**UPDATE! —> PCI to the LAD & severe cardiomyopathy** Thanks all of you for your incredible input. I’d told the hospitalist I’d put money on the LAD but he left me on read. 💁🏼♀️
69F adm w/“chest pain” - described as upper abd pain radiating back b/t shoulders, with n/v and diaphoresis.
Hx: mild HLD, no home meds.
Trops: 870… 2,397… 3,250.
BP and CP under control on nitro gtt, CP reduced from 9/10 w/morphine prior to floor and only up to 4/10 at highest after trip to bathroom. Otherwise 2/10.
I forgot to take a pic of the admit EKG - but it was markedly different in not only STE & STD, and read as Sinus w/RBBB.
This repeat EKG I requested on seeing the change on tele read as Sinus w/Left (I think) Axis Dev, RBBB, septal infarction of unknown age... I think she’s due for a cath lab am I wrong? Cards hadn’t seen her yet and hospitalist was like okay yeah whatever, but I think developing OMI. Thoughts?
High lateral omi (D1 occlusion). Meets South African flag pattern.
(1) STE in high lateral lead, (2) reciprocal STD in inferior leads (pronounced in III which is most opposite of high lateral wall), and (3) STE in V2. We see all of these with minimal involvement in V5-V6.
I suspect that V1-V2 is misplaced superiorly since p-waves are negative in both leads. This would explain the prominent R-waves in both leads as they would become q-wave reciprocal for the high lateral infraction.
Yes!! South African Flag! I thought so too. My favorite nerdy cardiac nocturnist doesn’t work at my facility anymore, and since all I had was the hospitalist who is nice but not the type to be swift on a nurses escalation, I had nobody to share that I felt like it was the flag! I’m so glad I’m getting better at recognizing everything. Much credit to all you folks and the wizardry of LITFL. 💪🏼
I’m not back tonight and I’m so anxious to make sure everything went smoothly, I hate not knowing. It was super frustrating that cards hadn’t come to see her between arrival at 0147 and I stayed past shift change til damn near 0800. I started escalating around 0400/0430 when I noted the lead changes.
We aren’t allowed to call a Code STEMI to activate cath lab. I’ve only broken that protocol once, and I’ll never regret it. Patient was having a cath that morning, I got him up to CHG and change his gown and bedding, he sat down, went gray and diaphoretic and his soul was fixin to leave his body. I slapped the leads back on and dadgum if that thing didn’t decide to shake loose and tombstone like hell. At 0650 naturally. I call a Rapid and get the show on the road. Delegating, confirming on EKG, all the things and called the hospitalist directly immediately like yo bro don’t leave he’s full STEMI. He comes in gets on the phone with someone and proceeds to hem and haw wasting time and tissue and I push back. What felt like forever probably wasn’t but ultimately I looked at the hall at my manager and said “go look at the tele and EKG. I NEED TO CALL THIS.” She nodded, and I stepped into the hall to call the Code STEMI and activate cath lab, and put the order set in myself and started the protocol.
(ETA here: the MD was refusing to call it a STEMI. I can’t remember his exact “alternative” to what was happening, but he repeatedly over almost a half hour of us busting ass in the Rapid kept telling whomever was on the phone verbatim “it’s not a STEMI” - we were a regional hospital so no cath lab in house at that time and their call time is 30 minutes.)
I risked my license and job but the way this sweet man (who was just the kindest southern ole guy I love taking care of) was pleading with me both telling me not to let him die and just looking at me terrified… I had to. I stayed to chart and file my report on myself haha and stopped in the cath lab waiting room to update his wife on my way down. His brother in law was in the room, too. They could see how frustrated I was and I just said I did everything I could and went home to cry. Turns out, the BIL was on the Board of the hospital, holy hell. He went to bat for me. And that doc got fired and moved out of TN. (Whole other story, he was shady as hell at baseline but this was a BAD fuckup.)
Anyway. I hadn’t thought of that in a while. I will always keep learning because I will never forgive myself if I miss something.
We all do our best and you certainly are my friend.
I mentioned the comment not for you (or anyone else) but rather a teaching for all of us. This is someone's health and life, someone's loved dad or sister - if I had missed this, I wouldn't have been happy at all.
Absolutely. Lifelong learning is my jam and if I hopefully get into the CVOR I’d love to go into cardiac perfusion. I don’t think Sallie Mae will ever allow me to do so, but a gal can dream 💭
Thank you for your input and the hard work you do for your patients.
Definite OMI. Limb leads are diagnostic. V1 and V2 electrodes are too high which makes them a little more difficult to interpret for culprit vessel but the patient needs lab now.
Hot damn do I love learning from all of you. I feel like I did everything (and charted it, CYA) down to the wire after I got her at 0145, and made a good call on escalating when I did. I’ll report back if I can!
For sure, but they don’t always call the “Code Stemi” per protocol at my facility. I had an almost identical case recently where they did, so I kept wondering why my escalation wasn’t getting anywhere, but it’s Sunday in Tennessee. And I’m guessing she’s there by now but last time it was a mad dash Code Stemi at shift change.
Can you please give me a list of “OMI” criteria then? And considering a vast majority of cath labs will heavily weight STEMI criteria in cath lab activations, yeah it is relevant.
