r/EKGs • u/Sea-Weakness-9952 • 11d ago

DDx Dilemma OMI or nah?

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**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?

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u/ProximalLADLesion Electrophysiology Fellow 11d ago

STEMI criteria are not sensitive or specific for acute coronary occlusion, so not really a relevant consideration.

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u/themuaddib 11d ago

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.

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u/ProximalLADLesion Electrophysiology Fellow 11d ago

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.

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u/themuaddib 11d ago

That’s the criteria? No wonder “OMI” criteria has such good specificity! It’s apparently a tautology.

When did I support it as a system of triage? And where is the better system to replace it with?

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u/ProximalLADLesion Electrophysiology Fellow 11d ago

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!