Is the following ECG concerning for OMI or do you need to pursue more diagnostic testing?
Assume every patient is presenting with chest pain unless told otherwise.
ECG 1
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- NO
- Slow (~48), regular, wide QRS with LBBB morphology and no p waves indicate idioventricular rhythm
- V3 STD may meet Smith modified Sgarbossa but could be motion; the 2nd beat does not show it
- Subtle symmetrical T waves V1-V4 + bizarre idioventricular rhythm should have you thinking hyperkalemia. This patient had K ≥ 7.0
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- From ECG Exercise 18 - OMI?, ECG #8
ECG 2
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- YES
- There are hyperacute T waves in V2-V5 concerning for anterior MI
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #9
ECG 3
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- NO
- Huge voltage, multiple LVH criteria met - cannot tell where the precordial R and S waves end
- STE V1-V4; V4 STE may be out of proportion to the S wave but it's hard to tell. Inferior STD with TWI, no high lateral STE
- Compared to a prior ECG from a year ago it is quite similar. New inferior TWI and normalization of high lateral T waves, but not enough to trigger STEMI activation
- STEMI was activated but the patient ruled out with troponins and did not receive cath
‣
- From ECG Exercise 6 - OMI, ECG 15
ECG 4
‣
- YES
- It does look a bit bizarre but this is a ventricularly paced rhythm with a LBBB-like pattern. Use Smith Modified Sgarbossa Criteria
- Hyperacute T waves and excessively discordant STE in II, III, avF, V5-V6 with reciprocal STD in I, avL
- Concordant STD in V2-V4
- Findings concerning for inferior-lateral MI
‣
- From ECG Exercise 21 - Hyperkalemia or OMI, ECG 16
ECG 5
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- NO
- This ECG is "non-ischemic"
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #26
ECG 6
‣
- YES
- Classic South Africa Flag Pattern with high lateral STE (I, avL), inferior STD (III, avF) and V2 STE
- Cath: D1 occlusion
‣
- From ECG Exercise 18 - OMI?, ECG #4
ECG 7
‣
- YES,
- This is concerning for an anterior MI. Do not be fooled by the lack of reciprocal changes
- Convex (rounded, tombstone-like) STE in V1-V3 with additional STE in V4-V5; TWI in I and avL
- Q waves in II, III, avF, V5-V6 with poor R wave progression
- Cath: 99% LAD
‣
- From ECG Exercise 6 - OMI, ECG 1
ECG 8
‣
- NO
- Prolonged PR (see V2)
- Symmetrically sloped peaked T waves
- Wide QRS but in RBBB+LAFB pattern rather than IVCD
- K was 7.4 meQ/L
‣
- From ECG Exercise 21 - Hyperkalemia or OMI, ECG 11
ECG 9
‣
- YES
- This is concerning for an anterior OMI
- STE in V1
- Hyperacute T waves in V2-V3 with terminal QRS distortion
- STE + hyperacute T waves in V4-V5
‣
- From ECG Exercise 18 - OMI?, ECG #13
ECG 10
‣
- NO
- Sinus tachycardia with RBBB/LAFB. STD w/ TWI are seen in V1-V2 which are typical of RBBB. This is not diagnostic of OMI
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #14
ECG 11
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- YES. Inferior MI.
- STE in II, III, avF with reciprocal STD in I, avL; subtle STD in V2 with tall R wave
- There could be posterior or R sided involvement (STE III > II)
- Cath: RCA occlusion
‣
- From ECG Exercise 6 - OMI, ECG 17
ECG 12
‣
- NO
- Bizarre-appearing, wide QRS, flattened / absent p waves
- Symmetrically peaked T waves
- Could easily be interpreted as a posterior MI (V1-V3 STD) + lateral MI (STE in avL, V5)
- K was 9.0 meQ/L
‣
- From ECG Exercise 21 - Hyperkalemia or OMI, ECG 18
ECG 13
‣
- NO
- This is LBBB as evident by the wide QRS, dominant S wave in V1-V2 and monophasic R wave in I and V6. Use Modified Sgarbossa Criteria
- No concordant STE; no concordant STD in V1-V3; the STE is excessively discordant
- Hyperacute T in V4? Maybe repeat the ECG
‣
- From ECG Exercise 18 - OMI?, ECG #1
ECG 14
‣
- YES
- STE in the inferior leads and reciprocal STD in I and avL suggest inferior MI. There is also isolated STD in V2
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #5
ECG 15
‣
- NO
- Diffuse STD II, III, avF, V2-V6 with slight avR STE - run through your avR STE w/ diffuse STD differential
- Heavy smoker with on-and-off chest pain for 2 days, otherwise stable
- Cath showed diffuse 3vd (no occlusions) and he received CABG
‣
- From ECG Exercise 6 - OMI, ECG 10
ECG 16
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- YES — Occlusive MI
- Tall hyperacute T waves that are not symmetrically sloped like in hyperkalemia
- Terminal QRS distortion in V3
- Cath: LAD occlusion
‣
- From ECG Exercise 21 - Hyperkalemia or OMI, ECG 2
ECG 17
‣
- YES
- Another avR STE with diffuse STD. Is this just LVH with strain? No - notice the deep STD in the inferior leads that seem disproportionately deep compared to the small R waves they accompany. These could be reciprocal to the isolated STE in avL
- There is also STE in avR and V1
- Cath was activated and showed critical left main stenosis and severe triple vessel disease
‣
- From ECG Exercise 18 - OMI?, ECG #15
ECG 18
‣
- NO
- Does show STD/TWI in the anterolateral leads but in the setting of high voltage, likely LVH. The TWI are asymmetric. Likely LVH with repolarization abnormalities rather than acute occlusive MI
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #32
ECG 19
‣
- YES
- Diffuse STD and avR STE — go through your differential
- New RBBB compared to prior, possible left posterior fascicular block
- Patient had recent PCI and med non-compliance with new RBBB - concern for stent thrombosis
- Cath: 100% RCA + LAD stent thrombosis
‣
- From ECG Exercise 6 - OMI, ECG 13
ECG 20
‣
- NO
- T waves appear tall, but not in comparison to most of the QRS complexes, so these less likely represent hyperacute T waves
- The T waves do have symmetrical morphology - patient was found to be hyperkalemic to ≥ 6.0
‣
- From ECG Exercise 18 - OMI?, ECG #5
ECG 21
‣
- NO
- Diffuse peaked T waves
- Bizarre appearing
- Very wide QRS (~200ms!)
