tag:blogger.com,1999:blog-549949223388475481.post5488969905390114631..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: "It isn't a STEMI," so cath lab refusal (again). Were they right?Unknownnoreply@blogger.comBlogger5125tag:blogger.com,1999:blog-549949223388475481.post-12349804633537757042020-10-01T20:00:58.518-05:002020-10-01T20:00:58.518-05:00@ Unknown — You were NOT at all “rude”! I think it...@ Unknown — You were NOT at all “rude”! I think it is great that you are asking the questions. As part of their ongoing research — Drs. Smith & Meyers have thoroughly reviewed the literature. Part of the problem as I perceive it — is too many in the cardiology community still negate the potential significance of OMI as an indication for prompt cath and reperfusion. “A picture is worth 1,000 words” — and among our goals on this ECG Blog is to show ACTUAL tracings that lack millimeter-definition of a stemi — yet which clearly suggest acute coronary occlusion. In the hope of constructive feedback — we call attention to cases in which the interventionist decision to cath was either delayed or refused — all with the goal of hoping to improve care in the future. Unfortunately, the cardiology literature still lags behind, and for the most part, has not yet caught up and acknowledged the concept of OMI. Please KEEP asking the questions! ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-24366839635743212852020-10-01T10:02:31.790-05:002020-10-01T10:02:31.790-05:00Thank you for your explanations! I was not trying ...Thank you for your explanations! I was not trying to be rude or anything, just wanted to hear your point of the view.<br />Good luck with your new papers, change can only be made with continuous (scientific) work. Love hearing from your studies and papers soon.Internal Med. Residenthttps://www.blogger.com/profile/14188548582117249874noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-23263740302224152562020-09-30T07:00:16.890-05:002020-09-30T07:00:16.890-05:00First, I do not say not to record posterior leads....First, I do not say not to record posterior leads. I say that if the initial 12-lead is diagnostic, do not record posterior leads. Better: record them, but understand their limitations.<br /><br />Here are the problems with the Pride study:<br /><br />There were too many important details missing from the methods: <br /><br />1. Isolated ST depression that is maximal in right precordial leads V1-V4 is much more likely due to occlusion (usually circumflex) and reflect posterior STEMI<br />2. Isolated ST depression maximal in V4-V6 more often reflects subendocardial ischemia and an open artery.<br /><br /><br />Methods: For the present analysis, only patients with isolated anterior ST-segment depression in leads V1 to V4 were included. Patients with ST-segment elevation in other leads were excluded.<br />They excluded patients with ST Elevation, however:<br /><br />1. Did they include patients who also had ST depression in left precordial leads V5 and V6?<br />2. Did they include patients who also had ST depression in limb leads?<br /><br />Related: <br /><br />3. Were patients included who had deeper ST depression in left precrodial leads V5 and V6 than in right leads V1-V4 included?<br />4. How many patients with MAXIMAL ST depression in V1-V4 were there, vs. MAXIMAL in V4-V6?<br />5. Was there any analysis comparing maximal in right vs. left precordial leads?<br />6. Were patients with < 1 mm of ST depression included?<br />7. Was there any subgroup analysis based on amount of ST depression?<br />Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-84269370024113454312020-09-30T04:10:00.136-05:002020-09-30T04:10:00.136-05:00Thanks for your comment!
