as this CAN be found in a patient with no underlying heart disease. THAT is an important lesson to be learned!<br /><br />Credit to Dr. Smith for his instantaneous right-on accurate diagnosis of acute RCA occlusion for ECG #2. For those not appreciating the subtle hyperacute inferior lead ST-T wave changes with near mirror-image opposite picture in lead aVL (to that seen in lead III) — the important point that should not be missed by clinicians on the front line is that no less than 6 leads show ST depression (leads I, aVL, V3-thru-V6) in this patient with “moderately concerning new chest pain” — and regardless of whatever “stemi criteria” one uses — ST depression of this degree should be enough to convey the need for timely cath. THANKS again to Drs. Meyers & Smith for this excellent blog post!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.com