Sunday, May 5, 2024

Do you need to be a trained health care professional to diagnose subtle OMI on the ECG?

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED.  It was recorded at 0530:

What do you think?

The young ED tech immediately suspected LAD OMI.

He interprets here:

"This EKG is diagnostic of right bundle branch block and transmural ischemia of the anterior wall, most likely from an occlusion of the proximal LAD. There is a hyperacute distribution of T waves from V1 to V4. V1 has inappropriate ST elevation with a terminally negative T wave. The T waves in V2, V3, and V4 are symmetrical, upright, and too large for their preceding QRS complexes. Leads I and aVL have hyperacute T waves as well. There are reciprocal changes inferiorly, most pronounced in lead III with a downsloping ST segment followed by a terminally upright T wave."


Smith: RBBB with OMI often is difficult to diagnose on the ECG:

See what happens when the consultant is "Not convinced of STEMI"


The ED tech knows the Queen of Hearts, and analyzed the ECG with the AI app:


Register for access to Queen of Hearts here

The ED tech inquired and realized that the doctor had not appreciated the ECG diagnosis.  

The provider had sent the patient for an aortic dissection scan which had shown extremely heavy calcification of the LAD.

He learned more about the patient: A 77 year old female with a past medical history of hypertension and hyperlipidemia presented to the ED at around 0520 after waking up at 0400 with 10/10 chest heaviness radiating to both arms. 

The patient had continued to have chest pain.

Therefore, the provider had appropriately recorded another ECG (but unfortunately unnecessarily delayed by 45 minutes at 0615):

Now it is obvious to everyone, not only to an expert.

The cath lab was activated.

There was a 100% proximal LAD occlusion that was opened and stented.  

But 45 minutes later than it should have been.

Later, the ED tech found a previous ECG for comparison:

This further proves that the OMI findings were indeed OMI findings.

Measures of infarct size are not available, but it is certain that it would have been smaller with earlier intervention.


Learning Points

Many of the most proficient interpreters of the ECG for OMI have little medical training.  But they have an interest in ECGs, lots of exposure to OMI ECGs as well as normals and mimics, an interest in acute coronary occlusion, and a talent for seeing the subtle waveform findings of acute OMI.  Such proficient interpreters include health care assistants and EKG technicians.  

Pendell Meyers had not started medical school by summer of 2012, but he had read every one of my blog posts over the preceding 4 years.  He was a paramedic at the time.  By the summer of 2012, he could read an ECG for OMI better than any doctor I knew.

A corollary to this is that though cardiologists have a vast knowledge of the heart, many just do not see OMI ECG findings that even an undergraduate might see.

Another corollary is that, due to the extreme difficulty and varying skill and talent at this, AI is the only answer.

And the Queen of Hearts interpreted OMI with High Confidence.

Register for access to Queen of Hearts here

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