-Regarding Pride et al, w...Thanks for your comment!<br />-Regarding Pride et al, we are aware of this study and cite it in the OMI Manifesto etc. Many potential things to say about this. There are all kinds of reasons why we might not be talking about the same ECG patterns as Pride et al. are. When we talk about STD maximal in V2-V4, we always try to make sure we give the caveat that we exclude all patients with an abnormal QRS that could be causing appropriately discordant STD in V1-V4, for example RBBB should have a tiny bit of STD in V1-V2. So it is possible that, if Steve Smith were to identify a population with isolated STD in V1-V4, the rate of OMI would be higher than 26% they found. We have some data on STD maximal in V2-V4 coming out soon - we will certainly put out a blog post when this happens.<br /><br />Second, their outcome is purely a TIMI flow grade 0/1, which is in my opinion too strict to catch all patients with real OMI. For example, Cox et al. (ref below) showed that 19% of obvious STEMIs had TIMI flow =3 of the lesion at the time of cath. So it is not surprising to me that only 26% of those patients in Pride et al. had TIMI 0-1. There is much more to the diagnosis of OMI than the TIMI flow snapshot at the time of cath. Finally, 26% is not an inconsequential rate of OMI even if that were the true number. All these NSTEMIs in Pride et al. need cath anyway, the only question is the timing - if you have a population that needs cath anyway, what percent of the population with OMI would warrant cathing them quickly vs. delayed? No one knows the answer to that.<br /><br /> (Am J Cardiol 2006.<br />Comparative early and late outcomes after primary percutaneous coronary intervention in ST‑segment elevation and non‑ST‑segment elevation acute myocardial infarction (from the CADILLAC trial). Am J Cardiol. 2006)<br /><br /><br />Regarding posterior leads: When you are not convinced about posterior OMI from the anterior leads, we recommend getting posterior leads because there is a portion of cases that are made easier to identify with posterior leads. When you ARE convinced about posterior OMI from the anterior leads, that is the scenario when we don't really see a good value of posterior leads. We have seen so many cases where posterior leads falsely reassured the provider and the clear posterior OMI was missed. You mention one case in which the posterior leads were truly negative, but we are also talking about situations like this case we are commenting on - even when the posterior leads BARELY show 0.5 mm (technically "positive"), people do not call them positive, instead in our experience people are somehow falsely reassured by how "small" and subtle the STE is in the posterior leads (due to low voltage). Indeed, in this very case above, the cardiologists did not believe that this posterior ECG met criteria. <br />Another similar case: https://hqmeded-ecg.blogspot.com/2020/04/guess-culprit-with-st-elevation-in.html<br />Another similar case: https://hqmeded-ecg.blogspot.com/2020/04/a-man-in-his-60s-with-chest-pain-st.html<br />Another: https://hqmeded-ecg.blogspot.com/2018/09/a-completely-healthy-30-something-woman.html<br />Another case where it is clearly positive but somehow the cardiologist doesn't agree because of the posterior leads: https://hqmeded-ecg.blogspot.com/2018/05/a-middle-aged-man-with-st-depression.html<br /><br />In summary, we do not have a large amount of data confirming or denying our experience/claim that posterior leads can cause false reassurance. We recommend that posterior leads can be helpful when posterior OMI is a possibility but the anterior leads are not diagnostic. I stand by my personal claim that, in a patient with ACS, and a normal QRS that should not produce normal expected ST depression, then: STD maximal in V1-V4 is highly concerning to me for posterior OMI until proven otherwise. And I hope to publish on this soon! We finally have the database to answer this question.<br /><br /><br /> Pendellhttps://www.blogger.com/profile/01445330667624442976noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-67081811882837649852020-09-29T10:21:21.155-05:002020-09-29T10:21:21.155-05:00Thank you for great case again, and for this great...Thank you for great case again, and for this great blog. However, as an emergency physician I have one big question for Dr. Smith and co. You keep saying isolated ST-depression maximal (or purely isolated depression only) in V2-V4 should be considered as OMI and total occlusion, and saying posterior leads should NOT be taken. <br /> - However, "Of the 1,198 patients with isolated anterior (V1-V4) ST-segment depression, 314 (26.2%) had an occluded culprit artery (TFG 0/1)". Subjects with ST-elevation in any other leads (including posterior leads) were excluded. Thus 3/4 subjects with isolated anterior ST-depression had NOMI. I believe this is greatly contrary to your statement of isolated ST-depression in V2-V4 should be considered as OMI/STEMI-equivalent. https://doi.org/10.1016/j.jcin.2010.05.012<br /> - In the following paper, it is stated that "23.5% had isolated ΔST elevation in ≥1 posterior lead without precordial ΔST depression." As such, the posterior leads should always be recorded since there can be ST elevation in V7-V9 without ST depression in leads V2-V4 https://doi.org/10.1016/S0002-9149(01)01431-X<br />- furthermore, in this paper "Posterior ST-elevation without ST-depression in V2-4 was present in 22% patients" https://doi.org/10.1016/S0735-1097(97)00538-X<br /> - lastly, I believe you have only described one patient with ST-depression v2-4 with "falsely" negative posterior leads and acute OMI? http://hqmeded-ecg.blogspot.com/2013/01/precordial-st-depression-what-is.html<br /><br />Any comment on these?Internal Med. Residenthttps://www.blogger.com/profile/14188548582117249874noreply@blogger.com