- Borderline extreme axis
- K here was 8.1 meQ/L
‣
- From ECG Exercise 21 - Hyperkalemia or OMI, ECG 1
ECG 22
‣
- YES
- This is an infero-posterior MI, with marked elevation (II, III, avF) and STD (avL, V1-V3). Tall R wave in V2-V3 with STD suggests posterior involvement
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #17
ECG 23
‣
- NO, not from ECG alone
- avL STE w/ inferior STD with TWI, no STE in I. Shallow TWI in V4-V5. J waves in II, V4-V6 suggest early repolarization
- Is this an evolving high lateral MI? It could be. It does not quite show South Africa Flag sign as there's no STE in I or V2. Consider repeating an ECG
- Inferior STD/TWI seem relatively shallow compared to the tall R waves they accompany, which may point to repolarization abnormality / strain-type pattern
- Case follow-up: transferred to PCI center, serial ECGs unchanged, MI ruled out with serial troponins. Cath not performed
‣
- From ECG Exercise 6 - OMI, ECG 18
ECG 24
‣
- YES
- STE (II, III, avF) with reciprocal STD in I and avL suggest inferior MI
- STD in V2 suggests posterior involvement
- STE in V4-V6 suggests anterolateral involvement
‣
- From ECG Exercise 18 - OMI?, ECG #2
ECG 25
‣
- YES
- Inferior STE with reciprocal high lateral STD
- V5-V6 STE, STD in V2-V3
- Findings concerning for inferior-posterior-lateral MI, possibly R sided
- Cath: LCX occlusion
‣
- From ECG Exercise 21 - Hyperkalemia or OMI, ECG 5
ECG 26
‣
- NO
- High voltage with diffuse ST/T-wave changes, but this is likely secondary to abnormal repolarization from LVH rather than MI
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #6
ECG 27
‣
- YES, concerning for a high-lateral, anterior MI
- High lateral STE (I and avL) with inferior STD (II, III, avF)
- STE + hyperacute T wave in V2 (T wave waayyy taller than the QRS complex); V3 may be hyperacute
- Classically known as South Africa Flag sign, seen in occlusions of the 1st diagonal branch (D1) of the LAD
- Cath: no report, but follow-up clinic notes report a stent somewhere in the patient's LAD
‣
- From ECG Exercise 6 - OMI, ECG 3
ECG 28
‣
- NO — this is a difficult one though
- There is diffuse STE, with QRS notching / J waves in most limb leads and the lateral precordial leads (V4-V6)
- No QRS terminal distortion in V2-V3 (there is an S wave in both)
- No reciprocal STD
- Positional chest pain after a post-viral syndrome. Serial troponins negative, ultimately diagnosed with pericarditis
‣
- From ECG Exercise 18 - OMI?, ECG #11
ECG 29
‣
- YES
- Inferior wall (II, III, avF) MI with reciprocal change in leads I and aVL. V1-V3 STD suggest posterior extension
‣
- From ECG Exercise 1 - McCabe OMI Test, ECG #1
ECG 30
‣
- NO
- Very tall QRS voltage meeting LVH criteria, with J waves (small positive notches) at the end of the QRS complexes often seen in early repolarization
- STD and TWI in the inferior leads; STE in avL, V2-V4
- This was a STEMI activation but the patient was ruled out by troponins and did not receive cath
- Classic STEMI criteria become significantly less specific in LVH. The STE and STD are relatively small compared to the large QRS complexes they keep company — think proportionality
‣
- From ECG Exercise 6 - OMI, ECG 11
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This post is for education and not medical advice.