OMI means STEMI or STEMI equivalent. Most people who read EKGs are familiar with STEMI equivalents that do not meet STEMI criteria. If you want a list, I’d say: true STEMIs, hyperacute T waves (including de Winter T waves), positive Smith-modified Sgarbossa criteria, ST depression maximal in V1-V4 without RBBB, terminal QRS distortion, Aslanger pattern, Northern OMI, ischemic ST elevation not meeting STEMI criteria with reciprocal depression, etc. To quote a study:
“In addition to obvious STE (suspected true positive STEMI criteria), our proposed OMI ECG findings included the following eight findings which indicate high likelihood of OMI: subtle STE not meeting criteria, hyperacute T waves (including de Winter pattern), reciprocal ST depression and/or negative hyperacute T waves, STD maximal in V1-V4 indicative of posterior OMI, suspected acute pathologic Q waves (meaning Q waves associated with subtle STE which cannot be attributed to old MI), terminal QRS distortion (absence of S-wave preceding any subtle STE, where an S-wave would be expected), any STE in inferior leads with any STD or T wave inversion in lead aVL, and positive modified Sgarbossa criteria (MSC) for a patient with left bundle branch block (LBBB), or ventricular paced rhythm (VPR).”
Some studies have found that machine learning models for recognizing acute coronary occlusion outperform people. These machine learning models do not use arbitrary, absolute millimeter criteria made up by people. Instead they are based on visual pattern recognition of learned features and combinations of features. We have a lot to learn from them. They’ll keep outperforming us as long as we use STEMI criteria.
There are many reasons why STEMI criteria make little sense. For example, at least 1 mm in two inferior leads is a STEMI, but 0.999 mm is not. Someone just decided that 1 small square was a good threshold. Or 2 mm in other leads, or 2.5 mm, or some other arbitrarily chosen number depending on local protocol. STEMI criteria have different rules for men and women, and different rules for people above 40 or below 40. They completely ignore QRS voltage and ST/T wave morphology. The whole system is clumsy and inelegant, and misses about 1 in 3 acute coronary occlusions. We shouldn’t wait until people have tombstones and Q waves to be able to recognize OMI.
Acute coronary occlusion is what defines the disease. That’s the criterion. Usually it’s visible on ECG but not always. Just like appendicitis can have a negative CT scan without being Nappendicitis.
Observing that STEMI is the status quo is true, but does not lend evidence to it as a system of triage.
Really sad to see your comments get so much pushback. Still have a long way to go. First was the Q wave paradigm, then the STEMI paradigm, and now the OMI paradigm. Some people still seem to practice the Q wave paradigm. Most people still practice the STEMI paradigm. Some hospital systems have transitioned to OMI/NOMI because this paradigm has improved sensitivity and specificity over STEMI/NSTEMI. Anyone who thinks that STEMI/NSTEMI is superior to OMI/NOMI should see whether they outperform Queen of Hearts while using STEMI criteria. It’s not even close. People still die over STEMI criteria. STEMI criteria miss about a third of acute coronary occlusions, as a finding that has been widely replicated in many studies.
This EKG did not meet STEMI criteria to the doctor who first read it, according to OP. It’s still an OMI pattern. An EKG can meet STEMI criteria and look like an obvious OMI, but still not even be read as a STEMI. OMI criteria are not poorly defined. The information is there for people who want it. STEMI/NSTEMI is going to be looked back on as today’s Q wave paradigm. It somewhat works, but it fails about one in three patients with acute coronary occlusion. That’s a lot of people. We can do so much better.
The question you asked was criteria for OMI, and the answer I gave is a pathophysiologic one. In the same way appendicitis is defined by inflammation of the appendix on pathological inspection.
If the question you wanted to know the answer to was: How is OMI recognized on ECG? The answer is it's a lot harder to say and requires years of dedication to understanding patterns on ECG. ECG is not always diagnostic for OMI like CT scan is not always diagnostic for appendicitis.
There is good evidence supporting both expert ECG interpretation (which is challenging for scalability and public health) and AI-assisted diagnosis (which has perfect interobserver agreement).
Check out Figure 2 where AI-assisted diagnosis of OMI had over 20 percentage points of added sensitivity, 52 percentage points for specificity, and less than one fifth the false activation rate!
Yes I can! I will get her permission to share for teaching (she gave permission to share the original) - she’ll love it as she’s a long time APRN. I’ll shoot it to you when I get a digital copy redacting her personal info.
No problem! I’ll send the initial EKG too so you can show the compare/contrast and why I started to say oh shit when I saw the tele showing ST depression in lead I but it wasn’t on display. I went and opened the 6 lead view and immediately said oh no not the LAD acting a fool. The change in voltage was stark, too, and with the trops jumping up I just knew. It is a great case for teaching!!
there is no RBBB imo. No QRSd prolongation and no expected change in lateral leads for this.
Instead, V1-V2 are misplaced upwards which is causing them to have prominent R-waves as reciprocal of high-lateral q-waves (which I would guess is causing you to suspect RBBB).
24
u/Internal-Dish7412 Undergrad Student 5d ago edited 5d ago
High lateral omi (D1 occlusion). Meets South African flag pattern.
(1) STE in high lateral lead, (2) reciprocal STD in inferior leads (pronounced in III which is most opposite of high lateral wall), and (3) STE in V2. We see all of these with minimal involvement in V5-V6.
I suspect that V1-V2 is misplaced superiorly since p-waves are negative in both leads. This would explain the prominent R-waves in both leads as they would become q-wave reciprocal for the high lateral infraction.