Sunday, February 4, 2024

What will happen if you implement the Queen of Hearts in your Hospital?

This case was sent by Dr. Jean-christophe Reiters, an interventionalist in Belgium.  He has been following the blog for 4 years.

He has now implemented the Queen of Hearts in his hospital.  

He wanted to share one of the first cases.

A 55 year old with no previous cardiac history presented with 3 hours of chest pain.  The pain was persistent and reportedly still present at the time of the ECG.

Here is the EKG:

Smith: It looks like a reperfused inferior lateral OMI.  (Inverted T-waves in inferior and lateral leads, with reciprocally upright (pseudo-hyperacute) T-waves in I and aVL.  But if the pain is persistent, as reported, then the patient must go to the cath lab even if the ECG suggests reperfusion.

The emergency physician asked the advice of Dr. Reiters because of absence of STEMI criteria.

Dr. Reiters wrote: "I was worried about hyperacute T-waves in leads I, aVL and V2, and perhaps a reperfused infero-lateral OMI because of the Wellens'-like waves in inferolateral leads.   I was not confident that it was OMI, but because of the persistent pain I used the PM Cardio app with Queen of Hearts interpretation:

This is from the PM Cardio app (in contrast to the Queen of Hearts on Telegram). The app is fully approved for clinical use in Europe, and has both the Queen of Hearts and 38 other diagnoses, such as LVH, rhythm diagnoses, etc.

Translation from French: Acute Occlusion Myocardial Infarction with High Confidence.

(The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH)

Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI.  This will be corrected in Version 2, coming soon.

So he activated the cath lab based on the Queen of Hearts, and here is the angiogram video:

Dr Reiter's angiographic diagnosis: This is total occlusion of the proximal circumflex.

Now opened up:

First troponin T returned after cath lab activation and was 400 ng/L

Peak high sensitivity troponin T was 5244 ng/L after rapid reperfusion

LV EF was 50-55% with infero-lateral hypokinesis

Final diagnosis: NSTEMI

Dr. Reiter's Learning Points:

OMI (+) STEMI (-)

Saved at least one hour compared with using first troponin

Saved 2 hours compared with European Society of Cardiology Guidelines.


If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.

This is for the version housed on Telegram:

You can get the full PM Cardio app here:


MY Comment, by KEN GRAUER, MD (2/4/2024):

Our appreciation to Dr. Jean-Christophe Reiters from Belgium — for his contribution to Dr. Smith’s ECG Blog. I’d add the following points from my perspective:
  • I find it reassuring when interpretation by the QOH (Queen OHearts) AI application comes to the same conclusion that I come to. Hopefully for other clinicians — this facilitates confidence for taking action on cases about which “the Answer” may not be initially clear.
  • The QOH application is both international in scope (Today’s case from Beligum— and continually improving (Drs. Smith and Meyers forever adding cases to QOH’s already amazingly huge data base of ECGs — with clinical follow-up on these cases for this AI application to learn from). This is in stark contrast to computer-based algorithms previously (and still presently) in use — which continue to regularly over- and under-diagnose acute OMI without possibility of improving their performance.

  • The above said — I feel the “approach” for optimal use of QOH shares one essential similarity with any computer-enhanced application: The clinician should assess the ECG himself/herself before looking at QOH’s interpretation. This sequence for assessment serves 2 KEY purposes: i) It ensures the clinician will not be biased by what QOH says. This adds the power of a 2nd opinion (ie, The unbiased clinician interpretation and the QOH interpretation — rather than acceptance by blind faith of the QOH alone);  and, ii) The BEST way to improve one's ability in clinical ECG interpretation — is to force yourself to come up with your own interpretation before you look at what QOH says! After all, the ultimate goal is both to optimize care of the patient (by incorporating the “experience and wisdom” of the QOH application from her expertise in assessing the likelihood of acute OMI)  and — to improve the abilities of practicing clinicians so that their future care of patients continues to improve.

Regarding Today’s Initial ECG:
As was later confirmed by cardiac cath — today’s ECG is diagnostic of acute infero-postero-lateral OMI, with ECG findings of diffuse reperfusion T waves at the time today’s initial ECG was recorded.
  • For clarity in Figure-1 — I’ve reproduced today’s initial ECG. There are obvious reperfusion T waves in no less than 10/12 leads.

  • Inferior OMI: Q waves are present in leads III and aVF. Although the Q in lead aVF is small — in proportion to the small QRS complex in this lead, this Q in aVF is clearly significant. ST segment coving with deep T wave inversion in leads II,III,aVF is consistent with reperfusion ST-T waves following new inferior OMI (being impossible to determine if the Q waves in III and aVF are from the current ongoing event — vs from prior inferior MI with superimposed new OMI).
  • The T waves in high-lateral leads I and aVL are disproportionately tall and peaked. I interpreted this mirror-image opposite ST-T wave appearance (compared to the ST-T wave in lead III) — as reciprocal changes to the inferior lead reperfusion T waves.

  • Lateral OMI: The disproportionately deep, symmetric T wave inversion in leads V5,V6 suggest lateral reperfusion T waves following lateral OMI.

  • Posterior OMI: We often emphasize that the normal appearance of the ST-T wave in anterior leads V2,V3 — is for there to be slight ST elevation with gentle upsloping of the ascending ST segment in these leads. As a result — the ST segment straightening without any ST elevation, culminating in much taller and more-peaked-than-they-should-be T waves in leads V2 and V3 in Figure-1 presents the mirror-image of inverted reperfusion T waves in anterior leads — which indicates posterior OMI, now in the reperfusion stage.

  • NOTE: Lead V4 shows ST segment flattening, with a trace of ST depression. I interpreted this appearance as simply reflecting that lead V4 is a “transition lead” located in between the disproportionately tall and peaked T waves of leads V2,V3 — and the deep, symmetric T wave inversion of leads V5,V6.

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

Our THANKS to Dr. Jean Christophe Reiters for sharing his case! 

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